Stressed Spaces: Mental Health and Architecture

MENTAL HEALTH AND ARCHITECTURE

LITERATURE REVIEW

Stressed Spaces: Mental Health and Architecture Kathleen Connellan, PhD; Mads Gaardboe, MA; Damien Riggs, PhD; Clemence Due, PhD; Amanda Reinschmidt; and Lauren Mustillo

ABSTRACT OBJECTIVE: To present a comprehensive review of the research literature on the effects of the architectural designs of mental health facilities on the users. BACKGROUND: Using a team of cross-disciplinary researchers, this review builds upon previous reviews on general and geriatric healthcare design in order to focus on research undertaken for mental health care facility design. METHODS: Sources were gathered in 2010 and 2011. In 2010 a broad search was undertaken across health and architecture; in 2011, using keywords and 13 databases, researchers conducted a systematic search of peer reviewed literature addressing mental health care and architectural design published between 2005 to 2012, as well as a systematic search for academic theses for the period 2000 to 2012. Recurrent themes and subthemes were identiied and numerical data that emerged from quantitative studies was tabulated.

AUTHOR AFFILIATIONS: Kathleen Connellan, PhD, is a Senior Lecturer in the Division of Education, Arts and Social Sciences in the School of Art, Architecture and Design at the University of South Australia in Adelaide, South Australia, Australia. Mads Gaardboe, MA, is the Head of School for the School of Art, Architecture and Design at the University of South Australia in Adelaide, South Australia, Australia. Damien Riggs, PhD, is a Senior Lecturer in Social Work and Social Planning in Social and Behavioural Sciences at Flinders University in Adelaide, South Australia, Australia. Clemence Due, PhD, is an Associate Lecturer and Research Associate in the School of Psychology at the University of Adelaide in Adelaide, South Australia, Australia. Amanda Reinschmidt and Lauren Mustillo are Research Assistants at the University of South Australia in Adelaide, South Australia, Australia.

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RESULTS: Key themes that emerged were nursing stations, light, therapeutic milieu, security, privacy, designing for the adolescent, forensic facilities, interior detail, patients’ rooms, art, dementia, model of care, gardens, post-occupancy evaluation, and user engagement in design process. Of the 165 articles (including conference proceedings, books, and theses), 25 contained numerical data from empirical studies and 7 were review articles. CONCLUSIONS: Based on the review results, especially the growing evidence of the beneits of therapeutic design on patient and staff well-being and client length of stay, additional research questions are suggested concerning optimal design considerations, designs to be avoided, and the involvement of major stakeholders in the design process. KEYWORDS: Evidence-based design, hospital, interdisciplinary, literature review, post-occupancy

CORRESPONDING AUTHOR: Kathleen Connellan, PhD, Division of Education, Arts and Social Sciences; School of Art, Architecture and Design; University of South Australia, City West Campus, Adelaide, South Australia 5001, Australia; [email protected]; +61 8 830 20355. PREFERRED CITATION: Connellan, K., Gaardboe, M., Riggs, D., Due, C., Reinschmidt, A., & Mustillo L. (2013). Stressed spaces: Mental health and architecture. Health Environments Research & Design Journal, 6(4), pp. 127–168

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Introduction he research question identiied for this literature review was: How does the intersection of mental health care and architecture contribute to positive mental health outcomes? We arrived at this research question because it is suiciently focused but still broad enough to incorporate important variables such as diferent models of care. he University of South Australia’s Mental Health Research Group was the catalyst for the formation of an interdisciplinary team of researchers across architecture, design, mental health practice, and psychology. he team, called “Stressed Spaces: Mental Health and Architecture,” won two consecutive university funding grants to conduct research in purpose-built mental health facilities in 2010 and 2011. As part of that collaboration, a survey on the existing literature on the crossover of mental health and architectural research was conducted. he scarcity of research literature dealing with both mental health and architecture along with the speciic lack of evidenced-based research was noted, prompting the team to conduct additional research. In the process, the team wrote this review article building upon the most recent literature review publications, from Ulrich et al. (2008) in general healthcare, to Dobrohotof and Llewellyn-Jones (2010) on geriatric healthcare. he objective of this article is to present an updated review of the literature across health and architecture, but with a speciic focus on mental health care and design in order to make a contribution to this ield and assist other researchers, architects, and clinical practitioners in their quest for improved mental health outcomes. he multiple considerations in the complex crossover of architectural design and mental health require multidisciplinary collaboration, as is evidenced by our team of researchers, policy makers, advisors, and partners. he team comprises two architectural irms that specialize in healthcare design, one based in Australia and the other in the United Kingdom; one experienced architect now heading the School of Art, Architecture and Design at the University of South Australia; two social scientists with backgrounds in psychology; one senior mental health nurse; one professor in mental health nursing at the University of South Australia; and one senior lecturer in design theory at the University of South Australia, specializing in design and well-being. Such collaborations have been indicated as an essential aspect of the development of nine more eicacious designs. he broad socio-economic and political context factors present at the time this article was written included the social context of an aging population in most Western and “developed” countries; the “modern” diseases frequently associated with those countries (such as depression and mental illness, substance abuse, diabetes, obesity, heart disease); the political power held by aging baby boomers (who form a large and comparatively wealthy demographic) to demand comprehensive health services; the technological impacts of extending life at all costs; the costs of providing the expected standards of healthcare; and the attendant hospital facility construction boom. With these contexts and issues in mind, we observed the emergence of the following themes from the current body of literature: nursing stations, light, therapeutic milieu, security, privacy, designing for

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the adolescent, forensic facilities, interior detail, patients’ rooms, art, dementia, model of care, gardens, post-occupancy evaluation, and user engagement in the design process. From these key themes, we learned that only some (25 of the 165) research articles generated evidence-based numerical data. From this data, we also know that the key themes also represent the areas that require more research as they are identiied as crucial to improved mental health outcomes. here is no question that the old institutional model of care with its associated asylum-style architectural design is anathema to mental health practice; however, with the construction of new facilities, we question the extent to which seemingly innovative designs match contemporary mental health models of care. he gaps in research represent the lack of reliable post-occupancy reviews of facilities. herefore, this review also questions why that gap exists. Do, for example, ethical protocols and concerns with qualitative methods on vulnerable populations present too much of an obstacle for researchers and hospitals? Of the 165 research articles, seven were literature review articles, published between 2000 and 2010. he primary reason for writing any literature review is, of course, to share the state of research on a particular subject with the community. However, this is not the sole reason for doing so, and each of the seven literature review fulills its own perceived need. Two concentrate upon aged care and design (Day, Carreon, & Stump, 2000; Dobrohotof & Llewellyn Jones, 2010), and the remaining ive center on design with diferent foci: light and lighting (Anjali, 2006); art (Daykin, Byrne, Soterious, & O’Connor, 2008); safety (Reiling, Hughes, & Murphy, 2008); patient rooms and well-being (Lorenz, 2007); and evidenced-based design (Ulrich et al., 2008). Each of the review articles summarizes the recommendations based on previous indings; however, the indings of these predominantly systematic reviews emphasized to us that this area of research runs the risk of losing itself in disparate detail. Consequently, there is a need for more frequent comprehensive reviews of the broad ield of mental health and architecture crossovers in the research literature so as to form a platform for other more focused and detailed studies.

Methodology For this article we combined comprehensive and systematic reviews of the literature on mental health and architecture. he reason for this lies in the two separate time periods dedicated to the literature surveys. he irst time period (2010) involved a scoping study, which included architecture and health websites and did not set dates or tight exclusions for the searches. In the second time period (2011) we utilized selected databases, set dates, and utilized a deined keyword search criteria (see Table 1). he initial scoping study resulted in 78 articles, of which 19 were annotated according to their mental health focus and empirical/numerical data. On the basis of these indings, we developed a systematic approach to build upon the irst literature search, retaining the articles that predated the set start dates for the second literature search. he dates set for searching the literature in the second (systematic stage) were 2000–2011. he keywords used for the searches are listed in Table 1 and the databases searched are listed in Table 2. he keywords were chosen based on



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Table 1. List of Keywords Used in Searches Mental health

Psychiatry unit

Built environment

Evidence-based design

Mental illness

Psychiatric hospital

Therapeutic environments

Post-occupancy evaluation

Mental health care

Psychiatry

Therapeutic gardens

Facility design

Mental health facilities

Wayinding

Healing gardens

Interior design

Architecture

Architectural design

Healthcare facilities

our 2010 scoping study as well as those used by other literature review articles (included for discussion in this article). In addition to peer-reviewed articles, the team inspected the bibliographical references of selected papers, and identiied key sources that could be added to the literature. Other than the search parameters already mentioned, additional exclusions for the searches were (a) government reports and (b) non-English language texts. Reasons for these exclusions were that government reports had been included in the initial scoping study and we subsequently found that signiicant indings of such reports were reconstituted into journal articles, and the language was restricted to English to facilitate understanding in an Englishspeaking research team. Once the literature was collated and annotated, we identiied key themes (Table 3); peaks and troughs in publication dates (Figure 1); and expertise and location of studies. he 13 major themes which emerged from the literature were security/privacy; light; therapeutic milieu; gardens; impact of architecture on mental health outcomes; interior detail/patients’ rooms; psychogeriatric dementia; post-occupancy evaluation; user engagement in design process; nursing stations; model of care; art; designing for the adolescent; and forensic facilities. For the purposes of this review article, we have combined and summarized the themes based on refereed articles and empirical indings; consequently, books, book reviews, theses, and theoretical papers contribute to the discussion but do not constitute the core material. We discuss the themes in an order that approximates (with some exceptions) the signiicance and visibility of the theme in the literature. Table 3 details the number of key articles for each theme and whether those include literature review articles.

Table 2. List of Databases PsycINFO

MEDLINE

MEDLINE Plus

Ovid Nursing Database

ProQuest, nursing and allied health source

ProQuest, theses

PsycArticles

Psychology a SAGE full text collection

SAGE Health Sciences

EBSCOhost

JSTOR Arts and Sciences I-X Collection

Wiley Online Library

Google Scholar

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Table 3. Key Themes Found in the Literature THEME

NO. OF ARTICLES

LIT. REVIEW

1.

Security

38

yes

2.

Light

24

yes

3.

Therapeutic milieu

34

no

4.

Gardens

21

no

5.

Impact of architecture on health outcomes

15

yes

6.

Interior design

11

yes

7.

Psychogeriatric

7

yes (x 2)

8.

Post-occupancy evaluations

11

no

9.

