Spaces for smoking in a psychiatric hospital: social capital, resistance to control, and significance for 'therapeutic landscapes'

Vitality and nature in psychiatric spaces: Challenges and prospects for 'healing architecture' in the design of inpatient mental health environments

Historically, nature has been considered central to healing and recovery in institutional mental health settings, with inpatient spaces designed to mirror the restorative forces nature may afford. Within contemporary healthcare architecture, the discourse surrounding nature's role has once again become prominent, especially in the concept of 'healing architecture'. While the literature on 'healing architecture' primarily considers how to connect recovery to nature through interventions in the built environment, less interest has been directed towards how nature is configured in design processes and what implications that has for the everyday experiences of patients and staff. In this paper we consider the design and implementation of one particular psychiatric hospital in Denmark to show that the 'nature' brought into this healthcare space can be experienced as anything but 'natural' and may reduce rather than enhance a felt sense of 'vitality' amongst patients. Based on our analysis, we end the paper by suggesting four principles for future healthcare design.

The Reorganization of a Psychiatric Unit During COVID-19: A Reflection for Psychiatric Hospital Design

OBJECTIVE

The COVID-19 pandemic has impacted healthcare systems worldwide. Although this disease has primarily impacted general medicine intensive care units, other areas of healthcare including psychiatry were modified in response to corona measures to decrease the transmission of the disease. Reflecting on the modifications to the environment provides an opportunity to design psychiatric environments for future pandemics or other demands for healthcare.

BACKGROUND

The therapeutic environment of psychiatric wards was modified in Friesland, the Netherlands, in response to COVID-19. During this time, an interdisciplinary team met consistently to contribute to the preliminary design of a new psychiatric hospital.

METHODS

During the first 18 months of the pandemic, clinical reflections were made to describe the impact of COVID-19 on the psychiatric care environment. Architects have created a preliminary design of a new psychiatric hospital based on these reflections, monthly collaborative design discussions based on virtual mock-ups and evidence-based design based on theoretical concepts and research.

RESULTS AND CONCLUSIONS

This theoretical and reflective study describes how an inpatient psychiatric environment was restructured to manage infection during COVID-19. The therapeutic environment of the psychiatric ward and patient care changed drastically during COVID-19. The number of patients accessing care decreased, patient autonomy was restricted, and the function of designated behavioral support spaces changed to manage the risk of infection. However, these challenging times have provided an opportunity to reflect on theories and consider the design of new hospital environments that can be adapted in response to future pandemics or be restructured for different care functions.

'Therapeutic landscape' experiences - redefining their relationship with the everyday

Feelings of removal from, and connection to, everyday life, are central to much of the 'therapeutic landscapes' literature, and to understanding of what makes 'therapeutic landscapes' 'therapeutic'. This paper develops understanding of the relationship between the everyday and 'therapeutic landscape' experiences, by exploring the origins of feelings of removal and connection. Data collected through a phenomenological approach (fieldwork sites: Buddhist meditation retreats, and non-Buddhist walking groups and conservation volunteering groups), targeted at capturing highly detailed information, demonstrates that both feelings of removal from, and connection to, the everyday, are bound-up with the everyday itself, with who we are and where we come from, and moreover, that these feelings exist alongside one another.

Therapeutic Landscapes and Psychiatric Care Facilities: A Qualitative Meta-Analysis

The environment in healthcare facilities can influence health and recovery of service users and furthermore contribute to healthy workplaces for staff. The concept of therapeutic landscapes seems to be a promising approach in this context. The aim of this qualitative meta-analysis is to review the effects of therapeutic landscapes for different stakeholders in psychiatric care facilities. A systematic literature search was conducted in the four data bases PubMed, PsycInfo, CINAHL, and Web of Science. Thirteen predominately qualitative studies were included in this qualitative meta-analysis. The methodological quality of these qualitative studies was assessed, using an adapted version of the Journal Article Reporting Standards for Qualitative Research, and a thematic analysis was conducted. The results were categorised into the three main themes of the physical (built and natural), social, and symbolic dimensions of the therapeutic landscape. Given the heterogeneity of the summarised data and an overall methodological quality of the included studies that can be rated as medium, the results should be interpreted with caution. Current findings are based almost exclusively on qualitative studies. Therefore, there is a need for quantitative study designs that investigate the relationship between specific environmental elements and mental health outcomes for different stakeholders in psychiatric facilities.

