Client-Centered Design of Residential Addiction and Mental Health Care Facilities: Staff Perceptions of Their Work Environment

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    http://qhr.sagepub.com/content/21/11/1527The online version of this article can be found at:

    DOI: 10.1177/1049732311413782

    2011 21: 1527 originally published online 1 July 2011Qual Health ResGabriela Novotn, Karen A. Urbanoski and Brian R. Rush

    of Their Work EnvironmentClient-Centered Design of Residential Addiction and Mental Health Care Facilities: Staff Perceptions

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    Client-centered approaches to health care are increasingly serving as guiding principles for service delivery and sys-tem design (Institute of Medicine, 2001; Mitchell, Closson, Coulis, Flint, & Gray, 2000), including treatment and support for people with mental and substance use disor-ders (Adams & Grieder, 2005). Rather than representing a single model of care, client-centeredness incorporates a broad array of operational and ideological approaches toward care planning and delivery. Examples include indi-vidualized service planning, multidisciplinary care teams, active client and family involvement in care planning and delivery, and broader efforts to facilitate personalization of services and access through administrative decentral-ization and localization nearer to clients (Adams & Grieder; Mitchell et al.; Reisdorfer, 1996). Ideologically, greater focus is placed on promoting independence, recovery, and well-being, and clients unique strengths, challenges, and goals are emphasized rather than their illnesses and symptoms.

    There is clear evidence that physical and architectural design promotes positive outcomes and well-being among patients in health care facilities (Karlin & Zeiss, 2006; Ulrich et al., 2008). This evidence-based facility design includes a number of principles consistent with client-centeredness (Hendrich, Chow, & Goshert, 2009) by

    413782QHR211110.1177/1049732311413782Novotn et al.Qualitative Health Research

    1McMaster University, Hamilton, Ontario, Canada2Harvard University, Boston, Massachusetts, USA3University of Toronto, Toronto, Ontario, Canada

    Corresponding Author:Gabriela Novotn, Department of Psychiatry & Behavioral Neurosciences, McMaster University, McMaster Childrens Hospital - Chedoke Site, 280 Holbrook Building, Box 2000, Hamilton, ON L8N 3Z5, CanadaEmail: novotng@mcmaster.ca

    Client-Centered Design of Residential Addiction and Mental Health Care Facilities: Staff Perceptions of Their Work Environment

    Gabriela Novotn,1 Karen A. Urbanoski,2 and Brian R. Rush3

    Abstract

    In this article we discuss the findings from a series of focus groups conducted as part of a 3-year, mixed-method evaluation of clinical programs in a large mental health and substance use treatment facility in Canada. We examined the perceptions of clinical personnel on the physical design of new treatment units and the impact on service delivery and the work environment. The new physical design appeared to support client recovery and reduce stigma; however, it brought certain challenges. Participants reported a compromised ability to monitor clients, a lack of designated therapeutic spaces, and insufficient workspace for staff. They also thought that physical design positively facilitated communication and therapeutic relationships among clinicians and clients, and increased team cohesion. We suggest that, from these findings, new avenues for research on achieving the important balance between client and staff needs in health facility design can be explored.

    Keywords

    addiction / substance use; focus groups; health care professionals; mental health and illness; program evaluation

    striving to support and enhance recovery and well-being through a physical setting that promotes client indepen-dence, environmental choice and control, and shared own-ership of therapeutic space. Examples might include private rooms where clients can personalize the space, noninsti-tutional furnishings and home-like amenities (e.g., kitchen equipment), and flexible and varied spaces for socializa-tion and quiet activities. Natural views and gardens, for example, have been cited as positive elements by clients themselves, in addition to being empirically linked to pos-itive outcomes (Karlin & Zeiss).

    The specific mechanisms linking facility design to health outcomes have not been extensively studied and, as a result, are not well understood. Stress has been identified as a potential mediator of the impact of physical setting

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    on health (Broyles et al., 2008; Shumaker & Pequegnat, 1989; Ulrich, 1991). Design elements that impede or chal-lenge the attainment of goals constitute a source of stress for users, which in turn erodes users attention, energy, and physical and psychological well-being. Identifying sources of stress stemming from issues of design, and linking them with downstream outcomes, are potentially important objectives for overall facility operations and evaluation.

    In exploring the impact of redesigning and renovating health facilities on the quality of care, we must take into consideration the fact that clients represent only one of many user groups; there are also managers, clinical and allied staff, and visiting family and friends who use these facilities. Different user groups interact with designed spaces in fundamentally different ways, leading to poten-tially important differences in the impact of a given design modification on the types of users who occupy a particular space (Shumaker & Pequegnat, 1989). Likewise, a given space might serve a number of therapeutic or other func-tions, and efficiency achieved in one function as a result of a design modification might be offset by a decrease in the efficiency of another. Therefore, we must attend to com-peting interests and needs related to space and design in postoccupancy evaluations (POEs) of health care facilities.