Nursing stations

12

no

10. Model of care

7

no

11. Art

5

yes

12. Adolescents

6

no

13. Forensic psychiatric facilities

2

no

Figure 1 shows that there has been an increase in research in the last 10 years, and particularly in the past 5 years. he x-axis includes the years when articles that included architectural design/space in addition to one of the 13 themes listed on the y-axis. he y-axis illustrates of the amount of articles published on those themes during those years and not a precise igure. hemes have been patterned diferently for visual recognition. Much of this research has concentrated on gardens, interior design, and nursing stations, together with the overall impact of architecture. he professional and academic expertise of lead authors contributing to this body of literature is concentrated in the ields of psychiatry (17 articles) and psychology (16 articles); there are also 17 articles with lead authors from the ield of architecture and 4 from interior architecture. he remaining areas of expertise show single igures in the number of articles represented for this study but they include public health, public administration, sociology, nursing, neuroscience, medical anthropology, health design, forensic psychiatry, engineering, medicine, arts, and animal behavior. We also noted that research across mental health and architecture is more concentrated in the United States—California in particular—Canada, Australia, the United Kingdom, and to a lesser extent Sweden, Norway, India, and Israel. he reason for less representation from Europe in this review may be that we only looked at English language publications for ease of comprehension.

Security he theme of security stretches across literature concerning all users of facilities, including patients, all staf, and visitors. he subthemes emerging from the literature are spatial analysis and spatial mapping; it for purpose; violence; crowding; environmental stress; quality of care; stigma; risk management; nurse safety; safe practice; and prevention strategies and assessment.



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Number of Articles Published

Figure 1. Peaks and troughs of publication dates, grouped by theme.

Kumar and Ng (2011) based their discussion on three background studies. he irst is Haller and Deluty’s 1988 study of 566 psychiatric and 898 non psychiatric beds from 16 psychiatric and general hospitals in the U.S., which reported 2.54 assaults per bed yearly among psychiatric wards, compared with 0.37 assaults per year in non-psychiatric units. he second is a 1991 British study completed by Davis, who collected data over 15 months and reported that the number of violent incidents in the second half of the study period constituted a highly signiicant (240%) increase over the number in the irst half. he third is an American study in which Reid, Bollinger, and Edwards (1985) reported a 32.9% increase in assault rates from 1978 to 1980. hese numbers make it clear that both patients and staf are at risk from widespread and increasing violence on psychiatric wards. Crowding appears to be emerging as one of many potential risk factors for safety issues. Kumar and Ng explain that density, privacy, and control are major contributing factors because “not only are patients objectively crowded, but they also may strongly experience subjective crowding in such high density situations” (p. 434). With density, patients lose privacy and also control over their immediate environment. his situation can be reversed by incorporating architectural principles that enhance the therapeutic environment, and Kumar and Ng cite Gulak (1991) in suggesting “dedicating space for social interaction; clearly indicating a room’s intended use; making areas visually distinct so intended use of diferent parts can be delineated from their appearance; using

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colors to enhance activities and spaces; using various materials to provide diferent tactile and visual experiences; using lighting to help deine space; and inally, making the spaces that have special meaning to patients stand out” (p. 434).

LITERATURE REVIEW

Not only are patients objectively crowded, but they also may strongly experience subjective crowding in such high density situations.

None of the above elements (or the lack thereof) provide the sole explanation for the violence associated with crowding; possible reasons can only come from combinations and examination of speciic sites. Kumar and Ng refer to Nijman and Rector’s 1999 study that found providing additional space on an acute-care psychiatric ward lessened episodes of aggression.

Johnstone (2004) notes that people in ward environments occupy 70% less space than did their counterparts of 150 year ago. Johnstone drew his indings from the National Patients Safety Agency’s (NPSA) country pilot audit that revealed that “out of 1,367 [statutory] mental health notiications, 89% relate to unsafe ward environments, [and within that 89%] 438 reports relate to violence and aggression, 300 reports relate to self-harm, 107 reports relate to absconding, and 39 reports relate speciically to the environment” (p. 30). Johnstone does not provide the additional report details but emphasizes that the goals to be achieved to ensure it for purpose are safety, privacy, dignity, and adequate areas for therapeutic treatment, and warns that even if a building is “big enough, clean and beautiful to look at” (p. 1), that cannot be seen as an end unto itself. It must be adequate in terms of both therapeutical potential and freedom of movement. Brickell and McLean (2011) focused on patient security in terms of quality of care, stigma and health outcomes. hey built upon existing research by soliciting the help of Canadian, Australian, and American mental health care professionals working in the ield of patient health and/or patient safety, which led to interviews with 72 participants. hese interviews revealed a diversity of perspectives on patient safety and mental health but an absence of a clear deinition, leading to the confusion over whose safety is covered by the term. One interviewee observed that “when you look at patient safety issues … [it’s] about keeping staf safe from patients, and it’s not about how do we keep the patient safe” (p. 41). hirty-two percent of those interviewed felt it necessary to balance patient safety with their rights and autonomy. Interviewees also cited such adverse events as slip-and-fall accidents, concerns about medication and substance abuse, the potential for self-harm or sexual assault, the issue of smoking and threat of ire, the risk of leaving the facility without authorization, and harm resulting from restraints as signiicant concerns. Security concerns were also implicated in terms of issues around measures taken to protect clients from self-harm. For example, Langan and McDonald (2008) addressed patient dignity via the clothes they are permitted to wear in the units. In an acute psychiatric inpatient setting in the Republic of Ireland, Langan and McDonald used a triangulation research design to investigate the prevalence of attitudes towards the practice of “dressing inpatients in night attire during daytime despite the lack of evidence to support its beneit in reducing absconding or self-harm.” Case note reviews from their study revealed a high prevalence of



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this practice (57%) and its signiicant association with involuntary admission. heir results also showed that “nursing staf believed that using night attire was efective at reducing absconding and self-harm, and that only voluntary patients should retain the right to choose their clothes. Most patients interviewed were uncomfortable in night clothes and indicated that they should be entitled to choose what to wear.” In fact, the researchers observed that, while it may run counter to the advice of some psychiatrists, it should be noted that “patients may perceive this as undermining their autonomy” and a diferent approach may be “more acceptable to patients and more respectful of their dignity” (p. 223). Jayaram and Herzog (2008) conducted a study under the auspices of the Committee on Patient Safety for the American Psychiatric Association in which they reviewed “SAFE MD”: •

S—suicide

•

A— aggressive behavior and promotion of the safe use of seclusion and restraints

•

F—falls

•

E—elopement

•

M—complications when dealing with medical co-morbidities

•

D—drug/medication errors

In addition, this study focuses on safe practice, prevention strategies, and assessment. he results deal with frequency of SAFE MD events applicable to psychiatric care. In an analysis of 3,548 events in 2005, the authors noted events that included suicide (13.1%), medication errors (10.1%), patient falls (5.3%), death or injury due to the use of restraints (3.9%), and elopement (1.9%). Commonalities among all publications that relate to safety and security include the acknowledgment of increased crowding and loss of privacy as a risk factor; “violence against patients and staf in psychiatric wards is both prevalent and increasing” (Kumar & Ng, 2001, p. 433); general recommendations are that standardized, single variable-acuity rooms mean that patients do not have to be moved when their condition changes, enhancing a sense of normalcy and controlling the spread of infection (where applicable). In addition, visually distinct spaces ensure that the function of the space is clear.

Light he second distinct theme that emerged as a signiicant design feature afecting mental health outcomes was that of light and lighting. Although we give light and lighting a separate focus in this review article, it is also the one theme that is common to all others. A major subtheme is that of natural light, which is linked to the following issues in the literature: eating disorders, depression, circadian rhythm, Alzheimer’s disease, sensory stimulation, therapeutic design, and therapeutic patient rooms.

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Joseph’s 2006 review of the available literature focused on the impact of light on outcomes in healthcare settings (without a speciic focus on mental health facilities) and divided the indings into several categories. he irst category was the way in which lighting enables accurate performance of visual tasks, logically, by reducing error. he second was how light afects mood and perception. In that case, it was noted that positive impacts included daylight and proximity to windows; alternately, the negative impact of “glare and thermal discomfort on mood and task performance” were evident. he third category in Joseph’s review focused on the control of the circadian system, which included a number of beneits (e.g., substantial increases in the quality of sleep and enhanced rest–activity patterns in patients with dementia). Joseph also mentioned eleven studies that suggested connections between exposure to bright light and depression; symptoms of seasonal afective disorder (SAD) and the depressive phase of bipolar disorder were diminished through exposures “between 2,500 and 10,000 lux,” with the greatest beneits found in the morning rather than the evening. Further, Joseph cited Beauchim and Hays (1996) as well as Benedetti et al. (2001) as documenting a connection between exposure to light and the length of depressed patients’ stays in the hospital. Joseph referenced the work of Watch et al. (2005) as to bright versus shaded sides of the hospital in stating that “patients staying on the bright side of a hospital unit were exposed to 46% higher-intensity sunlight on average; it was found that patients exposed to an increased intensity of sunlight experienced less perceived stress, marginally less pain, and had 21% less pain medication costs” (p. 6). he recommendations for adjusting light and lighting to facilitate good health outcomes from Joseph’s review pointed to the following: provide windows for natural light in patient rooms, with provisions for control of glare and temperature; orient patient rooms to maximize early morning sun exposure; provide high lighting for complex visual tasks—reduce errors; provide windows in staf break rooms (p. 9). In a paper on healing spaces, Schweitzer, Gilpin, and Frampton (2004) noted the diferent efects of natural versus artiicial lighting on patients, speciically in the areas of illuminance, uniformity, difusion, color, and UV radiation. hese, in turn, afect human chronobiology, contributing to, for example, seasonal afective disorder (SAD), sleep disorders, and work disruptions. In addition, the natural circadian rhythm of light regulates melatonin production, inluencing biochemical and hormonal body rhythms. On this topic, Basinger’s (2011) thesis says that the body’s circadian rhythms are governed by eating and regulation to natural light cycles; therefore, because eating disorder patients cannot use food to regulate the body, natural light is a key design consideration. Brawley’s 2001 article in Aging & Mental Health asserted that light requirements for older people may be ive times higher than that of young people. Older adults take between 5 and 30 minutes to adapt to change when entering space with considerably lower light level, such as entering from outside. Brawley focused on the links between Alzheimer’s, therapeutic design, and sensory stimulants, saying that lighting is important for more than just vision, afecting endocrine systems and producing Vitamin D, as well as other beneits already mentioned. he positive associations of daylight and routine activities outdoors with sensory stimulation



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and interaction with nature was seen to have a beneicial efect on patients suffering from Alzheimer’s; however, the problem of controlling indoor glare and licker were also acknowledged. In a study conducted in a psychiatric hospital in Edmonton, Canada, over a 2-year period in the late 1990s, Beauchemin and Hays (1996) observed that patients in brightly lit rooms stayed on average 16.9 days versus19.5 days for those in dimly lit rooms, a diference of nearly 3 days (2.6 days diference). Commonalities for all publications related to light include the importance of controlling the circadian system. Natural circadian rhythms regulate melatonin production, which inluences biochemical and hormonal body rhythms, which have the following efects upon mental health: reduced depression, decreased length of stay, improved sleep and circadian rhythm, lessened agitation, eased pain, and easier adaptation to night-shift work. he interdisciplinary aspect of light makes it a challenging theme for focused research; for example, Joseph’s 2006 literature review crossed the disciplines of architecture, medicine, psychology, ergonomics, and lighting design.