Bucking the system: Mitigating psychiatric patient rule breaking for a safer milieu

This article examines patients' understandings of rule breaking in the hospital setting. This work is important to inpatient psychiatric nursing because considering patients' perspectives about their own rule breaking can help nurses provide more therapeutic and safer patient care. The study finds that rule breaking behaviors are often a manifestation of patient resistance to institutionalization and loss of power. These behaviors are also related to nursing practice, as patients closely observe staff and look for gaps in the system to get away with or circumvent the rules. These findings suggest rule breaking behaviors can be reduced not by trying to further curtail the patient's autonomy but, rather, by changing the rules and/or how they are administered by staff to accommodate patients' perspectives and needs for freedom. Also, nurses must be clear in communicating with patients about the rationale for rules, and be consistent in how they enforce them.

"It is a different world in here": collective identification and shared experiential knowledge between psychiatric inpatients

This paper explores the social relations between inpatients in psychiatric wards. Combining Barker's (2002) concept of 'collective illness identity' with Nelson's (1993) concept of 'epistemological communities', I draw attention to the inpatients' collective identification and experiential knowledge. Through the analysis, three aspects of the inpatients' relationships are unfolded. First, how the inpatients, through bodily expressions and narrative accounts, construct a collective illness identity based on shared experiences of symptoms and suffering. Second, the ways in which the inpatients use their shared experiential knowledge to support one another and challenge the mental health professionals. Third, how the inpatients' reflections on the long-term potential of their relationships reveal a number of concerns related to their continuation. Centrally, the paper points to the potential and challenges that arise from the inpatients' relations to one another and their embeddedness in a specific time and space. Empirically, the paper draws on five months of participant observation conducted in two psychiatric wards in Denmark and interviews with 14 psychiatric patients.

How to design psychiatric facilities to foster positive social interaction – A systematic review

Psychiatric facilities are often criticised of being poorly designed which may contribute to violent incidents and patients’ complaints of feeling bored and lacking meaningful interactions with peers and staff. There is a lack of understanding how to design environments for staff, patients and visitors to engage in positive social interactions (e.g. conversation, sharing, peer support). We conducted a systematic literature review on which architectural typologies and design solutions facilitate helpful social interactions between users of psychiatric facilities. Several interventions were identified such as choosing a community location; building smaller (up to 20 beds) homelike and well integrated facilities with single/double bedrooms and wide range of communal areas; provision of open nursing stations; ensuring good balance between private and shared spaces for patients and staff; and specific interior design interventions such as arranging furniture in small, flexible groupings, introduction of plants on wards, and installing private conversation booths. These interventions range from simple and non-costly to very complex ones. The evidence should inform the design of new hospitals and the retrofitting of existing ones.

Recovery from severe mental illness in Québec: The role of culture and place

This paper examines the role of culture and place in recovery from severe mental illness amongst a group of Québécois living in Montreal, Canada. Results indicate that dominant cultural characteristics of Québécois, such as a marked Roman Catholic heritage, use of the French language and a close affiliation with the natural territory of Québec can all play important roles in recovery from severe mental illness. The findings suggest that participants weave together places with cultural, familial and personal meaning to create their own healing landscapes. We propose ways to leverage place and dominant cultural traits to facilitate recovery.