    Despite the known implications for care quality and client outcomes, the perspectives and behaviors of clinical staff have been underrepresented in evaluations of hospi-tal design and redesign (Shumaker & Pequegnat, 1989; Tyson, Lambert, & Beattie, 2002). As with client-centered care in general, design modifications focused on client-centeredness require that control over space and the thera-peutic environment is partially relinquished on the part of staff. Staff perceptions of this process and the implications for client care and the work environment are highly valu-able avenues for exploration and documentation. Changes to the workspace environment might require staff to alter established routines and workflow patterns. Design mod-ifications that enhance space for clients might come at the cost of space designated for clinicians and clinical work. In addition, merging spaces for joint use by clients and health professionals tends to force both groups of users to stay in proscribed roles at all times (Shumaker & Peguegnat). Each of these examples might constitute potential stressors for clinical staff and might negatively impact their work envi-ronment and well-being.

    Complex associations between hospital redesign and renovations and clinical staff perceptions of their work environments have been empirically demonstrated. For example, refurbished interiors at psychiatric inpatient units have been perceived positively by staff (Cleary, Hunt, & Walter, 2009; Devlin, 1992; Stahler, Frazer, & Rappaport, 1984) and, in some studies, improved staff morale has been documented after facility renovation (Christenfeld,

    Wagner, Pastva, & Acrish, 1989; Stahler et al.). At the same time, however, disruptions and changes to the work envi-ronment associated with hospital redesign have been linked with reductions in job satisfaction and organizational commitment (Ingersoll et al., 2002). Following major renovations in a psychiatric hospital, involving a switch to largely single bedrooms and causing a reduction in the number of beds overall, and significant changes to building layout and usage policies for therapeutic and social spaces, Tyson et al. (2002) documented positive valuations of the new space by staff and increases in positive interactions between clients and staff. At the same time, however, they found increased levels of burnout and stress among staff. In discussing their findings, the authors suggested that the success of design-based modifications ultimately lies with organizational and managerial efforts to reduce environ-mental uncertainty and ensure that the needs of all relevant user groups are addressed (Tyson et al.).

    Our aim is to contribute to the literature through a qual-itative examination of staff perceptions of their work envi-ronment in a new therapeutic setting designed to emphasize client-centered care. We conducted focus groups with clinical staff at redesigned units that were part of a 3-year mixed-method POE of new residential units at an existing mental health and substance use treatment facility in Canada. The evaluation was conducted to provide a pre/post comparison of clinical programs prior to and follow-ing the introduction of the new units. The units themselves (described in more detail below) were built in keeping with principles of client-centered care to provide an alter-native therapeutic setting to more traditional inpatient units. The introduction of the units represented a major change for the mental health and substance use programs involved, and afforded a unique opportunity to examine the impacts of cultural and architectural change on staff, clients, and service delivery. We used these focus groups to explore the experiences of clinical staff concerning the redesign process and the functionality of units in the new setting. Although cautious of potential stressors related to the renovation and relocation, clinical personnel expected that the new units would represent a positive change for clients and staff alike.

    MethodsSetting

    The evaluation took place from 2007 to 2009 in a mental health and substance use treatment facility located in a large urban center in Ontario, Canada. It involved a range of activities that provided client- and program-level data both pre- and postoccupancy. Using focus groups con-ducted both prior to and following the redesign of the units, we gathered qualitative data on staff expectations,

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    perceptions, and experiences relating to service delivery, the work environment, and the physical setting. We also supplement this information with relevant findings of behavior mapping conducted at the new units concerning the use of designed spaces.

    Two hospital-based residential programs participated in the evaluation. One of the programs offers residential care for individuals with mood and anxiety disorders, whereas the other focuses on substance use disorders. Both programs experienced unique changes related to the open-ing of the new units. The mood and anxiety residential pro-gram was a new care modality for the hospital. Prior to the redesign, there was a 16-bed inpatient unit serving indi-viduals with acute crises related to mood or anxiety disor-ders. The inpatient unit was traditional in design, with a typical length of stay of approximately 2 to 3 weeks (although this varied among clients). After the redesign, this tradi-tional unit remained open and was supplemented with a 24-bed alternative residential unit, where clients prepared more fully for transitioning to independent community living. In contrast, the substance use program was preex-isting but moved from an external site to the main hospital grounds as part of the redesign. Provided services included short-term, medically assisted withdrawal management and a 3-week, structured, group-based program focused on relapse prevention, stress management, and related skill development. In addition to the physical relocation and concomitant changes in building design and layout, the medical withdrawal service increased capacity from 12 to 24 beds. However, services and programming remained largely unchanged in the new units.

    The newly designed units are now housed in three low-rise buildings located at one end of the main hospital cam-pus. Each unit has a capacity for 24 clients, with six clients on each of four floors. These were designed purposefully to provide a supportive therapeutic milieu in a more home-like setting, where clients reside and focus on the skills needed for successful transition to independent living in the community. The units resemble dormitories and include six private bedrooms, a shared kitchen/dining area, and a common living room on each floor. Each bedroom also has an ensuite bathroom equipped with a sink, toilet, and shower. There is at least one multipurpose room with a door on each floor, providing space for quieter social or solitary activity. Clients have electronic key cards for their rooms and for the main entrances to the units. They attend programming and other therapeutic services in adja-cent buildings, rather than in the units where they reside.