Therapeutic Milieu he therapeutic milieu incorporates a range of thematic features that overlap with other key issues but which we combine into a single theme that encompasses the social and psychological aspects of environmental design. herapeutic milieu is a term that is also interchangeable with patient-centered design and healing environments. Consequently, the subthemes included here are both numerous and varied; they include rehabilitation, best practice considerations, ambient features, social features, nursing stations, staf perceptions, program evaluation, the Planetree approach, positive design, multidisciplinary input, architectural change, and psychiatric intensive care units. Novotna, Urbanoski, and Rush (2011) focused on staf perceptions and program evaluation in client-centered design of residential addiction and mental health care facilities. hey discussed the indings of a 3-year series of focus groups, conducted both pre- and post-occupancy between 2007 and 2009, using mixedmethod evaluation of clinical programs in a large mental health and substance abuse facility in Canada. he main priorities of their research were (a) the impact of the physical design on clients and service delivery; and (b) the impact of physical design on the working environment. Positive outcomes and perceptions from the focus groups made repeated reference to comfort, abundance of natural light, freedom, reduced stigma with new spatial designs that mimicked a “normal” community setting and an enhanced sense of well-being; however, these were partially balanced with negative outcomes and perceptions around limited staf space and the ability to share conidential information, and staf concerns due to reduced sightlines to clients as a result of the changes meant to facilitate greater movement among staf and clients. Golembiewski (2010) looked at the signiicance of architectural design in psychiatric care facilities and analyzed the architectural elements that may inluence mental health. He explored Antonovksy’s salutogenic theory “that better health

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results from a state of mind which has a fortiied sense of coherence” (p. 100) from an architectural perspective. From a psychiatric point of view, the salutogenic perspective is that the relationship between a patient and environment is understood as being transactional and not ixed. Generally salutogenic now indicates a focus upon holistic human wellbeing rather than disease cause and efect. In this way, Golembiewski notes the environment should ensure that perceptual cues are present to assist perceptual processes; clear textures, objects and lines should prevent the possibility of perceptual distortion and ambiguity. Object comprehension is manufactured through ilters of memory, culture and epistemology; therefore, the environment should be familiar to psychotic patients as this helps stabilize both comprehension and delusions. Such an environment should mimic a safe and cozy home where noise is kept to a minimum; echoes, as well as repetitive sounds, should be eliminated as much as possible as this exacerbates delusional “voices.” In terms of control and meaningfulness, the salutogenic approach should encourage day to day “outside” domestic tasks (cooking, washing) and limit the number of [B]etter health results from a people in shared spaces. he outside world should not be sepastate of mind which has a rated from the patient. For that reason, access to nature, pets, and supported communication with family and friends is fortiied sense of coherence. essential to rehabilitation. To this end, environmental stimulation should provide sensory gratiication. Stichler’s (2008) article, “Healing by Design,” reviews the Planetree approach to architectural design. his is not dissimilar to Golembiewski’s (2010) interpretation of the salutogenic model; however, Stichler’s work does not focus on mental health as such. She states that architectural aspects of healing environments include those elements that create an optimally restful patient environment. hese components include views to the outside or, if that is not possible, at least images of nature; adequately sized bathrooms; extra seating provided as an alternative to the bed; reduced noise levels; a variety of lighting options; comfortable room temperatures; and close attention paid to aesthetics. And for “staf, designs should address: the work low process of caregiving to minimize the steps necessary to secure supplies and equipment; safety features that reduce employee injuries resulting from repetitive movement, patient lifting, mobilization, and transfers; visual access of patients from nursing stations or documentation alcoves; security designs to enhance protection of staf from hostile visitors; and staf stress reduction with the design of respite rooms (quiet, meditative environments)” (Stichler 2008, p. 507). hese features incorporate some of the nine Planetree elements of patient-centered care, which are: 1. Human interaction 2. Consumer and patient education 3. Healing partnerships with the patients’ family and friends 4. Nurturing through food and nutrition 5. Spirituality 6. Human touch 7. Healing arts and visual therapy



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8. Integration of complementary therapies 9. Healing environments created in the architecture and design of the healthcare setting (p. 504) he Planetree elements and the salutogenic model are commensurate with the aims of he Center for Healthcare Design’s Pebble Project (http://www.healthdesign.org/pebble) as well as models for “new residentialism” and “critical regionalism,” as explained in Verderber and Fine (2000). All of these approaches strive to move away from both the bureaucratization locked into some of the architectural language of modernism (Verderber & Fine, 2000) and to depart completely from conservatism of the institution. Karlin and Zeiss (2006) reviewed environmental and therapeutic issues in psychiatric hospital design over the 50 years prior to their article and noted several considerations for best practice, including patient-centered design; ambient features; architectural features (physical plan, layout, size and shape of units); social features; and nursing station design and placement. hese authors recommended the enhanced privacy associated with single rooms and private visiting areas that facilitate intimacy but noted that unit design should also encourage family participation and group activities. hey mentioned that gardens and views of nature serve as positive distractions. In terms of interior design, furnishings should be such that they have minimal institutional connotations, and they observed that while the studies of the optimum choices for wall color show inconsistent results, blue tones can be calming and bland color schemes and trendy palettes should be avoided. hey also suggested that it is important to incorporate spatial lexibility into design and that social features are also applicable to staf, who require lounges and/or a garden to promote their own communication and job satisfaction. he theme of the therapeutic milieu in healthcare design, particularly mental health care design, is even more dependent upon multidisciplinary expertise than other themes. his is not a recent realization, and papers from the late 1990s include research indings regarding multidisciplinary input to design, architectural change and positive outcomes that have remained relevant. For example, Gross, Sasson, Zarhy, and Zohar (1998) review empirical studies and, in particular, one case study of a psychiatric hospital in Israel where design and execution was conducted by a multidisciplinary team of architects, psychiatrists, and other mental health professionals and administrators. he major design goal was for the “humane, eicient containment and reduction of severe psychopathology. Here it was the role of psychiatrists and other mental health workers to redirect the focus of ward design to the patients and their families” (p. 108). As a result, design elements included no overcrowding so that patients were not forced to interact with too many people; provision of a variety of spaces that supported social interaction; an abundance of “classical” daylight and fresh air; openness of design to encourage staf to leave the nursing station and spend more time in the day room; meticulous care of buildings and grounds to reduce vandalism; easy observation of patients; and segregation of staf work and rest areas. Dix and Williams (1996) made recommendations for the design of psychiatric intensive care units, suggesting that the sites/wards should be on the ground

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loor with access to enclosed gardens with standard fencing or hedges; that they should have a separate entrance, and corridors should be wide enough to accommodate four abreast; there should be a good-sized quiet recreation room away from the day room and that numerous corners and corridors should be avoided. hey recommended disturbance buttons, louver-type observation panels in bedroom doors that are operable from outside, and vandal-proof light ittings, but also advocated ixtures and ittings that provide a homely environment. Mazuch and Stephen (2005) explained how the London-based architectural irm, Nightingale Associates, combined psychotherapeutic methods with traditional architectural methods to create healing healthcare environments. he authors dubbed this “humanistic architecture,” which “draws on international research in the ields of psychology and sociology, biology and physiology into the efects of the environment on health” (p. 48). hese architects used emotional mapping based, in general, on all the senses but also on colors associated with the predominant emotional response aroused in particular areas. For example, they noted that blues have been indicated to subdue aggressive individuals and “visual monotony can contribute to physiological and emotional stress” (p. 50). In terms of touch, Mazuch and Stephen noted the important role this can have in the recovery of patients, as surfaces help to “re-engage with the materiality of the world” (p. 50). hey emphasized that perceptual confusion should be avoided (e.g., a wood-grain inish on a metal door would give inaccurate sensory information because a metal door will be heavier and colder than would be expected with a real wooden door). As to sound, excessive noise has implications for increased heart rate, blood pressure, respiration, and blood cholesterol; they stressed that hard materials absorb less noise. he architects noted that smell can relax muscles and aid concentration; pleasant smells help produce endorphins and can decrease heart rate. Further, they noted the hypothesis that pleasant smells can reduce the amount of anesthetic administered during surgery (p. 50). In the areas of light and nature, Mazuch and Stephen observed that a lack of windows and connection to the outside world can heighten stress and depression. To reiterate, the commonalities across the literature on providing a therapeutic milieu through the design of facilities for mental health care focus on the elements of light; adequate personal, communal, and work space; home-like comfort; and access to gardens.

Gardens he theme of gardens includes open spaces within the precincts of the hospital. Subthemes include therapeutic gardens, Alzheimer’s facility, historical perspective, moral therapy, landscapes, therapeutic relationships, natural environments, directed attention, attention restoration theory, restorative experience, stress, nurses, evidenced-based design, and environments for renewal/stress relief. he theme of gardens is not conined to mental health care design per se because the healing garden is emerging as a topic for mental health in the context of general healthcare as well. It is therefore a holistic theme that, due to its very nature, is highly relevant to mental health care.



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Hartig and Marcus (2006) recognize that the concept of healing is not synonymous with cure; clearly, gardens are not curative and misconceptions concerning this notion should be avoided. However, they note that “healing gardens … are allied with a broad conception of health, one that recognizes that a person can move between greater and lesser degrees of health along diverse physical, mental and social continua” (p. S36). hey ofer several recommendations as to the structure of such healing gardens—there should be an absence of harsh noises and unwanted demands, landscape architects with knowledge of healing plants should be employed to translate medical approaches. Unfortunately, as the authors note, “sadly, many opportunities to make gardens available have been wasted” (p. S37). his is something that Connellan et al. (2011b) also found in their ethnographic observations of a purpose built mental health unit in Australia. he upkeep and expense of gardens are mentioned as deterrents for their wider use. In the subthemes of nurses, evidence-based design, and environments for renewal/stress relief, Naderi and Shin’s (2008) study ofers useful information concerning the beneits of outside spaces in a medical environment. hey conducted a two-part nursing staf survey in the United States based on a landscape design project at a healthcare center in Texas. he results of Naderi and Shin’s survey showed that the availability of an outside space was important to those nurses surveyed; 88% said it was important to get outside during their workday and nearly all of the participants felt it was important for their co-workers to get outside. Favorite activities included sitting (25%), walking (21%), and eating (10%). Nine percent expressed the need to be close to nature and get some sunshine and fresh air, while others went out to be social, with 18% going outside to talk to friends and 3% to engage in people watching. However, the survey found that 52% of nurses went outside to be alone and if nurses did go out in a group, it was with one (26%) or two (20%) other people. he need for some improvements in existing outdoor spaces was noted: 54% didn’t use the courtyard when it rained; 44% didn’t use it when it was too hot or sunny; 23% didn’t use it due to lack of seating; 16% because the entrance was sometimes blocked; and 11% because they felt privacy was compromised. As a result of the survey, two courtyard garden designs were proposed and, incorporating nurses’ responses to the proposals, landscape architects designed a courtyard garden primarily for their use.

