Legends Lounge Seminars

Laura will be presenting the findings from two systematic literature reviews that she has led and delivered to inform the development of the mental healthcare built environment (mHBE) Quality Assessment Tool produced by NHS Scotland Assure and the Scottish Government. The systematic literature reviews identified, critically assessed and synthetised existing research on the factors of the facility design that (1^st literature review) act as a therapeutic intervention for service users, and (2^nd literature review) impact or are important to staff. The focus of both reviews is on adult mental health inpatient settings.

This presentation will involve: input from those with lived experience; a CAMHS Consultant Psychiatrist; a senior operational leader; and Medical Architecture.

The theme will be the journey of developing the case for and the design of a CAMHS PICU in Poole, Dorset. The presenters will bring together the patient experience, the clinical need, the operational drivers, and the design piece.

The recognised shortage of CAMHS PICU beds nationally, makes this a live issue. The proposed new-build PICU will have a number of state-of-the art therapeutic spaces. The focus of the sessions will be about relating design, to the PICU clinical model and patient experience.

An audit of mental health patients carried out by Lewisham & Greenwich NHS Trust in August 2019 found that more than half of the people who went to emergency departments (EDs) for help because of their mental health waited more than four hours to get the right care. One in seven spent more than 12 hours in ED, exposing patients, NHS staff and visitors to additional stress. This figure is probably far greater now.
The project involves collaborative working between the Queen Elizabeth Hospital (QEH) and Oxleas NHS Foundation Trust, to improve the collaboration and partnership between mental health departments and ED teams. The new area will allow mental health patients to receive higher quality care by providing them with a specialised area for their specific needs, staffed by specialist nurses from Oxleas.
The new Mental Health Assessment Area (MHAA) at QEH will offer the local population a suitable and safe environment for patients who present in crisis, in which to be assessed and treated whilst awaiting next steps in their care pathway or whilst awaiting transfer into a clinically appropriate environment. This will give a better patient experience by removing patients from the overly stimulating ED environment and by allowing patients to access therapeutic intervention.
The presentation will focus on the collaboration and partnership of the MH and EDs teams and in specific on two of the biggest challenges which were:
• To find and agree on a location within the existing and busy hospital to host the new MHAA, considering the importance of the relationship with the EDs and mental health teams, and
• The consultation with all the different groups of stakeholders to build strong ERs and to deliver a mental health friendly and functional environment which can work for all the stakeholders.

We are all the experts on ourselves. Ideally, we need to stay within our homes and communities. However, if a facility is needed it needs to feel comfortable and the person needs the space and opportunity to learn who they are. Let’s be open to the idea that western psychiatry is not necessarily the right answer for some and maybe multi-cultural approaches can be beneficial.

Several studies departing from the experiential worlds of patients and staff have explored the links between the architectural design of forensic psychiatric buildings and the patient recovery process. Others have proposed models of how psychiatric wards may be designed to reduce stress and aggression. Nevertheless, one of the most prominent recommendations in the literature concerning psychiatric hospital design is to minimize the institutional atmosphere and instead promote a more homelike environment. Even though current literature has affirmed the importance of the physical environment in supporting better outcomes in mental health services, more rigorous research is needed to establish the link between structural surroundings and mental health outcomes.
In November 2018, the psychiatric Aarhus University Hospital (AUH), dating back to 1852, relocated to a new modern purpose-built psychiatric hospital. The relocation presents a unique opportunity to examine the effect of structural surroundings on aggression and how the physical environment may impact recovery.

Aim of study
To explore how inpatients and staff in medium secure forensic psychiatric wards experience the structural environment, focusing on homeliness and how the structural surroundings may impact recovery and aggression.

Methods
The study design is mixed-method. We perform semi-structured interviews with staff and patients, collect structural data from official blueprints and building databases on the old and new forensic wards. Interview data will be coded in Nivivo12 and analyzed using thematic analysis inspired by the literature on patient recovery. We depart from a model of how architecture may support the reduction of aggression in wards and evaluate what kind/if critical architectural features are recognized as essential to minimize the risk of aggression.

Results
Will be presented and discussed at the conference.

In 2020, The NHS declared its journey to net zero vision. This ambitious vision includes mile-stone targets for an 80% reduction in the carbon footprint by 2028-2032 and a 100% reduction in the carbon footprint by 2040 (net zero carbon performance). Achieving these targets demands that we collaborate, acting now, acting decisively, and acting correctly.

This is a great ambition, and it must be delivered whilst maintaining a patient first approach to health care. Based on feedback from service users given in the 2021 Designing in Mental Health Conference, the environmental condition within rooms has a pronounced effect on patient well-being, health and recovery.

Following the successful response to our presentation at last year's conference we would like to come back and present further findings over the year and how current net zero carbon thinking is affecting service user experience.