    Workspace for clinical staff on the units is purposely limited, with two small staff centers that function as nurs-ing stations located on alternating floors. The purpose of such an arrangement is to facilitate staff interactions with clients outside of clinical spaces and, compared to more traditional models of care, to limit time spent in nursing

    stations and staff centers. Allied health professionals, includ-ing social workers, occupational and recreational thera-pists, and psychologists, have either offices or cubicles located in adjacent buildings. In both programs, the physi-cal separation of staff offices from the treatment units was new for staff. In addition, the movement to cubicles for many staff of the substance use residential program rep-resented a significant change from private offices in the previous setting.

    Focus GroupsFocus groups are a valuable research tool for gathering qualitative data in health and social services research (ODonnell, Lutfey, Marceau, & McKinlay, 2007), with the ability to elicit rich experiential data by capitalizing on the interactive processes within a group (Rapport et al., 2010; Sim, 1998). As part of the larger evaluation, the focus groups with staff provided a highly relevant contextual background for understanding and interpreting data col-lected from clients and other stakeholders, as well as cap-turing the subjective accounts of clinical staff regarding the redesign process and the new therapeutic setting. Given the dearth of previous research on staff perceptions of mental health and substance use treatment facility design, we selected this qualitative methodology to afford an open exploration of the salient design issues for staff. In addi-tion, the focus group approach provided an efficient and expedient exploration of the attitudes and opinions of multiple participants concurrently, while simultaneously attending to the dynamics of individual clinical teams (Sim).

    Over the course of the evaluation, we conducted seven focus groups. Groups were conducted separately by pro-gram, to allow participants to concentrate on issues most relevant to their particular clientele and services. We used a convenience sample of clinical staff members on each of the units, and with the assistance of program management and flyers advertising the groups, recruited focus groups participants. Three focus groups (FG1, FG2, FG3) were conducted with staff in the existing or old units, approx-imately 7 to 9 months prior to the redesign and relocation (June to September, 2007). A total of 17 staff members participated, including 7 from the existing mood and anx-iety inpatient unit and 10 from the substance use program. Four focus groups (FG4, FG5, FG6, FG7) were held in the new units in December 2008 and January 2009, approximately 8 to 9 months after the redesign and reloca-tion. These included 23 staff members, 12 from the mood and anxiety program and 11 from the substance use pro-gram. On average, 5 to 6 clinicians attended each focus group. In addition to the participants, a facilitator attended each group and led the discussions, while two observers made notes on group dynamics and discussions during or

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    immediately after each meeting. The facilitator and observ-ers were members of the evaluation team and were not oth-erwise affiliated with the clinical services.

    The purpose of the preoccupancy focus groups was to explore staff ideas, perceptions, and expectations related to the redesign of the new units. In the postoccupancy phase, discussion focused on experiences and lessons learned dur-ing the first months of operation, including any unique devel-opments in fostering client-centered care. Membership in each group came from a range of disciplines, and was broadly representative of the disciplinary complement of clinical staff teams in each program. Participants included nursing staff, social workers, occupational and recreational therapists, psychologists, and counselors. This heteroge-neity is, according to Clavering and McLaughlin (2007), beneficial to creating a space where the different profes-sional backgrounds of research participants facilitate the exploration of differing professional positions and views on issues being discussed. At the same time, the groups reflected a certain level of commonality in terms of their relevant knowledge, skills, and professional affiliations with the units, thus creating a shared understanding of the examined clinical environments. Three individuals partici-pated in groups both pre- and postoccupancy, providing highly valuable insight into the evolution of the programs over time. The role of managers and supervisors was lim-ited to assisting us to schedule the focus groups so as to not disrupt regular services and workflow patterns. In addition, we held the groups in closed rooms, to provide a forum for staff to feel safe to freely express their views and to support their sense of empowerment and cohesion as a group.

    Participants were given a predefined list of open-ended questions to guide the overall discussion, although, in keep-ing with our exploratory aims, they were encouraged to raise any topics they found relevant to the discussion. The predefined issues included (a) staff opinions and experi-ences of the relocation and redesign; (b) the perceived role of the new therapeutic milieu within the broader con-tinuum of care available to clients; (c) the impact of the physical design of the new units on clients and service delivery; and (d) the impact of the physical design of the new units on their working environment. In this article, we focus primarily on the findings that pertain to the third and fourth issues, as well as issues that spontaneously arose over the course of discussions touching on client-centeredness in physical design.

    Behavior MappingBehavior mapping is a technique for studying environ-mental influences on human behavior (Ittelson, Rivlin, & Prochansky, 1976). We briefly describe the method we used to triangulate our findings from the focus groups

    with behavior mapping data. In this evaluation, behavior mapping facilitated our exploration of relations between the physicalarchitectural design of treatment units and the behavior of the individuals occupying them. Nonparticipant observation activities were conducted by the members of the evaluation team throughout the postoccupancy phase to document the use of designed spaces on the units. We held 12 observation days over a 14-month period; four observation rounds were made on each day in all designed spaces within the units and surrounding areas (i.e., outdoor patios and lawn areas). Members of the evaluation team observed client and staff use of the spaces, which was recorded in spreadsheets, and classi-fied it into broad categories based on the nature of exhib-ited behaviors. No personal data or identifying information were recorded.

    AnalysisWith the consent of research participants, we digitally recorded the focus groups and then transcribed the record-ings verbatim. Focus group moderators reviewed these transcripts to ensure accuracy and completeness of data. Immediately after the focus groups, the moderator and members of the evaluation team prepared brief documents reflecting their observations on the discussed topics and group dynamics. These documents became part of the data analysis as well.