“[S]adly, many opportunities to make gardens available have been wasted.”

In terms of the speciic needs of psychiatric patients, the writings of Clare Hickman (2005, 2009) provide a particular perspective based on moral therapy and historic associations with landscapes and gardens. In the 2009 article, Hickman draws upon English Romantic poetry, landscape painting, and the PreRaphaelite art movement in the 19th century to develop her arguments on the important relationship between mental health and nature. She refers to poets’ and artists’ beliefs in the “morality” of the landscape and the potential of natural environments for the prevention of what was considered to be “immoral” behavior. Hickman discusses in detail themes such as the Garden of Eden and being in nature as providing a closeness to God, a rural work ethic, and the romantic notion of man in and of the landscape. She refers to Louis James’s “Lines Com-

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posed a Few Miles above Tintern Abbey” regarding civilization and industrialization bringing about insanity because of the exodus from the rural idyll. Her 2005 article refers speciically to the large old parks and gardens of the 18th and 19th century asylums. he moral therapy that was part of those asylums’ treatment protocol was focused on the placement of a patient in a carefully designed environment and seeking to minimize physical restraints. It was believed that viewing the landscape had positive efects on the patients and therefore buildings were designed so the landscape could be viewed from inside the building as well. Design features included verandas, conservatories, airing courts, ornate aviaries, pagodas, and even a Chinese gallery; however the cost of creating complex landscapes restricted such designs to institutions accommodating a wealthy clientele. he presence of the gardens can be one of the most positive aspects of psychiatric treatment. Curtis, Gesler, Priebe, and Hickman (2009) noted that in the postasylum age of mental health care, long-term patients were known to return to the asylums in which they were housed in order to walk in the gardens because of an attachment to and their positive associations with the therapeutic beneits of such places (citing Parr, Philo, & Burns, 2003). In one article that emerged from the initial scoping study, “the restorative beneits of nature” are discussed in terms of developing an integrated framework that concentrates on directed attention, attention restoration theory, and restorative experiences for health outcomes (Kaplan, 1995). Kaplan included three components that are necessary for the restorative experience: “being away,” which implies not merely entering a new setting, but instead a change that “involves a conceptual rather than a physical transformation” (p. 173); an environment that is rich but that maintains coherence; and compatibility between the environment and one’s own goals. In reference to attention restoration theory and the natural environment, and drawing upon further empirical evidence to support nature as a restorative element, Kaplan noted that being in nature requires less efort than being in a “civilized” environment; that intervention measures suggest that the use of nature as a restorative method have longer term beneits and participants were more likely to, for example, start new initiatives after the intervention. he area of mental health aged care and gardens has a growing body of evidenced-based research but Heath’s (2004) research is particularly useful for the design of Alzheimer’s facilities. Heath looked at post-occupancy studies that had been done to evaluate the therapeutic qualities of gardens and gardening in an Alzheimer’s facility. It is a multilevel care facility in British Columbia, Canada, which opened in 1995 and has eight courtyard gardens. he interview data revealed that 75% of visitors reported feeling more relaxed and calmer and 25% felt refreshed. he gardens were designed with ive major goals: 1. To provide a safe outdoor environment; 2. To provide a place for relection; 3. To provide a place for relaxation; 4. To provide a place for socialization; and



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5. To provide a place for people to maintain the hobby of gardening (2004, p. 239). he results of the post-occupancy evaluation showed that of the respondents, 83% visited the gardens and 96.5% of those liked them. Additional information from this study included that 80% of respondents said the aims of the gardens were met, except for providing a place for people to maintain a gardening hobby, as the gardens were already fully planted with no free space; and more family members used the gardens than did patients or staf, with suggested reasons being that some patients are not independently mobile, staf lacked the time to do so, or family members found the gardens a relaxing way to relieve the stress of ailing family members. here were also recommendations for improvements, such as the use of signs, maps, and automatic doors to increase access and awareness; further education of both staf and volunteers; the need for lawns where families could gather rather than areas dominated by paths and garden beds; leaving space for residents to create their own gardens; a lack of spontaneity in the plantings; and a lack of lexible, multi-use spaces. Common points of discussion across the literature include the use of the various uses of gardens, access issues, retreats for staf, and speciically designed gardens.

The Impact of Architecture on Health Outcomes he ifth theme is another general category and although it would be ideal to have each theme discreet and separate, as was the case with “therapeutic milieu,” there were too many articles that centered on one issue and merely mentioned others. herefore, while this theme does overlap with others, its focus is largely on the impact of architecture on health outcomes. Among other issues, this category of publications addresses aesthetics and sensory stimulation as well as spatial design. he subthemes include mental health services, psychiatric care, salutogenic theory, sense sensitivities, emotional mapping, physiological responses, psychological responses, design models, evidenced-based healthcare design, and healthcare quality outcomes. By far, the most extensive and inluential research on the impact of architecture upon health outcomes is that of Ulrich and his colleagues, speciically, their 2008 comprehensive review of the research literature on evidence-based (general) healthcare design published in this journal, Health Environments Research & Design Journal (HERD). his review by Ulrich et al. expanded on a previous (2004) review, especially in relation to the scale of hospital-acquired infections. he keywords in Ulrich’s 2008 review were “evidence-based design, hospital design, healthcare design, healthcare quality, outcomes, patient safety, staf safety, infection, hand washing, medical errors, falls, pain, sleep, stress, depression, conidentiality, social support, satisfaction, single rooms, noise, nature, and day light.” he three main areas of focus were patient safety, other patient outcomes, and staf outcomes. Although this review was on general health, we regarded it as a strong foundation for the work that needs to be done in the area of mental health care. Ulrich et al. tabulated their indings (p. 148), showing where empirical studies have revealed relationships between particular design factors

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and healthcare outcomes. Ulrich’s table also indicates where “is especially strong evidence (converging indings from multiple rigorous studies) indicating that a design intervention improves a healthcare outcome” (p. 148). Single bed rooms, natural and appropriate lighting, and nature views are the three most signiicant design factors that contribute to positive health outcomes. For example Ulrich et al. showed that patient privacy and conidentiality as well as communication improves with single bed rooms; day and appropriate lighting contributed positively to 14 of the 16 health outcomes listed; and nature views contributes signiicantly to reduced pain and stress and also to ive other health outcomes (p. 148). Ulrich et al. (2008) used a two-step approach to their review, and one upon which, to some extent, we modeled our own review. For the Ulrich study, the irst step was a 32-keyword search across the literature and then a crossreferenced search using Ebsco Host, which enabled the search of multiple databases. his was supplemented with searches through ISI Web of Knowledge and Google Scholar to obtain additional sources from reference lists. heir second step or stage involved screening all identiied references using two criteria: that the study “should be empirically based and examine the inluence of environmental characteristics on patient, family, or staf outcomes;” and, “that the quality of each study was evaluated in terms of its research design and methods and whether the journal was peer-reviewed” (p. 102). heir report was organized according to three types of outcomes: 1. Patient safety issues, such as infections, medical errors, and falls. 2. Other patient outcomes, such as pain, sleep, stress, depression, length of stay, spatial orientation, privacy, communication, social support, and overall patient satisfaction. 3. Scientiic research relevant to staf outcomes, such as injuries, stress, work efectiveness, and satisfaction (p. 103). he authors noted the increasing number of rigorous studies across design and healthcare but also observed that, despite this, “it is also important to address the limitations of the quality of existing evidence [because] in medical ields, a randomized controlled trial or experiment is considered the strongest research design for generating sound and credible empirical evidence [but Ulrich et al.’s review] found relatively few randomized controlled trials linking speciic design features or interventions directly to impacts on healthcare outcomes” (p. 103). Dennard’s (1997) review of David Halpern’s book, More Than Bricks and Mortar? Mental Health and the Built Environment, although written some time ago, highlights the publication of a book that is rare in this cross disciplinary ield. Dennard reviewed Halpern’s approach of cause-and-efect associations of the built environment according to the following four categories: as a source of stress; as an inluence over social networks and support; through symbolic efects and social labeling; and through the action of the (building) planning process itself. Creative conlict often arises in inding a balance between what is best for the patients, how the community perceives the design, and health and building regulations and policies. he perfect patient facility may not be feasible due to conlicts between the these factors.



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Golembiewski’s previously mentioned (2010) theoretical study on salutogenics in architectural design for psychiatric care used Antonovsky’s Salutogenic perspective, and speciically that the patient and environment are understood as being transactional, to inform his analyses. Golembiewski acknowledged that salutogenics do not replace evidence-based studies but said that in the absence of evidence-based design for mental health facilities, applying salutogenics “in a methodological way” can provide a useful framework for informing architects regarding the functionality of facilities and improving mental health outcomes (p. 100). Acknowledging that unwell people do not necessarily adapt easily, Golembiewski suggested that “the salutogenic model seems an appropriate broad framework in which to locate the stress model because it supports the stress model with much needed substance; efectively illing the causation gap between action and efect” (p. 103). herefore, although patients might not always adjust well to innovations, if the environment can be designed to change for and with the patient’s sensory and perceptual abilities, positive outcomes could result. Golembiewski drew upon Hall (1975) in that “perception is a complex neuro-chemical process that is highly reactive to the surrounding environment and yet it is the only channel for receiving new information of any sort” (p. 103). With this in mind, the author explained the comprehensibility of the salutogenic model as providing perceptual cues to assist the perceptual processes and providing an environment that is ubiquitous and desirable and is understood through the familiar and which can help stabilize comprehension and delusions. In terms of manageability of the model, it is important to allow patients to control their environment though meaningfulness. his goal can be attained by “enriching the environment with complexity, order and aesthetic considerations” (p. 114); allowing pets and personal items on the premises; and providing a stimulating milieu.

It is important to allow patients to control their environment through meaningfulness.