Moving Beyond the Behavior-Change Framework for Smoking Cessation: Lessons for a Critical Ontology From the Case of Inpatient Psychiatric Units

BACKGROUND: Leading scholars have called on nursing schools to pay more attention to smoking cessation in the education of nursing students. AIM: This article argues that attention to this subject should include a rethinking of the behavior-change framework that forms the methodological basis of this field. METHOD: Drawing on classic and contemporary work in sociology, anthropology, and critical public health, this article explores the specific example of smoking in long-term inpatient units to illustrate the limitations of a behavior-based ontology and suggest an alternative conceptual vocabulary. RESULTS: An alternative approach posits smoking as a social practice. It sheds light on situational factors that incentivize smoking and might be contributing to patient resistance to cessation. CONCLUSIONS: A different conceptual framing of smoking can point to interventions beyond the level of individuals, focusing instead on the broader interface between people and situations, where decisions and desires meet institutional and organizational dynamics and structures of opportunity and access.

A constructivist grounded theory of generalist health professionals and their mental health work

Generalist health professionals, often without formal mental health training, provide treatment and care to people with serious mental illness who present with physical health problems in general hospital settings. This article will present findings from a constructivist grounded theory study of the work delivered by generalist health staff to consumers with mental illness on the general medical/surgical wards of two metropolitan hospitals in Sydney, Australia. The results analysed included three participant observations, two focus groups, and 21 interviews and hospital policy and protocol documents. A substantive theory of mental health work in general hospital settings is illustrated which conceptualizes the following categories: (i) the experience: conflicting realities and ideals; (ii) The Context: facilitating social distancing; and (iii) the social processes: invisibility affecting confidence. The categories are understood through the theoretical lens of symbolic interactionism with the theory providing insights into how the generalist health professionals understand their sense of self or identity.

'Hopeful adaptation' in health geographies: Seeking health and wellbeing in times of adversity

Living with adversity can create wide-ranging challenges for people's health and wellbeing. This adversity may arise through personal embodied difference (e.g. acquiring a brain injury or losing mobility in older age) as well as wider structural relations that shape a person's capacity to adapt. A number of dichotomies have dominated our understanding of how people engage with health and wellbeing practices in their lives, from classifying behaviours as harmful/health-enabling, to understanding the self as being defined before/after illness. This paper critically interrogates a number of these dichotomies and proposes the concept of 'hopeful adaptation' to understand the myriad, often non-linear ways that people seek and find health and wellbeing in spite of adversity. We highlight the transformative potential in these adaptive practices, rather than solely focusing on how people persist and absorb adversity. The paper outlines an agenda for a health geography of hopeful adaptation, introducing a collection of papers that examine varied forms of adaptation in people's everyday struggles to find health and wellbeing whilst living with and challenging adversity.

“Resisting the Ban”

Purpose

The purpose of this paper is to present an evocative story “Resisting the Ban” which illustrates the ethical and pragmatic issues that nurses face when contending with smoking ban policies in inpatient psychiatric settings.

Design/methodology/approach

The creative story “Resisting the Ban” was developed based on an organisational auto-ethnographic approach. The story was crafted through employing creative writing techniques and through framing and critiquing memories via several theoretical frames.

Findings

The story illustrates how smoking ban policies have created pragmatic and ethical issues on wards. The work practices of nurses have changed as have their relationships with patients. The liberties of involuntary patients have also been infringed.

Research limitations/implications

This approach can illuminate links between acts of resistance and issues associated with public policies.

Practical implications

The effects of smoking bans need to be considered more carefully particularly in relation to their effects on workers and patients. The social meaning of the smoking bans needs closer investigation. Policy needs to be recrafted so that it better addresses the liberties of involuntary patients. Also ward nurses need to be able to carry out their roles in a manner which is consistent with their values.

Social implications

Public policies, such as smoking bans, can produce negative consequences maligning relationships, practices and cultures. Critical auto-ethnography provides a means of understanding issues that have resulted from problematic policies.

Originality/value

Scholarly work conducted on the relationship between everyday resistance in workplaces and public policies is rare. This study offers new “insider” insights into the negative effects of a smoking ban policy in psychiatric inpatient settings.