    In the data analysis, we identified and coded themes per-taining to the topics outlined in the predefined questions, as well as other issues raised by research participants. The internal consistency of coding was enhanced by the fact that the same team members conducted the analyses, partici-pated in many if not all of the focus groups and debriefings, and regularly communicated with the other members of the evaluation team (Kidd & Parshall, 2000). We used content analysis to identify themes that emerged during the focus groups. After we reached data saturation for all groups, we assessed the validity of our findings by comparing them with similar themes and issues in relevant literature (Kidd & Parshall). Furthermore, the focus group data were cor-roborated with the findings collected through behavior mapping and observation of staff use of spaces. Finally, we allowed focus group participants to review and comment on our findings to ensure completeness and accuracy (Marshall & Rossman, 2006; Patton, 1999).

    All evaluation activities, including focus groups and behavior mapping, were approved by the facilitys Research Ethics Board. Staff members who volunteered to take part in focus groups verbally consented to audio recording of the discussions. Flyers reporting the behavior mapping activities and indicating the presence of the evaluation team members were posted on the premises. To protect

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    participant confidentiality, transcripts and analysis docu-ments were stored on a secure computer network drive at the evaluators institution, and direct quotations presented in this article are identified only by focus group number.

    FindingsWe identified themes concerning the impact of physical design on clients, service delivery, and the staffs work environment. Presented below, we recognize that these themes are intertwined in a dynamic fashion. We use quo-tations from the focus groups to illustrate the main issues identified in the analysis.

    Impact of the Physical Design on ClientsIn both the pre- and postoccupancy focus groups, themes arose connecting the units physical design to benefits for recovery and stigma reduction. Prior to the redesign, there was a general impression among staff participants that the new units would ultimately be more aesthetically appealing, comfortable, and home-like. The existing appear-ance of old units was seen to contribute to public misper-ceptions of mental illness and addiction. Participants believed that the new units helped promote a positive image of the hospital as providing good quality services.

    Supporting recovery. The private bedrooms were a spe-cific feature that staff thought clients would appreciate. In one of the groups, participants felt that the private bedrooms and the expected aesthetic appeal of the buildings and interior spaces would support recovery. Specifically, participants expected that clients would enjoy the greater levels of freedom, autonomy, [and] independence (FG1) facilitated by the architectural design, and that this in turn might assist them with success-fully navigating their social space and transitioning back into the community:

    They will just learn what it is like to have your own key, to turn the door, to cook when you want. It will benefit them, because what they will learn there, during that little stay, is something that theyre going to take with them. (FG2)

    Reducing stigma. The theme of stigma reduction also surfaced. Participants expected that the attractive build-ing exteriors would promote a positive image of the hos-pital in the community, as well as among family members and friends of clients:

    For a family member to see this nice posh building, [they might think] its not bad, you know. Some people come, like you feel theyre fearful of the

    buildingof coming inside, seeing all these people. But this is a new building, a totally different setting, and at least bringing your family members to a mental hospital will not be as big [a deal], not an embarrassment. (FG1)

    Allowing control over the environment. After the rede-sign, these same sentiments pertaining to recovery and stigma reduction were reiterated, although this time they emerged more universally. In both programs, participants commented on the physical design, describing it as respect-ful of client privacy and independence, and these were linked with improved quality of life and empowerment. Participants commented specifically on the open, client-friendly layout, abundance of natural light, and comfortable furnishings. Participants felt that clients increased control over their immediate physical and social environments was positive and unique within the hospital:

    I think they really appreciate [it]. They put pictures on the walls, they do things so that they personalize it, which they cant do if theyre on another unit. Its lovely, bright, it encourages people getting together, taking a walk together. (FG4)

    Opportunities for clients to choose between the pri-vacy of their bedrooms and socializing with other clients or visitors in the communal spaces also factored into staff perceptions of greater client control over their environ-ment. Recognizing the beneficial role of peer support in recovery, participants in one group qualified the new set-ting as particularly supportive of healthy relationship development by providing clear boundaries for personal space and other opportunities for control and responsibil-ity. As in the groups conducted prior to the redesign, the appealing and attractive buildings were linked by staff to improved perceptions of addiction and mental health care in the community.

    Impact of the Physical Design on Service DeliveryThe impact of the physical design on service delivery at the new units was a topic that elicited strongly opin-ionated observations from the focus groups. Although clinicians appreciated the impact of the new therapeutic milieu on client independence, empowerment, and well-being, concerns about client safety were discussed as a salient issue in all focus groups both pre- and postoccu-pancy. The challenge of reduced therapeutic space was another important theme that emerged regarding therapeutic implications of the physical design. A related theme arose concerning the impact of unit layout on communication

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    between staff and clients, and the resulting implications for the therapeutic relationship.