In their assessment of the role of environment on behaviors, actions, and interactions, Schweitzer, Gilpin, and Frampton (2004) focused on physiological and psychological responses. he authors hypothesized “a hierarchy of efect of environmental elements ranging from simply nontoxic to safe (both physically and psychologically) to ‘providing a positive context’ to being actively salutogenic” (p. S71). his article, published in The Journal of Alternative Medicine, advocated design to facilitate intention and awareness; wholeness and energy; healing relationships; health promotion; and collaborative treatments. Schweitzer et al. presented the existing research in terms of physical parameters, and as including the following preferences in a healthcare setting: smells, noise, temperature, environmental complexity, fresh air and ventilation, color, nature, art/aesthetics and entertainment, and nursing stations. In terms of personal space, there is a preference for single rooms; patient satisfaction is related to perceived pleasantness of décor, cleanliness, courtesy of housekeepers, temperature and noise, and (citing Kaldenberg, 1999) “how well things work” (p. S73). As with Mazuch and Stephen (2005), Schweitzer et al. noted that existing literature reveals the importance of the sensory environment in terms of smells, saying that pleasing aromas may reduce blood pressure, slow respiration, and lower pain perception levels, while unpleasant odors stimulate anxiety,

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fear, and stress. here was also some evidence that (a) excessive noise increases patients’ length of stay as well as causing interruption of sleep and increased stress; (b) environments with greater complexity correlate with greater cognitive functioning and beneicial physical activity in the elderly; and (c) sensory variation in ambient conditions between spaces and over time is preferred by building occupants. he authors’ comments on light are covered in the “Light” section of this article, above. he viewing of nature was dealt with separately from the experiencing of nature. Regarding the former, Schweitzer et al. noted Ulrich’s (2008) points concerning the lack of a window, which may have a negative efect by reducing positive stimulation and aggravating the negative efects of sensory deprivation; access to views of nature with gardens, through windows and in artwork, can reduce stress; and patients residing in units without windows developed more symptoms of depression. In terms of actually experiencing nature, the literature reported evidence of “lowered stress and muscle tension” (Schwetizer et al. 2004, p. S76) and fewer incidences of violence. Indoor plants were also shown to be beneicial. As to the last theme, Schweitzer et al.’s literature review included a section related to arts, aesthetics, and entertainment. Here, a preference was shown for visual art encompassing nature images, positive facial expressions, and depiction of caring relationships, whereas ambiguous or abstract imagery was shown to have negative outcomes. Schweitzer et al. also pointed to research that demonstrates the positive efect of music on health and also positive distractions such as humor and entertainment, which may lead to greater optimism, socialization, cooperation, and decreased dependence on medication. hese authors also covered nursing stations (see “Nursing Stations,” below). Commonalities in the literature on the impact of architecture on mental health outcomes include: •

Perceptual cues assist the perceptual processes, help avoid confusion.

•

Enriching the environment with complexity, order, and aesthetic considerations is beneicial.

•

Access to nature can have positive mental health outcomes and add complexity and stimulation.

•

here is a general preference for single rooms.

•

Smells: pleasing aromas may reduce blood pressure, slow respiration, and lower pain perception levels; unpleasant odors stimulate anxiety, fear, and stress.

•

Access to views of nature with gardens, through windows and in artwork, can reduce stress.

Interior Design his theme relates speciically to interiors; subthemes of varying importance include interior design and furnishings, interior design and color, wayinding, cognitive mapping, spatial organization, and type of patient room (multi-occu-



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pancy, semi-private, and private). Lorenz’s (2007) integrative research review, “he Potential of the Patient Room to Promote Healing and Well-Being in Patients and Nurses,” addressed the issue of multi- and single-occupancy patient bedrooms in general healthcare. Within this study, Lorenz synthesized empirical and chiely quantitative studies on patients’ rooms in the acute care hospital in terms of “promotion, maintenance or restoration of healing and well-being for patients” (p. 263). Lorenz also focused on patient outcomes and the ability of nurses to provide optimal care. Studies deemed relevant fell into three general categories related to the patient room type: 1. Clinical outcomes 2. Patient perceptions 3. Staf perceptions Outcomes were generally measured in length of stay, utilization of narcotics, and physiological and behavioral responses. Lorenz concluded that the gaps in the literature related to room type and impact on patient falls and medication errors; and how room type relates to speciic patient populations and impacts on their clinical outcomes. She also noted that further study is required to expand the study of room type to include the design of the patient care unit. Vaaler, Morken, and Linaker (2005) conducted a carefully controlled study in the acute care Østmarka Norwegian psychiatric hospital between 2000 and 2001. Vaaler et al. wrote that in the 140,000 catchment area of the city of Trondheim, “600 patients above 18 years sufering from acute psychiatric conditions are admitted each year” (p. 20). he researchers conducted the study in a unit that had been refurbished 4 years prior; the traditional interior design consisted of grey colors, no window curtains, a single lamp in 4-meter-high ceilings and tubular metal beds and chairs. In close collaboration with architects, one of the wings was redecorated and refurnished to make it look like a standard Norwegian home, with the goal of allowing a comparison between the symptoms, behaviors, treatment, and relative satisfaction of the patients staying in the traditional area as opposed to those housed in the redecorated wing. his involved “colorful wallpaper and paintings on the walls, lowering the ceilings and installing multiple lighting spots, tastefully curtaining the windows, putting wardrobes, chairs, lowers and personal items in the patient rooms and Italian ceramic tile covered the entire bathroom” (p. 21), while the other wing was left unchanged. he indings included “no negative efects of changing to a more pleasant and home-like environment” (p. 22); non-signiicant tendency toward symptom amelioration in the traditional wing; creating a pleasant environment does not generally increase length of patient stay; and there was a “complete lack of vandalism” (p. 23) on the new side. he authors concluded that “interior and furnishing like an ordinary home … created an environment with comparable treatment outcomes to the traditional dismal interior, and had positive efects on many patients’ well-being, at least among the women” (p. 19). And although the outcomes were not markedly diferent, the researchers emphasized that they “… ind little to justify the often-dismal interiors of wards used to seclude severe-

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ly mentally ill patients. his practice should be abandoned unless there are very speciic reasons to introduce it for special cases” (p. 24). Salmi’s (2008) comments on wayinding for people with disabilities, although not focused on the hospital environment or mental disabilities speciically, threw light on universal applications for developing better wayinding in interior design. She concentrated on spatial organization—architectural features, destination zones, spatial overview opportunities and overall layout—advocating landmarks that are distinct in shape and color and with appropriate signage. For example, signage should be properly designed and well-placed. It should be perpendicular to the line of travel and at eye level for wheelchair users; the readability must be legible, incorporating large text and high contrast with the background; it should designed mindful of glare and paired with a graphic image. Color should reinforce links with the environment; directories should cluster information, be accompanied by graphics, use simple color coding, and be placed in relation to the speciic loor. Maps should be less cluttered—“You Are Here” designations are of the greatest importance. he most telling studies are possibly those that have been able to map behavior through pre- and post-renovation data. Devlin (1992) reported on such a study involving four psychiatric wards in New England in the late 1980s; changes were made to interior decorating including color schemes/painting, indoor plants, new furniture, bathroom renovations, and similar minor works. he method was primarily an environmental design survey that involved staf rating design features; these ratings were analyzed and combined with observations and behavior mapping. Devlin emphasized patient population and seasonal variation (warm weather) as a determining factor in understanding reactions and movements in a spatially altered and renovated area; however, there was suicient data to indicate a decrease in stereotypic behavior among patients and improved staf morale after elements such as wallpaper, live plants, increased light, colored walls, and upholstered furniture replaced the previous spaces that had green and gray walls and “mismatched vinyl-covered chairs” (p. 71).

Psychogeriatric Research literature on aged care is growing with the worldwide concern about a huge aged population in the coming decades, one which will put pressure on both the social and economic infrastructures. It is therefore not surprising that the impact of facility design in psychogeriatrics is an area that has seen two literature review articles within the last decade, those of Dobrohotof and Llewellyn-Jones (2010) and Day, Carreon, and Stump (2000). Subthemes that emerged from both include psychiatry, violence, design, dementia, and therapeutic design. Dobrohotof and Llewellyn-Jones focused more on psychiatry and violence in psychogeriatric units (PGUs), noting the historically deleterious efect of hospital environments on psychiatric patients, where depressing environments convey regression and loss of control and present as intimidating for patients and families. hey searched the databases of Medline (1950–2010), psycINFO (1806–2009), EMBASE (1980–2009), and CINAHL (1982–2009) for literature concerning PGU design, from which they reviewed 200 papers,



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including some government reports and non–peer-reviewed articles. hey note that “there are few good quality studies to guide the design of acute PGUs and much of the existing literature is based on opinion and anecdote or, at best, based on observational studies. Randomized controlled studies comparing diferent designs and assessing outcomes are virtually non-existent” (p. 1). With regard to violence, these authors show that in the literature they reviewed, 18% of dementia patients were violent during admission, speciic factors relating to prevalence of violence were not well-studied, and staf working in noisy conditions with poor lighting were more likely to be assaulted (citing Soares, Lawoko, & Nolan, 2000). As to trauma, 34% of post-discharge patients “felt frightened, unsafe, a sense of intrusion and lack of privacy, disgust and embarrassment, powerlessness, and feeling undermined at some time during their hospital stay” (p. 3). here had been no systematic research into the efect of various ward environments on patients’ experiences; the loss of self-esteem, patients’ sense of self-worth, intensiied psychiatric symptoms, and a reduction in patient’s participation in their care may be caused by “sanctuary harm” (citing Robins et al., 2005). Dohrohotof and Llewellyn Jones make the following recommendations for designing the optimal physical environment:

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•

Optimize patient and staf safety, manage patients’ physical health, design a productive ward environment.

•

Ensure access to a psychiatric intensive care unit (PICU) or high dependency unit (HDU).

•

Provide space—a garden, a quiet area, a seclusion suite, an activity and games room.

•

Include separate bedrooms with louver-type observation panels, doors that open two ways, vandal-proof dimmer light ittings, and safe ixtures and duress alarms.

•

Design an environment that is secure, structured, with minimal stimulation, non-intrusive, and supportive.

•

Create a design that facilitates patient observation as well as high nurseto-patient ratios.

•

Facilitate limited use of restraints and seclusion.

•

Make it possible for cognitively impaired patients to be segregated from those who are not cognitively impaired.

•

Create separate male and female sections.

•

Provide direct access to usable outdoor space.

•

Have clear indications for the intended use of each area or room.

•

Optimize the location of nurses’ station to enable direct line of sight to as much area as possible.

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Ensure locked doors on secure wards.

•

If possible create good external visibility and access to public transportation.



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In addition, design should incorporate deinstitutionalizing features such as: •

Separate living and treatment areas.

•

he elimination of long echoing corridors and highly reverberant spaces.

•

Residential features such as a laundry and galley kitchens.