Mental health starts with physical health: current status and future directions of non-pharmacological interventions to improve physical health in first-episode psychosis

People with psychotic disorders have reduced life expectancy compared with the general population. This difference is primarily due to increased prevalence of cardiovascular disease associated with antipsychotic drugs and with modifiable risk factors, including weight gain, low exercise, poor diet, and high prevalence of cigarette smoking. We review non-pharmacological interventions for physical health behaviour in patients with chronic and first-episode psychosis. Our findings suggest that weight loss and attenuation of weight gain are achievable but limited and might not persist beyond the end of an intervention. Evidence for smoking cessation interventions is scarce. The case for early intervention to prevent deterioration of physical health is strong. We propose a framework for development of interventions, which addresses three main factors largely absent in previous research: (1) examination of aetiological factors related to poor physical health, (2) theory-driven interventions that target aetiological factors, and (3) assessment of feasibility.

Therapeutic micro-environments in the Edgelands: A thematic analysis of Richard Mabey's The Unofficial Countryside

The concept of therapeutic landscapes, as introduced by Gesler, has had a significant impact on what has become a reformed geography (or geographies) of health. Research in this field has developed the number and type of sites that have been characterised as therapeutic landscapes. A wide range of environments have now been explored through the analytical lens of the 'therapeutic landscape'. This research further expands current descriptions of such environments by exploring Edgelands as therapeutic micro landscapes. Edgelands refer to the neglected and routinely ignored interfacial zone between urban and rural that are a routine characteristic of the urban fringe resulting from dynamic cycles of urban development and decay. Using a hybrid method of thematic analysis incorporating both inductive and deductive approaches, this research explores Richard Mabey's seminal work on this topic, The Unofficial Countryside. Previous examinations of the features of therapeutic environments are therefore scrutinised to explore both scale and the possibility of further extending the kind of environments that may be described as therapeutic to include Edgelands. This approach is informed, in part, by principles of mindfulness, a historically Eastern, but increasingly Western approach to exploring oneself and the environment. This research identifies that these overlooked and neglected landscapes are in fact vibrant, resilient and enthralling environments teeming with life, renewal and re-birth. Examination reveals that there are three crucial outcomes of this research. The first relates to the issue of scale. Mabey's book provides evidence of the importance of micro environments in providing a therapeutic environmental focus. Secondly, this research explores the potential of mindfulness as an approach in Geography. Lastly, this research also identifies Edgelands as therapeutic sites and calls for an increased understanding and appreciation of their potential.

Compassionate containment? Balancing technical safety and therapy in the design of psychiatric wards

This paper contributes to the international literature examining design of inpatient settings for mental health care. Theoretically, it elaborates the connections between conceptual frameworks from different strands of literature relating to therapeutic landscapes, social control and the social construction of risk. It does so through a discussion of the substantive example of research to evaluate the design of a purpose built inpatient psychiatric health care facility, opened in 2010 as part of the National Health Service (NHS) in England. Findings are reported from interviews or discussion groups with staff, patients and their family and friends. This paper demonstrates a strong, and often critical awareness among members of staff and other participants about how responsibilities for risk governance of 'persons' are exercised through 'technical safety' measures and the implications for therapeutic settings. Our participants often emphasised how responsibility for technical safety was being invested in the physical infrastructure of certain 'places' within the hospital where risks are seen to be 'located'. This illuminates how the spatial dimensions of social constructions of risk are incorporated into understandings about therapeutic landscapes. There were also more subtle implications, partly relating to 'Panopticist' theories about how the institution uses technical safety to supervise its own mechanisms, through the observation of staff behaviour as well as patients and visitors. Furthermore, staff seemed to feel that in relying on technical safety measures they were, to a degree, divesting themselves of human responsibility for risks they are required to manage. However, their critical assessment showed their concerns about how this might conflict with a more therapeutic approach and they contemplated ways that they might be able to engage more effectively with patients without the imposition of technical safety measures. These findings advance our thinking about the construction of therapeutic landscapes in theory and in practice.