    Concerns around safety. The limited ability of staff to monitor clients on the new units was a specific concern. Prior to the redesign, staff were uncertain about the extent of their accountability and responsibility in the new set-ting. In this regard, one focus group participant asked, How much accountable will we be and how much [will] they [the clients] be? (FG1). Subsequently, on the new units, participants reported tension in maintaining a safe therapeutic environment that was simultaneously sup-portive of client autonomy:

    Its sure easier to use drugs when you can close the door to your bedroom by yourself. It is easier for them to get drugs in, if other people are leaving every day and going home, out in to the community. Are they going to check these people when they come back properly, and are they going to screen these people properly? (FG2)

    What I think the big difference is physically, right now they might have their own rooms but theyre in the same building as us, so if we have any concerns or they dont come to their classes or whatever, we can just walk upstairs and go and check on them. But if theyre in their own building, its going to be more difficult to keep track of where they are and whats going on. (FG2)

    Selected design elements, including the lack of a nurs-ing station on every floor, the physical layout of the new nursing stations and lack of direct sightlines to clients, and the absence of call buttons in client bedrooms and bath-rooms were linked by staff to challenges in responding quickly to clinical and behavioral issues and emergency situations:

    If its a three-floor setting and theres only one nursing station on one floor, to me, on the other two floors there could be something going on. How would you know that something critical is going on [on] that floor? (FG1)

    Staff members sense of responsibility for offering quality services, consistent with broader expectations for hospital-based care, was affected by this tension: In fact, its an alternate setting, its a home-like setting but still, were in a hospital (FG4).

    Insufficient therapeutic space. Staff from both programs reported challenges associated with a lack of designated therapeutic spaces on the units. Mention was made of a lack of space for group-based programming, as well as for individual consultations with clients or other staff

    members. Participants reported occasionally conducting therapeutic consultations in clients bedrooms when no other space was available. This was validated by members of the evaluation team conducting behavior mapping activ-ities; communication with a client that required a certain level of confidentiality did, indeed, sporadically occur in clients bedrooms. This was perceived as problematic for reasons of safety, and because it was considered inconsis-tent with the design intentions for the spaces.

    Overall, accommodating clinical needs on the new units had perceived repercussions for client comfort and right to privacy, and for staff safety and well-being. Staff from both programs saw the lack of private space for one-on-one encounters with clients as posing potential obstacles to confidentiality. Others reported feeling less efficient in their daily routines because they had to spend more time looking for appropriate meeting spaces. This situation was compounded for staff members who did not have private office space in the adjacent buildings:

    When you actually want to sit down and talk to someone and say, Okay, I cant find a space here. Come and meet me over in [another building], and then we say, We dont have offices, we have cubi-cles. Right? You cant have a meeting in a cubicle; you cant. So you have to plan and hope you find a room and then you might not be able to do it, so I think theres a lot of time essentially wasted on things that you dont need to waste time onspace planningwith a client. (FG5)

    Communication and the therapeutic relationship. Preoc-cupancy, focus group participants expressed some uncer-tainty regarding the implications of limited staff workspace on their abilities to fulfill their therapeutic roles. Nonethe-less, postoccupancy staff communication and teamwork did not seem to be negatively affected. In one focus group conducted postoccupancy, staff discussed the ways that the physical design supported the development of thera-peutic relationships with clients. Participants reported that unit layout facilitated increased communications between clients and staff by presenting a lesser boundary of staff-designated spaces. Interestingly, participants reflected on both positive and negative repercussions of this issue for clients. On the positive side, there was a sense that the oppor-tunities for increased informal communications might benefit the therapeutic relationship:

    I also find that the boundaries for the nursing station [are] not that rigid as on the acute setting. The patient wont feel [as] nervous or restricted in terms of approaching the nursing station and talking [to] the nurses, or even cracking jokes with the nurses some-times. Its a lot more relaxed. (FG4)

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    Another participant noted, Actually, weve been told that were more approachable, and have a better understand-ing, [are] more welcoming, that theyre not treated as a client or a patient (FG4). Behavior mapping activities on the units also revealed frequent and informal commu-nication between staff members and clients, occurring mostly in the client lounges, adjacent kitchens, or lobby areas. Participants in this same group also noted that cli-ents did not want clinicians to be around them all day. In this way, the physical layout of the units was described as being somewhat inconsistent with their clinical realities:

    I think this overall objective they had for nurses and clinicians to be more interactive with the patients rather than staying in the nursing station all day is kind of unrealistic, not saying that nurses should be encouraged to stay in the nursing station all day, but its just this daily reality that patients dont want nurses around them every day. (FG4)

    Impact of the Physical Design on the Work EnvironmentDistinct from the themes discussed above related to ser-vice delivery are those that concern the impact of physical design on staff themselves, and their work environment. Reflective of the major transition they experienced over the course of the evaluation, staff discussed their percep-tions and experiences of the preparation and planning phases. Participants identified additional themes concern-ing stress related to insufficient staff-designated space, balanced with benefits to team cohesion.