•

Reduced psychopathology among younger patients facilitated by design solutions that encouraged social interactions: ward kitchen, an open nursing station, and a dayroom module for crafts and other occupational therapy activities.

he second, earlier literature review (Day et al. 2000) on psychogeriatrics focused speciically on therapeutic design and dementia. hese authors commented on the problem of small sample sizes in studies on design and dementia, noting that more than 30% of the studies reviewed used samples of fewer than 30 participants (p. 398), with many including fewer than 10. With respect to this factor, it should be noted that the majority of studies Day et al. looked at in their 600-paper review article were qualitative, where small sample sizes are acceptable. Despite this, they mentioned the increased rate of research on design and dementia, from 6 research reports from 1981 to 1985, to 17 research reports from 1986 to 1990, to 26 research reports from 1991 to 1995, and 21 research reports already published since 1996 (p. 398). Day et al. provided a useful table that lists all the papers reviewed with summaries for each. Sections include: 1. Concept and focus of study; 2. Research design; 3. Sample information; 4. Outcome measures of well-being; 5. Physical environment features; and 6. Major indings of environmental impacts on well-being. he authors’ method for collecting papers to review stipulated empirical indings as one of the criteria. heir indings can be summarized as the beneits of group living for patients with dementia; the disorienting problems with changes to their environment; the beneit of reduced use of psychotropic drugs and a decline in behavioral disturbance in Secure Care Unit (SCU) design that showed clearly colored wayinding, names on doors, photos of family, separate activity areas, secure exits and closets, visual tapes across glass, and appropriate sound proofing; other aspects such as the beneits of nature and natural light, recreational activities and personal as well as gendered spaces were shown to be beneicial to both staf and patients. Commonalities across both of the Dobrohotof and Llwellyn Jones (2010) articles and the research of Day et al. (2000) included security issues, gender separation, and gardens.



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Post-Occupancy Evaluations Post-occupancy evaluations (POEs) are rarely carried out, yet it is known that architectural designs for mental health care contribute to mental health outcomes; therefore, in order for these results to be positive for both the patients and the community, it seems strange that evaluations are not routinely carried out and the results disseminated. Carthey (2006), in conjunction with the University of New South Wales (UNSW) and the New South Wales (NSW) health department in Australia, conducted research into the reasons for the lack of POEs and worked toward establishing a standardized model for post-occupancy evaluations across healthcare. Carthey ofered three diferent types of evaluations, which might sometimes be confused: 1. Post-occupancy evaluations (POEs)—he process of examining and evaluating the functioning of a building in a systematic way after completion and occupation (from 12 months to 2 years) (p. 58). 2. Post-implementation review (PIR)—“he last step in the process,” which includes closure of the “feedback loop” that takes lessons from previous projects (p. 59). 3. Post-completion review (PCR)—A systematic comparison of original brief and objects with the actual outcomes (p. 62). Although Carthey does not state this speciically, “POE” is the most commonly used term encompassing all three. he complexity and variables present in healthcare design evaluations give rise to subthemes across the literature reviewed for this article: interdisciplinary research; evidenced-based design; environment and behavior; occupant’s feedback/users’ needs; psychiatric unit; serious game; service planning; and service users. Some of the publications concentrated on suitable methodologies for conducting evaluations, and all agreed that interdisciplinary research and input is essential (Marmot, 2002; Veitch, 2008; Vischer, 2009; Whitehead, Polsky, Crookshank, & Fik, 1984). However, Veitch notes that interdisciplinary research presents barriers such as diferent disciplinary cultures and professional “languages” and that parties are required to challenge institutional policies that may hinder collaboration such as the choice of journals in which to publish results, academic publication rates, the ability to write for peer reviewed journals, and promotion opportunities. Marmot (2002) noted that the relative scarcity of evaluative research on buildings may be related to cost, fear of negative outcomes, perceived uniqueness of buildings—lessons learned in one location for particular set of consumers may not be applicable elsewhere—,and determining what conclusions to draw amid many variables and inluencing factors. herefore, Marmot said that assertions of design briefs are rarely tested properly. he title of Liddell’s 2010 article in Health Estate, “Good Data Critical to a Successful Outcome,” speaks for itself. Liddell examined what to look for in developing a POE process for large hospital environments, what is actually required to

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perform a rigorous POE, and what can be expected from the process. he goals of Liddell’s project on post-occupancy strategies to arrive at the best process for critique involved documenting generic project information to enable comparison of similar sized projects; reviewing the planning and construction phases of the project; reviewing the operation of the facility and the communications strategy; and providing comment on the current NSW POE Guidelines. Liddell detailed the reasons that POEs are not pursued more efectively, observing that “the Government even has a manual on the subject … which itself notes that there are a number of reasons why post-implementation review is not pursued more efectively” (p. 26). hese include the temporary nature of teams involved; 3- to 5-year timeframes between feasibility and occupancy; the changeability of factors such as service delivery, budgets, political climate, the economy, unwillingness to criticize participants, budget shortfalls; and the inability of the asset management to engage in efective critical examination and evaluation. Liddell’s recommendations included the Evidence-based design has active involvement of key staf and stakeholders throughout evolved out of the precedent the planning process and continuing through every stage of the project, implementing document management systems set by evidence-based medicine. and initiating POEs before the project team disbands. Vischer’s (2009) review article on designing intelligently and designing intelligent buildings stated that when POE studies are conducted, the “voluminous amount of research indings lie unread on desks or are published in academic journals that practitioners seldom read” (p. 240), also that designers frequently go to new sites, measure in accordance with number of users, and therefore resort to reinventing the wheel. While Vischer did not discount the usefulness of traditional POEs that ascertain the efectiveness of a building by gathering information from users and testing hypotheses, she emphasized that “in the real world” the newer focus on evidence-based design (EBD) is a better option. She therefore compared the POE process with EBD, using healthcare design as one of her two areas of focus. Vischer cited her own 2008 research, noting that an inherent deicit of the POE approach is that this form of measurement measures “people’s preferences and perceived needs rather than the efectiveness of building design and operation decisions” (p. 242); further, she argues that the traditional POE accumulates building users’ subjective likes and dislikes, information that is not helpful to designers who need to know exactly how aspects of the building function. In contrast, “evidence based design has evolved out of the precedent set by evidence-based medicine” (p. 242). herefore, if both the methods and results of EBDs are targeted, their uptake by both designers and healthcare professionals is more purposeful and the outcomes are arguably more accurate. In an older study (but one directed speciically at a 30-bed psychiatric unit), Whitehead, Polsky, Crookshank, and Fik (1984) considered the “Objective and Subjective Evaluation of Psychiatric Ward Redesign.” hey posited four psychoenvironmental hypotheses for evaluation: 1. Environmental alteration correlates with changes in social behavior. 2. Environmental alteration correlates with altered spatial distribution of behavior.



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3. Environmental alteration correlates with reduced psychopathology. 4. Social organizers may be used to focus the alterations in therapeutic and socializing ways. hese authors assessed a unit that had been redesigned in accordance with psychoenvironmental principles as they aimed to ascertain the efectiveness of such an approach. Using behavioral mapping derived from ethological studies among psychiatric patients, the researchers mapped and recorded the movements and behavior of patients in particular parts of the wards and whether they presented pathology. he observation was detailed and noted the following behaviors in areas such as hallways, sitting rooms, etc.: head even, looking at person, oriented toward neighbor, sitting quietly, talking, or no pathology. heir conclusions were positive in terms of clinical outcomes but limited; the authors noted that length of stay was not reduced substantially by the redesign and that the results would have been more informative if patients could be returned to the older designed units and observed there. A recurring theme through the literature on post-occupancy evaluations is that of the patient/user engagement in process of design. While users have been engaged, this happens to varying extents, and there are luctuations in the degree to which their recommendations are applied. Fitzgerald, Kirk, and Bristow (2011) described and evaluated “serious game intervention to engage low secure service users with serious mental illness in the design and refurbishment of their environment” (p. 316). he advantages of a serious game (deined as a game that has a useful purpose or models real life situations) “lie in the familiarity of its format, its non-threatening facilitation of communication and the creative and fun approach to serious issues” (citing Lamey & Bristow, 2007). his self-selecting process of engagement resulted in 25 of 30 service users participating in the game. Feedback from participants was overwhelmingly positive. he use of the serious game format has potential for mental health services to successfully engage service users in collaborative dialogue such as treatment planning, illness education and recovery. “he game begins, similar to the ‘Go’ square in ‘Monopoly’ and as in real life on the ward, at the airlock square. Instead of streets, as in Monopoly there were themes that were grouped in accordance to questions and issues submitted by staf, architects, management, estates and builders” (p. 318). Simple questions such as “what would you like in a dining room” and “how would you like your medication dispensed” were some of the questions used in the game, with prizes as is the case with most board games. Fitzgerald et al. wrote that these service users had not been part of the original design decisions and management wanted to know what was working or how it could be improved; previously, the meeting and consultation style of communication to obtain feedback from users had not proved successful and the resulting information from the game was better. he authors said that the game removed barriers present in the meeting style consultation and recommended that these games be used earlier and speciically in the design conceptualization stage of projects.

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Nursing Stations In terms of physical spatial design, nursing stations (also often called “duty stations”) emerge as the single most signiicant factor in mental health facility design. Issues in nursing station design overlap with security and models of care; therefore, the subthemes include nurse-patient relationships, staf safety, space and control, and function and work environment. Andes and Shattell (2006) explored “the meanings of space and place in acute psychiatric settings, to discuss how these meanings afect human relationships, nurses’ work environment and patients’ perception of care, and to present how the design and use of nursing stations afects therapeutic relationships” (p. 699). hese authors concluded that the generally positive features of nursing stations and space control include the fact that nurse-only and patient-only spaces are beneicial to both groups and positive nurse-patient interactions “increased dramatically” after redesigns that “include more private areas for nurses” (p. 702). And in terms of negative design outcomes of nursing station design and space control, Andes and Shattell determined that, in the minds of both patients and nurses, psychiatric patients cannot and will not respect the nursing station as a work area. he physical barriers used in the design of nursing stations reinforce the idea that they are of-limits to patients and impede the development of interactions. Andes and Shattell airmed that psychiatric nurses had few meaningful interactions with patients because They found signiicant positive of interpersonal barriers (e.g., an impoverished view of personpsychological, behavioral, and al eicacy) and organizational barriers (e.g., short lengths of hospitalization and high patient acuity). hese authors stressed social effects after the removal the “hospital should be designed in such a way as not only to of glass partitions from serve as a temporary home [for psychiatric patients], but its psychiatric unit nursing stations. environment should aid recovery” (citing Shrivastava, Kumar, & Jacobson, 1999, p. 703). Brown (2009) noted that, while the objectives of the nursing station is to make staf feel safe, open areas are essential to “encourage interactions between patients and staf” but that “staf must have a private space where they can retreat and conduct administrative tasks” (p. 22). his reiterates Connellan, Due, and Riggs’ (2011b) note that, in an ethnographic observational study of a recently completed purpose built mental health unit, the design of the nursing station combined intense administrative activity with patient interaction with the result inadequate patient-staf communication. Brown identiied that the optimal design of the nursing station needed to incorporate appropriate seating, stimulants, acoustics, and size to suit the intended function of the space and to place therapy spaces close to nurse stations. A sense of boundary to the patient is necessary but there still needs to be high visibility. Karlin and Zeiss (2006) noted that open nursing stations have been recommended by several sources; they refer to Edwards and Hutts (1970) indings of “signiicant positive psychological, behavioral, and social efects after the removal of glass partitions from psychiatric unit nursing stations. Patient requests of nurses at nursing stations were dramatically reduced, as were the negative beliefs of those patients, and improvements in ward milieu and patient-staf communica-