Architecture is a discipline that helps organise environments to suit the user's requirements and needs. This is fundamental to our design philosophy, none more so than when we work on mental health projects. We believe that creating autism friendly environments is central to any scheme and that, no more, should people with autism have to fight for their rights.
In many cases we see that surrounding environments contribute to a person's disablement. The same person set in the right environment could then be seen as an able person.
The main design principles, which we apply to all our projects, have evolved through consultation and engagement with trustees, clinical staff, facility managers and, more importantly, in talking with and respecting people with autism and other learning difficulties and their families.
The presentation will focus on
• How to engage with people with Autism at the design stage
• Autism friendly colour palette research with Hilary Dalke at Kingston University
• Proxemics and sensory space perception
• Specific challenges: finding the right balance between a building that will resist challenging behaviour and the need of sensory stimulation to avoid self harming

Environments are far from neutral backdrops to psychological life; instead, they should be considered active participants in psychological processes and interpersonal relations (Brown & Reavey, 2015; 2018). People and place, together. In mental health environments, this relationship is crucial, given people who use services often enter with difficult and even traumatic histories that involve complex and conflict-ridden relationships from the recent and distant past. However, the histories of service users are often rendered invisible on entry into inpatient services and yet we would argue, the environments can compound existing traumatic responses and strengthen problematic ways of relating. Using data across several qualitative studies, we show how physical and psychological barriers built into certain environments, via expressed emotion in social spaces, a lack of stimulation in places of isolation and seclusion, as well as the invisible barriers created between staff and patients in several key areas on the ward and in bedrooms, render these environments psychologically un-safe. We finish by suggesting ways in which psychological safety might be enhanced, using a memory and trauma informed approach.

Working with NHFT for over 10 years - Fleet will be sharing the work on 2 retrofit projects with the Trust - the first is a relocation of CAMHS into an existing PFI operated estate including a modest extension to accommodate art and education activities. The second is a respite residential care facility for guest from 4 to 16 years old derived from an existing and very tired Local Authority run facilty.

Both projects are a result of a very productive user-architect relationship and both push the limits of retro-upgrades to existing estate with distinct complications and limitations.

I've been designing hospitals for the past 25 years and with the current state of mental health globally, now more than ever has it become evident how our immediate environment impacts on our thoughts & actions. Whilst recently working closely with neuro diverse patients who all were suffering with eating disorders, this observation played out with remarkable results. Initially these patients within a day care facility demonstrated violent reactions within the facility they were forced to occupy. It was only in changing the dynamic of their immediate environment that aided the patient's wellbeing, with positive outcomes. The lessons learnt are essential for all healthcare facilities to implement now.

A thicket of useful knowledge has grown within the fields of planning and design for people who are experiencing mental illnesses and those that care for them.  This development of new learnings, research, and best practices has certainly been helpful in our work to improve care environments for both service users and care providers.  Nonetheless, at points along this journey a thoughtful clinician or designer might have had reason to pause and reflect for a moment about some of the contradictions that are inherent in our work and wonder how we might proceed without what we have currently accepted as a necessary dissonance.

Our focus on patient safety, as an example, can easily lead to environments that, while safe, are also some combination of sterile, featureless, or containing an abundance of alien (but safe) fixtures. Similarly, the vast literature on whether nurse stations/care desks should be open or closed is replete with seemingly contradictory impulses that either favor openness for clinician patient communication or enclosed to provide staff with the comfort of an impregnable safe place.   Can we have one without the other?  Where and how do we achieve a proper balance?

Our natural tendency to see and hear care providers and service users through the prism of their roles compounded by their own natural tendencies to speak and advocate from the place of those roles in the care process inevitably adds a series of very concrete project drivers and expectations that inevitably adds additional sources of transactional dissonance.  We all compartmentalize around what we see as our role in a given situation to the disadvantage of what we might see, understand, request or provide through the essential lens of our own basic humanity.  In a very real sense, this natural focus on roles and the needs arising from roles is a basic building block of stigma.

This presentation is the outcome of an ongoing personal conversation about how to cut through this thicket of knowledge and roles by finding a way to understand what is absolutely essential to a successful care process for both the service user and a care provider.  The presenter's thesis is that by taking the time to discern the essential, and then giving the essential priority in satisfying the needs of the important, we might create better environments with far less contradiction.

Our conversation will be about an ongoing working process; one where the path is more important than the current conclusions.  While these will be shared as a catalog of the important in the context of those essentials and a catalog of design examples as a response, that sharing is only meant to be  a start of a conversation about the need to attend to the important only in the context of the consideration of the essential.  The field will be more likely to come to agreement about the essential and the place of the important within those essentials if we in initiate a conversation among care providers, service users, and designers who are considering the problem from this perspective.

Coproduction has become a buzz phrase within the NHS mental health care. What does it really mean? How can designers, clinicians and architects truly meaningfully consult with people with lived experience – and get the most out of the experience to ensure that their plans are effectively coproduced? Issues of language and accessibility, hierarchy and interpretation all have a part to play – as does the role of peers and facilitators with lived experience in bringing out the voice of the service user in the area of design.

In this panel discussion, Raf Hamaizia Lived Experience Lead for Cygnet Healthcare and Emma Sithole, CEO The Recovery Foundation talk about their experience of meaningful coproduction, what constitutes and facilitates it, and how to maximise its impact in the built environment.