    Uncertainty and lack of input into planning. At both time points, participants discussed issues pertaining to commu-nication and information sharing during the preparation and transition phases of the redesign. Prior to the rede-sign, participants from both programs expressed a degree of uncertainty over the design details of the new units, the specific ways in which they would differ from the exist-ing ones, and the ultimate implications for operations. Nevertheless, when this issue was revisited postoccu-pancy, staff in both programs indicated overall satisfac-tion with communications from management and transition teams prior to occupancy:

    It was helpful that we had, I think every month, a kind of retreat. They were trying to let us know, give us information [about] whats going on here, send everybody to come here, let everybody to see the place. (FG5)

    Instead, they were dissatisfied more when this information sharing failed to extend to meaningful involvement in the planning process. They expressed a need for staff to be

    genuinely heard during planning and transitioning phases of hospital redesign: Somebody had a whole lot of feed-back on those things, decided it anyway, and now weve gone through a cycle and saying, You know what? We have a problem (FG6). A participant from another focus group expressed similar views:

    I heard from people that said the staff will need more space. They said it over and over again, and it was very specifically done differently. I mean its not like they didnt know or they hadnt heard from people. They had gotten the feedback and they decided on it anyway. (FG4)

    Another focus group participant reflected on the plan-ning phase of redevelopment, believing that by acknowl-edging issues raised by clinicians would have prevented some of the challenges experienced after relocating to the new units:

    So, you felt like you were informed the way things were going through in the months leading up to the move, but you werent necessarily involved with it. I think had we been listened to, I mean really listened to, some of this would not have happened. (FG5)

    Insufficient space for staff. Both pre- and postoccu-pancy, a second strong theme emerged regarding staff-designated space on the new units. This included space for paperwork and other work-related tasks such as stor-age and filing, extending to space for breaks, socializing, and recharging while on shift. The lack of staff-designated spaces was seen to have negative repercussions for client care and for staff well-being. For instance, participants in one group discussed how the lack of communal space for staff limited their ability to model prosocial behaviors for their clients, such as gathering together for a meal rather than sitting alone in an office. Concern was voiced regard-ing the impact on clinical team functioning:

    Staff dont have a place to meet at all. Were sort of tucked in. I mean, were supposed to be this big happy family unit, interdisciplinary place, but we dont have a place where we can meet and socialize together and talk. We dont even have a lunch room. (FG5)

    Others expressed this in terms of a limited ability to remove themselves from the clinical setting while on shift: [W]e all work in a field where were constantly facing very ill people and so weve got that, and theres only so much protection you can have. I mean, you dont have a door that you can close (FG4).

    Participants noted explicitly that the lack of staff space affected all disciplines; however, nursing staff appeared

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  • 1534 Qualitative Health Research 21(11)

    to experience particular challenges associated with the nursing stations on the new units. These were described as small and overcrowded, particularly during shift changes, again with insufficient space for charting and file storage: Absolutely inappropriate size of the nursing station, if you can be a part of it its very confusing, its very diffi-cult sometimes (FG6). Another participant also noted, Here the nurses station is a lot smaller, so you tend to get a little more claustrophobic (FG6).

    Staff from both programs commented on a perceived disconnect between client-centered and staff-friendly design. This issue encompassed not only spaces for work-related duties but also more general uses, including desig-nated staff washrooms, lounges, lunch rooms, and storage space: I think that this new building is really all about fostering greater care, self-care for the clients, but what about the employees? (FG7). Another focus group par-ticipant felt similarly about this issue: Certainly talking about more facilities for staff, they do an excellent job with the patients, but theyve got to make a focus more on safety and staff facilities (FG7).

    One of the multipurpose rooms, serving as a work-space for staff in the absence of suitable alternatives, was described as insufficient to accommodate the needs of all staff members:

    Im always busting in there. I feel like Im interrupt-ing something when a client is there but I need to go in there to check orders, the chart. Its almost like a multipurpose room for staff, but it shouldnt be, there should be a room thats confidential to make a phone call, and really there is not such space at all. (FG5)

    This comment suggests that staff were adapting to the new units by coopting spaces originally designed for other purposesa suggestion that was bolstered by postoccu-pancy renovations designed to increase staff-designated spaces. In one unit, these took the form of removing a wall between two multipurpose rooms to create a single larger room for staff meetings and to serve as a staff lounge. This kind of accommodation took place to some degree and through various means in both programs in the months following occupancy. Behavior-mapping activi-ties confirmed that multipurpose rooms were being used as staff-only spaces, providing a quiet space for comple-tion of clinical and paper work. Focus group participants also reported instances of receiving conflicting informa-tion regarding organizational expectations for sharing communal spaces with clients. They articulated that the units were to be generally understood and treated as the clients home environment, and that staff should respect their privacy and use the communal spaces only when necessary. One participant, however, relayed an experience

    of being told by a supervisor to feel free to eat in a client common area.

    Team cohesion, communication, and greater service inte-gration. Preoccupancy, staff of the addiction program had positive expectations regarding increased proximity of other services, promising opportunities for consulting with professionals from other programs. Indeed, from the discussions in both programs, and despite the above-mentioned challenges, the increased capacity for professional collaboration and service integration in the new setting was perceived as a positive aspect of the redesign:

    Theres [a professional] in mental health and, you know, I heard that she had this and she said, Yes, come on over and see what weve got going on and well share. Weve obviously [got] different back-grounds, but were cross-pollinating a little bit, and its information sharing, very different populations but [in] all kinds of small ways as well as more of the formal. (FG7)

    In one focus group, staff expressed the belief that the increased capacity for professional collaboration enhanced communication and cohesion among clinical team mem-bers: We work more cohesively together as a unit. [We] more or less know each others roles, theres general cohesion of the team (FG4). Staff members were credited with a willingness to be flexible and adapt; however, the spatial layout of the units and the sharing of clinical spaces among team members was also seen to enhance commu-nication and, ultimately, the quality of care on the unit. In this group, the bright and clean physical environment was believed to enhance staff well-being at work. More gen-erally, participants appeared to be proud of being involved in care delivery in the new units: Its just such a pleasure to be part of what we have to offer, part of the team being able to offer this kind of environment to clients (FG4).