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tion were also noted” (p. 1378). Karlin and Zeiss wrote that “available reports of experiences with open nursing stations do not support concerns of patient abuse of increased access to nurses, although additional empirical research on this issue is needed. Contiguous, secure, closed to patients, is recommended to maintain conidentiality of patient records” (p. 1378). hese authors observed that, prior to the dawn of efective psychoactive medications, closed nursing stations were the norm, but they fostered a perception that the staf members were inaccessible and welcomed neither patients nor visitors to their environs. Schweitzer, Gilpin, and Frampton (2004) reported that large centralized nursing stations separated from patients by half-walls or glass partitions that are located some distance from the rooms of the patients “clearly distance staf members from patients, sending the message that they are busy and inaccessible” (p. S78). hese authors stated that “a decentralized nursing work station that is small, open and located outside clusters of 4–6 patient rooms, with the main nursing station completely open to patients, suggest[s] that healing is a collaborative process and not something exclusively under the purview of ‘professionals’” (p. S78). he above research, published in the last 6 years, difers from some of the earlier studies, which did not use ethnographic observational studies or include the views of the patients and their families. For example, a study that came out of our original scoping of the literature asserted that the positioning of the nursing station should allow observation of all patients, use one-way mirrors, and surround the nursing station with Plexiglas. In that study, a survey of nurses’ attitudes proposed strengthening of windows for the station and improved sound-prooing of quiet rooms (Dix & Williams, 1996). he commonalities for all publications which relate to nursing stations include the need for discreet and separate spaces for nurses and other staf to relax and also for spaces away from patients where they can attend to administrative tasks. In addition, open areas are necessary to encourage interactions between patients and staf because closed nursing stations often convey an image of staf inaccessibility and are not welcoming to patients and visitors.

Model of Care he literature shows that the numerous types of models of care are one of the chief reasons for the complexity in designing for mental health care (Cleary, Hunt, O’Connor, & Snars, 2010; Costello, 2007; Killpsy, Ritchie, Grerr, & Robinson, 2004). Subthemes emerging from the literature include phase of illness model of care, therapeutic space, inpatient care, bio-psycho-social approach, built environment, length of stay, homelessness, and engagement. Cleary, Hunt, O’Connor, and Snars (2010) shared their indings on the Concord Centre for Mental Health’s new “phase of illness” model of care, asking whether this is the direction in which we should be moving. he professionals at the Centre had come to question their traditional approach to mental health treatment, “rehabilitation and acute psychiatry were perceived as dichotomous … [i] npatient rehabilitation was something to which a person was referred … after all other avenues had been exhausted” (p. 247). heir main points included attempts

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to integrate “early intervention” approaches into the philosophy of a large institution to provide services responsive to the diferent phases of a patient’s illness; the need to combine management of risk and vulnerability with an emphasis on the patient’s experience and “journey” to recovery; to acknowledge the prevalent levels and ranges of disability; and to discount the perception “that ‘rehabilitation’ should be targeted at only those with severe levels of disability” (p. 247). Costello’s (2007) thesis advocated for an architecture that balances supervision, treatment, freedom, and community integration, and noted the problems with current models of mental health care facilities, hospitals, independent living situations, and group homes include being insuicient as a continuum of care model for mentally ill patients; hospitals disregard therapeutic qualities of long-term care centers (focus on stabilizing and releasing); other options such as living alone or in a group home eliminate medical stability and enhance patient independence, but without suicient connection to therapy; and group homes can be problematic as they can act as small isolated islands within the community. Key design principles recommended were: •

Balance between connection with the community and retreat.

•

Retail as a bufer between life in the facility and life in the larger community.

•

Integrated building form (its into the existing urban landscape).

•

Interactive wayinding.

•

Facility design should support multiple levels of interaction.

Fitzpatrick’s (2007) study addressed mental health care from a bio-psycho-social perspective, one that aims to treat the patient holistically, using psychological therapy including individual therapy and spirituality as well as social networking, and which includes group and family therapy in a community. Fitzpatrick noted that personal visual elements may ground a person’s sense of self, and a sense of self can add to the experience of space. In addition, being able to withdraw is important as well as aiding a person with self discovery. Length of stay in healthcare is a signiicant factor in terms of demand for beds and economic factors but short lengths of stay do not necessarily equate with recovery or a stable condition, and this is particularly signiicant in mental health care. Frank and Lave (1986) provided an analysis that showed that the treatment of psychiatric patients and their length of stay responds strongly to inancial incentives. heir analysis focused on the U.S. Medicaid program, a federally supported, state-administered program that pays for medical care provided to eligible low-income individuals and families. Aligned to economic issues and length of stay in mental health care is that of homelessness, Killapsy, Ritchie, Grerr, and Robinson’s article was aimed at the assessment of “whether admission to a designated ward for the homeless mentally ill improves outcomes 12 months after discharge in terms of housing stability and engagement with services” (2004, p. 593). hey found that, although



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the idea of a designated ward seemed the best alternative for a population that was both mobile and resistant to services, those admitted were no more likely to be discharged or to move on to or remain in stable housing than were those in the control group, although this might be explained by the patients’ comparative degree of ingrained homelessness. However, there was an improvement seen in engagement with services for those who were admitted as well as diminished issues with medication non-compliance.

Art his theme includes a systematic literature review article by Daykin, Byrne, Soterious and O’Connor (2008) on the impact of art, design and the environment on mental health care. Daykin et al. reviewed over 600 papers published between 1985 and 2005, including discussions of contextual and policy literature, as well as 19 reports of quantitative and qualitative studies. heir inclusion criteria were international papers on arts, architecture or design initiatives in healthcare; papers on participatory arts in healthcare; artists in residence; and intervention studies. Exclusion criteria were not relevant to arts or design initiatives in healthcare; not relevant to participatory arts in healthcare; art forms (music, drama, play, dance); art therapy where art was a purely diagnostic intervention; patient arts; not English language; and pre-1985. he authors revealed that there are few studies that directly examine arts interventions and a notable absence of evidence-based studies. Of these studies, two are reviews, one does include art therapy but speciically its efect upon schizophrenia; Daykin et al. explained that the “methodological challenges of evaluating the clinical efects of art, design and environment are illustrated in a report [that of Ruddy and Miles, 2005] of a systematic review of art therapy for schizophrenia” (p. 87). he other review mentioned is that of White and Angus (2003), “Arts and Adult Mental Health Literature Review.” hey also noted small sample sizes, which make it diicult to detect signiicant results. However, a key inding of one empirical study by Staricof and Loppert (2003), who measured psychosocial efects after art interventions, was that “depression and anxiety were respectively 34% and 20% lower where intervention had taken place than with groups not exposed to arts” (p. 88). Eight studies examined the impact of environmental conditions, sometimes taking into account aesthetics as well as functional considerations; two studies used structured assessment tools to evaluate healthcare facilities (Daykin et al. 2008, p. 88). he authors pointed out the issue of difering perspectives regarding art among the various stakeholders in mental health care, stating the “[w]hile there is some convergence of agendas, the growth of the arts for health agenda has raised challenges. First, there is a need to identify the respective contributions of the varied disciplines involved in arts for health. As well as art therapists, an increasing number of stakeholders are involved in projects, such as arts agencies, artists, community arts workers and designers. hese groups may draw on diferent perspectives when it comes to artworks and environments in healthcare” (p. 86). hese authors acknowledged the limitations of their own study, notwith-

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standing their eforts to make the selection transparent through software such as REFworks. Nanda, Eisen, Zadeh, and Owen (2011) published a paper focusing on the “Efect of Visual Art on Patient Anxiety and Agitation in a Mental Health Facility and Implications for the Business Case,” which was aimed at investigating “the impact of diferent visual art conditions on agitation and anxiety levels of patients by measuring the rate of pro re nata (PRN) incidents and collecting nurse feedback” (p. 386). he results did indeed show a substantial efect of the nature of the displayed art work on the amount of PRN medication dispensed for anxiety and agitation, being signiicantly higher when abstract art was featured than when the patients viewed a realistic landscape. hese results were complementary to those of a 2008 study conducted by Nanda, Eisen, and Baladandayuthapani at St. Luke’s Episcopal Hospital in Houston, Texas, in which “[i]mages selected covered a wide range: pure, contemporary abstract with nonrepresentational graphic forms; classic works of art from grandmasters such as Van Gogh, Chagall, and Klimt, which used representational forms; and inally, stylized nature images. Only one of the seven images was a realistic image of nature” (p. 276). Patients were encouraged to comment on their subjective experience of the art works rather than judge them. Two questions were asked: “How does this painting make you feel?” and “Would you hang this picture in your room?” (p. 285), with answers on a Likert scale. “Hospital in-patients consistently preferred images of realistic art with nature content over images that were stylized or abstract” (p. 295), as opposed to the students from a neighboring university who rated stylized and abstract images highly. Patients rated the autumn waterfall image as their highest preference overall. he subthemes coming out of all the literature are art in a healthcare setting, design, environment, visual art, and nature. Commonalities across the literature relate to the therapeutic beneits of visual art in healthcare environments.

The Adolescent Many mental health and other health facilities focus on a speciic population, usually children, adults, or the aged. herefore, the needs of young people who are subject to extreme bodily changes in their bodies and their lives during their adolescent period are a crucial category for study, particularly in terms of treatment for mental illness. Subthemes emerging from the literature include hospital design, family-centered care, visual preferences, and evidenced based design. In his 2010 article in Behavioral Healthcare, Hufcut asks if design can actually promote healing, and then answers that question through the use of research in evidence-based design (EBD) and how its principles can be utilized to “sculpt the space within long-term facilities to better meet the needs of adolescents” (p. 33). Hufcut cites surveys of adolescent inpatients conducted by an architecture design team concerning their preferences in the design of the facility. heir suggestions, which included “calm down” spaces with in-depth, lifelike imagery;



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the use of cool colors (blue and purple); increased daylight; and varied seating options (with males in favor of seating placed around the television), coincided with features suggested by previous EBD research. In Blumberg and Devlin’s (2006) study, they observed that the needs of a sick child are quite diferent from those of adults, and to meet those needs, “the design of pediatric therapeutic settings difers greatly from those in adult or general care facilities” (p. 296). hey too made use of a survey to ascertain the preferences of adolescents, should they require hospitalization. According to the majority of the young participants, access to a television (97%), music (96%), and a telephone (95%) was of utmost importance. To explain these choices, the authors cited the research of Brown, O’Keefe, Sanders, and Baker (1986), which demonstrated that, for young people, the most common coping measure in stressful situations is attention distraction, which can be provided easily by television, music, and conversations with friends. In terms of spaces beyond their rooms, Blumberg and Devlin’s research revealed that an area in which to visit with friends was of a high priority; “a gym or exercise room to work out in was selected by 82% of participants, and an accessible kitchen was selected by 79% of participants” (p. 310). hey also addressed adolescent need for privacy, stating that [t]he speciic developmental traits of adolescents seem to call for distinct amenities, such as private bathrooms, single rooms, and comfortable full-coverage pajamas, to provide for the expression of identity” (p. 315). In the thesis, “View Out of a Window: Visual Preferences of Dually Diagnosed Adolescents Residing in Group Homes,” Boggavarapu (2002) observed that the adolescents surveyed had very distinct preferences in terms of what they saw every day from the windows of the facility in which they resided: medium vegetation was preferred over dense or sparse vegetation; they wanted variety— plants, trees, bushes, shrubs, vegetation with fruits, lowers, vegetables, and greens; some form of body of water was a favorite, with a pool the most preferred choice; “houses” were the most preferred kind of building, beating stores, playgrounds, schools, roads, and oices. Almost two-thirds (62.2%) of participants wanted equal proportions of vegetation and buildings. Research from previous studies showed nature was always preferred over man-made; this study indicated they were desired equally. It should be kept in mind that it is possible that results of this study are not consistent with earlier studies. here are two plausible reasons for this: irst, the earlier studies were conducted on mentally normal people and this sample of population would not be considered “mentally normal.” Second, familiarity and preference can be both positive and negative, depending on the context. It’s possible that dually diagnosed adolescents whose group homes are generally built away from residential communities may prefer man-made settings. Commonalities for all publications relating to designing for adolescents relate to the need for connection with the outside world.

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Forensic Psychiatric Facilities he last key theme in this literature review is that of designing for forensic psychiatric facilities. Key themes emerging here are architectural design, safety, privacy, and escapes. Commonalities for all publications relating to the designing of forensic psychiatric facilities include a comfortable domestic scale and ambience; security; a pleasant, domestic atmosphere that is well-lit by natural light; and ample space for the patients. In their study, Dvoskin et al. (2002) addressed the requirement for a secure forensic psychiatric hospital as derived from the preferences of professionals in that ield. According to those surveyed, design considerations should include ambience and a comfortable domestic scale, the use of good lighting, bright colors and subdivided spaces, and a safe environment that promotes both privacy and observability and fosters the acquisition of skills. In addition, designers should be mindful of the fact that one of the most signiicant stressors in prisons or psychiatric hospitals is the virtually constant level of noise; anything that can be done to bufer excessive noise would be very helpful. In terms of organization of space, the best design would ofer “a compromise between staf eiciency and a reasonable therapeutic milieu;” it was believed that this could be “achieved with relatively smaller social units” that aforded a reasonable degree of freedom to the patients (p. 490). Enser and MacInnes (1999) examined a serious issue concerning secure facilities: the link between building designs and escape. heir research revealed that the primary areas mentioned when discussing escapes are perimeter fencing, roofs, and internal and external windows. hey found that security breaches and building design correlated, in that units with design problems are units that experience a greater number of escapes, and escapes becomes much less likely the higher the garden fence. Design features that add security without compromising patient care include secure bedrooms overlooking an inner courtyard, any covering of that courtyard modiied by a feature that cannot be climbed, fencing with a double overhand, the installation of closed circuit television, airlocks and alarms on exit doors, and new and secure window ittings.

Conclusion he research question that led us to review the literature was, How does the intersection of mental health care and architecture contribute to positive mental health outcomes? Our combined comprehensive and systematic review of the literature revealed 13 major themes. In order of prevalence these are (1) security/ privacy; (2) light; (3) therapeutic milieu; (4) gardens; (5) impact of architecture on mental health outcomes; (6) interior design; (7) psychogeriatric; (8) post-occupancy evaluation,; (9) nursing stations; (10) model of care; (11) art; (12) designing for the adolescent; and (13) forensic psychiatric facilities. he themes overlap and some statistics apply to several themes. However, for the purpose of some clarity, we will summarize according to themes. he irst theme comprises security, violence, privacy, and overcrowding, showing that people in ward environments occupy 70% less space than their counterparts of 150 years



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ago (Johnstone, 2004). Violence against patients and staf in psychiatric wards is widely prevalent and increasing (Kumar et al., 2011). his has important implications for the architectural design of psychiatric units, including the importance of demarcated spaces for particular activities and extra space provided where possible. he second theme, light, includes natural light and artiicial lighting. he primary indings here were the importance of light for controlling the circadian system thus reducing depression, agitation, sleep, eating patterns and also easing pain in some instances. Patients in brightly lit rooms stay on average 2.6 days less in hospital than those in dimly lit rooms (Beauchemin and Hays, 1996). Signiicant diferences were found between natural and artiicial lighting including for both staf and patients, for example, a lack of natural lighting can cause seasonal afective disorder (SAD), changes to hormonal body rhythms, glare and licker, work disruptions, increased staf stress, and decreased staf satisfaction (Ulrich et al., 2008; Schweitzer et al., 2004). he third theme of the therapeutic milieu includes therapeutic design and environments; patient-centered design; healing environments, especially the Planetree approach, and positive design (Stichler, 2008); and the need for a multidisciplinary approach to healing. his theme overlapped extensively with the fourht theme, regarding gardens and contact with nature. he fourth theme of gardens is revealed as extremely important for both patients and staf for renewal/restoration of attention, stress relief, and for its social aspects, with evidencedbased research showing high percentages to support this (Naderi & Shin, 2008). he ifth theme, the impact of architecture on health outcomes, also overlaps with other themes but the literature shows that architecture can enrich the environment with complexity, order, and aesthetic considerations ofering perceptual cues to assist and avoid confusion. Access to nature and sensory/salutogenic considerations (Golembiewski, 2010) are important themes within this literature as is the need for privacy and a preference of single bedrooms. he sixth theme of interior design, which includes the subthemes of furnishings, color, wayinding, cognitive mapping, spatial organization, and type of patient room, shows the need for clear visual communication balanced with a home-like environment (Lorenz, 2007). he seventh theme is that of psychogeriatric considerations, which include dementia, violence, and trauma as major subthemes that highlight the need for quiet spaces and gardens, with an emphasis on deinstitutionalizing design features to encourage social interactions (Dobrohotof & Llewellyn-Jones, 2010; Day, Carreon, & Stump, 2000). he eighth theme of post-occupancy evaluations (POEs) deals with the lack of efective evaluations in health architecture generally and mental health particularly. he literature calls for an interdisciplinary approach to POEs, using evidence-based design including building performance factors but also with the speciic need for occupants’ feedback (Carthey, 2006; Liddell, 2010).

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he ninth theme is that of nursing (duty) stations. he efectiveness of the nursing station is addressed by the literature, with nurse-only and patient-only spaces found to be beneicial to both groups. Closed nursing stations often convey an image of staf inaccessibility to patients and visitors (Andes & Shattell, 2006). he tenth theme, model of care, incorporates several subthemes such as the biopsycho-social approach that deals with the patient holistically, length of stay, personal visual elements in the environment, and homelessness. he literature shows the need for a balance between drug-therapy, environmental context and psychological and social therapy and interactions (Cleary, Hunt, O’Connor, & Snars, 2010). he eleventh theme is the role and importance of art, not only as an activity but also as an aesthetic therapy. Daykin et al. (2008) note that few studies directly examine arts interventions, however a key inding is that depression and anxiety were 34% and 20% lower, respectively, in contexts where patients were exposed to arts. he twelfth theme, of designing for the adolescent mental health patient, is one that highlights the need for maintaining connectedness to the outside world, including family-centered care; the role of visual preferences, including medium density gardens with water; as well as the need to keep personal items, have access to movies, and have private bathrooms (Hufcut, 2010). he thirteenth theme is forensic psychiatric facility design. Here the subthemes include safety, privacy, and escapes. he literature emphasizes a pleasant domestic atmosphere that is well-lit with natural light and provides ample space for patients (Dvoskin et al. (2002). Finally, the literature shows that there is a need for more research concerning evidence-based design, and for user input into design across all themes. Despite the noted diiculties with post-occupancy evaluations there is a need to have an evidence base in terms of design for mental health units.

References Anderson, S. E., Good, L.R., & Hurtig, W. E. (1976). Designing a mental health center to replace a county hospital. Hospital & Community Psychiatry, 27(11), 807–813. Andes, M., & Shattell, M. M. (2006). An exploration of the meanings of space and place in acute psychiatric care. Issues in Mental Health Nursing, 27(6), 699–707. doi:10.1080/01612840600643057 Applebaum, D., Fowler, S., & Fiedler, N. (2010).The impact of environmental factors on nursing stress, job satisfaction & turnover intention. The Journal of Nursing Administration, 40(7-8), 323–328. Arneill, B. P. (1959). Award winning design for mental health center. Psychiatric Services, 10(6), 37–39. Au, D. H., McDonell, M. B., Martin, D. C., & Fihn, S. D. (2001) Regional variations in health status, Medical Care, 39(8), 879–888. Baker, A., Davies, R. L., & Sivadon, P. (1959). Psychiatric services and architecture. Geneva, Switzerland: World Health Organization.



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Mental health and the World Health Organization Mental health law ...

Mental health and the World Health Organization Mental health law ...

Health, Mental Health and Disabilities

Mental spaces, space builders and bilingual ... - CiteSeerX

Mental health and the global agenda - Mental Health and Family ...

Social exclusion and mental health ocial exclusion and mental health ...

Society and Mental Health

SPIRITUALITY AND MENTAL HEALTH

Athletics and Mental Health

Aging and Mental Health:

Mental health and the

Psychiatry and Mental Health

Lifestyle and Mental Health

Lifestyle and Mental Health

RELIGION AND MENTAL HEALTH

Networked Parking Spaces: Architecture and ... - Semantic Scholar

Mental Health and Mental Illness - CHEO

world mental health day - Mental Health Europe

Perinatal mental health - Maternal Mental Health Alliance

about mental health - Mental Health Europe

Interactive Architecture in Domestic Spaces