    DiscussionAlthough the literature on evidence-based design in health care highlights the importance of staff concerns and needs when designing new facilities or renovating existing ones (Karlin & Zeiss, 2006; Ulrich, 1991; Ulrich et al., 2008), there is a dearth of empirical research exploring staff perceptions of design modifications. Facility redesign and renovations impact not only the physical environ-ment, but also the therapeutic, operational, and psy-chological environments. New social and occupational patterns, norms, and routines need to be established, and this process can cause a certain amount of stress across the groups who occupy the new space. The present study documented staff perceptions and experiences of a new

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  • Novotn et al. 1535

    client-centered therapeutic setting through a set of focus groups conducted prior to and following unit occupancy. Postoccupancy behavioral-mapping activities also helped us to understand the uses of the newly designed spaces and the aspects that staff found both challenging and reward-ing. The physicalarchitectural milieu of the new units allowed for greater client independence than is typical on traditional inpatient units, with limited space for staff. There was an organizational expectation that these changes would prove to be beneficial for both clients and staff.

    Considering the differences in the targeted clientele and nature of the services, there is a remarkable consistency to the findings. Staff appreciated and confirmed the client-centered aspects of design, identifying a number of bene-fits for clients. Perceived benefits converged primarily around issues of independence, privacy, and control of the immediate physical and social environment by clients. The same design elements that were seen as beneficial were also thought to have negative repercussions for both clients and staff. Client monitoring and surveillance were particularly complicated on the new units, and this was perceived as a source of stress for staff and a potential dan-ger for clients. The tension between respecting client privacy and promoting independence and monitoring to ensure client well-being and safety has been reported previously (Shumaker & Pequegnat, 1989; Tyson et al., 2002), and might speak to a general tension that staff feel in promoting client autonomy while maintaining a safe therapeutic environment. Similar to the present study, Tyson et al. found that the same features perceived by staff to be beneficial for clients were seen to be disadvantageous for staff.

    Overall, staff appeared to view the new spaces more positively for clients than for themselves, and quite clearly articulated what they saw to be a trade-off between a client- and staff-friendly design. Their concerns are consistent with previous research on evidence-based health facility design. For instance, reviewing the findings from avail-able research on the physical design of mental health care facilities, Karlin and Zeiss (2006) reported that a staff lounge or other space where staff are free to congregate and inter-act is important for promoting morale and job satisfaction, as well as professional communication. Unit layouts that involve merging staff and client spaces are elsewhere described as potential design-related stressors because they require clinicians to stay in role for the duration of their shifts (Shumaker & Pequegnat, 1989, p. 186). Given the salience of findings in this and previous work pertain-ing to the balance of client and staff needs in facility design, additional research is needed to identify and eval-uate methods of offsetting tensions in this regard, both in the design and planning phases preoccupancy and during the period of acclimatization postoccupancy. Studies elucidating the role of management and the larger

    organization in supporting and fostering a climate of change and adaptation might also contribute to understand-ing the mechanisms of a successful facility redesign. Research into the costbenefit ratio of restorative spaces for health professionals is needed, with respect to staff designated spaces and the optimal allocation of finite space resources, to identify their overall impact on client care and to provide empirical justification for their inclu-sion in or exclusion from future hospital redesigns.

    Previous work outlines a potential role for stress in determining the impact of physical settings (Broyles et al., 2008; Shumaker & Pequegnat, 1989; Ulrich, 1991). For staff of a hospital undergoing a major redesign or renova-tion, environmental uncertainty might constitute an impor-tant source of stress and, therefore, represent one potential mechanism through which design-related stressors impact on unit functioning. In this sense, environmental uncer-tainty refers to the degree to which expectations and under-standings of the new units are clear and unambiguous (Kagan, Kigli-Shemesh, & Bar-Tal, 2004). Such percep-tions, assessed prior to relocation, have been linked to heightened anxiety among staff up to 6 weeks postoccu-pancy (Kagan et al.), as well as burnout, decline in job satisfaction, and lower overall commitment to the organi-zation (Garrett & McDaniel, 2001; Ingersoll et al., 2002).

    In this study, staff perceptions of the extent to which they knew what to expect in the new units were somewhat mixed. Preoccupancy, participants expressed a fair degree of uncertainty regarding operational procedures and design elements; however, postoccupancy perceptions were more positive about the efforts of the organization and man-agement to prepare front-line staff for the new setting. Nonetheless, there were some indications of confusion in the rules and expectations around staff uses of spaces on the units, and participants perceived conflicting informa-tion about the appropriateness of their use of the available communal spaces for either work-related tasks or breaks. Additional investigation of the links between environmen-tal uncertainty, stress, and unit functioning during and fol-lowing unit redesign is warranted.

    To explain the ways in which users adapt and modify a space after occupancy to suit their purposes and needs, Kelner (1975) used the term human factor to describe the reciprocal relationship that develops between spaces and people. Clinical staff play an important role in creating norms and setting expectations for the uses of designed space that match with clinical and operational realities on hospital front lines (Shumaker & Pequegnat, 1989). Examples of this were apparent in the present study; for instance, in the subsequent conversion of multipurpose rooms into staff lounges and workspaces. Postoccupancy renovations on one unit supported the creation of a staff-designated space, again consistent with literature docu-menting the need for such spaces in mental health care

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  • 1536 Qualitative Health Research 21(11)

    facilities (Karlin & Zeiss, 2006). These findings might be seen as supporting participants perceptions of need-ing more meaningful involvement in planning phasesanother issue that has received attention in past research on processes of hospital redesign (Davis, Glick, & Rosow, 1979; Shumaker & Paquegnat). More recently, calls have been made for increasing nurses input into design plan-ning processes, by including nursing representatives on multidisciplinary design teams and providing continuing education opportunities for nurses to increase their com-petencies and skills in areas of design and architecture (Cesario & Stichler, 2009; Gregory, 2009).

    To some extent, these findings might simply reflect a resistance to change on the part of staff. Nevertheless, it should be recognized that, in the groups conducted post-occupancy, participants were able to provide very specific examples of how the design of the new units matched and did not match their clinical realities. The specificity of their comments argues for a certain degree of genuine dis-satisfaction with their role in the planning process that is difficult to discount entirely. Furthermore, staff responses were not uniformly negative to the changes that had taken place, highlighting a number of benefits for clients and staff, as well. We can expect that perceived benefits for both clients and staff will alleviate staff stress as they con-tinue to settle into daily routines on the new units and adapt the spaces to their needs. The degree to which these ben-efits, accompanied by postoccupancy renovations, offset the identified stressors might be a fruitful direction for more research on these units at a later date.

    It should be noted that the groups were held over a short time frame during unit operations, but during a period of major change. Therefore, the findings reflect a period of transition and early experiences rather than the long-term impact of a physically and architecturally novel environ-ment on unit functioning. There are additional limitations associated with the use of focus groups in evaluating stake-holder opinions and perceptions. The degree to which there is true attitudinal consensus among participants, vs. con-formity to the views of others based on specific group dynamics, remains an ongoing question (Sim, 1998). In addition, we were limited in our ability to reflect the strength of stated opinions, as opposed to simply their presence or absence. Focus group findings are generally challenged because of their efficacy to distinguish the nature and extent of overall agreement among participants, and whether this agreement resulted from any external pressure or self-censoring (Sim). That said, triangulation of findings with data collected through behavior mapping on the units, where environmental influences on the use of space by dif-ferent user groups were examined, increases our confidence in the validity of themes (Kidd & Parshall, 2000).

    Finally, it is difficult to establish empirical generalizabil-ity of findings from focus groups of this nature. Given that our aim revolved around documenting staff perceptions and experiences following a major unit redesign in one large facility, the use of a qualitative methodology appropriately allowed us to explore these experiences and yielded a rich set of observations. This kind of broad exploration of staff concerns was particularly appropriate given the paucity of existing research on this topic. That our findings are largely consistent with other work evaluating staff experiences of facility redesign and client-centered design modifica-tions, both qualitative and quantitative in their methodolo-gies (Karlin & Zeiss, 2006; Kelner, 1975; Shumaker & Paquegnat, 1989; Tyson et al., 2002), speaks to their poten-tially broader generalizability beyond this particular facility.

    ConclusionThe present study supports and extends previous work on the implications for staff of health facility renovation and client-centered approaches to design. Findings suggest that, although moving into a redesigned client-centered clinical environment might enhance the capacity of existing clini-cal services and create a positive empowering milieu, it might also lead to challenges in service delivery and impor-tant alterations in staff perceptions of their workspace. The impact of hospital redesign on clinical staff is not unimportant. Staff satisfaction and a positive work environ-ment are inextricably linked to positive client experiences and treatment outcomes (Tyson et al., 2002). Achieving a balance between client-centered space and the practicali-ties of day-to-day clinical work requires careful planning and ongoing negotiation of the needs of all participating user groups during all phases of redevelopment. A physical redesign that reconciles the spatial, architectural, therapeu-tic, and logistical needs of all users can provide an effective means to enhance the quality of provided care. Implications of the present study extend to both research and practice in mental health and substance use treatment services by suggesting potentially fruitful areas for future research and by providing useful insights into the practical reali-ties of applied models of care and their intersection with physicalarchitectural design.

    Declaration of Conflicting Interests

    The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

    Funding

    The authors received no financial support for the research and/or authorship of this article.

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    Bios

    Gabriela Novotn, PhD, is a postdoctoral fellow in the Department of Psychiatry and Behavioral Neurosciences at McMaster University, Hamilton, Ontario, Canada.

    Karen A. Urbanoski, PhD, is a research fellow and instructor in the Department of Psychiatry at Harvard University in Boston, Massachusetts, USA.

    Brian R. Rush, PhD, is a senior scientist and co-section head, Health Systems Research and Consulting Unit at the Centre for Addiction and Mental Health in Toronto, and a professor in the Department of Psychiatry at University of Toronto, Toronto, Ontario, Canada.

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