The physical environment of hospitals is a critical component of care that has direct functional and psychosocial effects on patients and families and significant implications for safety, quality, and efficiency of care (U.S. Department of Veterans Affairs, 2010). However, despite the prevalence of older adults in acute settings and the accompanying rhetoric of person- and family-centered care, research examining the experience of older adults and their families in an environmental context is lacking. The current article addresses this gap by reporting findings of a study that examined how the physical features of a geriatric psychiatry unit positively and negatively affected the care experience of patients and their families.
Although few studies have been conducted that specifically examine the environment of in-patient geriatric psychiatry units, research conducted in related clinical areas supports the notion that physical environment plays an important role in promoting good patient care. Small pilot studies, expert opinion articles, and anecdotal reports provide helpful guides for environmental interventions (Dobrohotoff & Llewellyn-Jones, 2011; Karlin & Zeiss, 2006). On the whole, this literature supports the claim that a supportive environment can promote functional ability and recovery, reduce stress and confusion, as well as enhance safety in older adults (Cohen-Mansfield, 2001; Parke & Chappell, 2010). One of the most consistent recommendations in the literature in regard to the general adult psychiatric hospital environment is to reduce the “institutional feel” and create a familiar and home-like atmosphere. For example, Edvardsson (2008) found that slower pace of care, familiar smells of food and coffee, and reduced noise fostered a relaxed and safe atmosphere. The sound environment may be particularly important. Music has been shown to reduce stress and anxiety among patients in hospitals (Joseph & Ulrich, 2007), whereas other acoustic interventions may include the use of noise absorbing materials (e.g., carpeting, ceiling tiles) and single-patient rooms (Ulrich et al., 2008). Providing some form of access to the natural world has also been shown to be beneficial. Access to views of grass, trees, flowers, and gardens may have a calming effect and promote healing for hospitalized patients (Sternberg, 2009). Keeping corridors free from clutter and using symbols and clear signage to indicate function of rooms seems to support orientation for individuals with dementia (Day, Carreon, & Stump, 2000). In addition, single/private bedrooms offer space and privacy to the family and patient, whereas comfortable furnishings encourage family participation and support care (Chaudhury, Mahmood, & Valente, 2009).
In a recent nurse-led project in the United Kingdom, nurses worked in partnership with patients to improve the environment of an orthopedic ward and a geriatric ward by adding quality lighting, photographs and artwork, repainting walls, adding memory boxes to assist in way-finding, and personalizing spaces. They reported positive results, including a decrease in the number of falls and incidents of challenging behaviors, reductions in the use of antipsychotic medications, and improvement in staff morale (Waller, 2012).
Traditional acute care hospitals are generally designed for young adults and may not accommodate age-related changes or support optimal function in older adults. Patients with mental health needs and dementia have even greater challenges, as their ability to adjust or cope with environmental stressors is decreased. The current study explored how the physical environment in a geriatric psychiatry unit may play a role in either supporting or obstructing patient and family care needs.
Design and Setting
This qualitative study was conducted on a locked 16-bed geriatric psychiatry unit in a 60-year-old urban community hospital. A focused ethnographic method (Cruz & Higginbottom, 2013) was chosen because conducting observations and interviews together allowed patients with memory deficits to show and express their views about the environment as events were happening. The layout of the unit is L-shaped, with patient rooms (single bed, double bed, and four beds) along one wing, a nursing station in the center of the L, and common rooms, including a lounge with afternoon access to a small outdoor balcony along the other wing.
Sample and Data Collection
The authors used purposive sampling to ensure recruitment of patients with a variety of functional and behavioral needs. The study sample included seven geriatric patients with depression, dementia, or both with responsive behaviors (four men, three women; ages 70 to 92) and four family members. Five researchers independently conducted observations and interviews with patients and family members on days, evenings, and nights throughout the week. Twenty hours of observation occurred in 15- to 60-minute intervals over a 3-month period in the spring. Mealtimes, group sessions, and unstructured activities in common areas as well as in patient rooms were observed. “Go-along interviews” (Carpiano, 2009) were used to allow participants to comment spontaneously on the physical environment and their experiences as events happened during observations. Data collection was completed when researchers believed nothing new was being observed or heard in interviews.
Data were analyzed following the procedures outlined by Braun and Clarke (2006), which offer clear guidelines on a step-by-step approach in thematic analysis. The final thematic map is presented in Figure 1. The transcribed data from interviews and field notes were read, reread, and initially coded independently by all five researchers. The researchers had in-depth discussions to reach consensus, compared data across all data sets, then collectively grouped the codes into categories and further reduced the categories into broader themes and sub-themes. Regular meetings were held biweekly to perform ongoing data analysis, debrief issues, problem solve, and make plans for further data collection. Ongoing reflexive discussions took place to ensure pre-assumptions were maintained. One author (A.P.) is a research expert in gerontological nursing; she provided mentorship throughout the research process. This collaborative work, reflexive efforts, systematic process, and the use of multiple data source and methods contributed to ensure credibility of this research.
The study received ethics approval from the Research Ethics Boards of the university and regional health authority prior to the recruitment of participants. A process consent approach (Dewing, 2007) was used to reinform and recheck consents and assents with all participants throughout data collection to ensure their rights were protected. To maintain confidentiality, only pseudonyms were used and the actual names of the participants did not appear on the digital recording, transcript, or final document.
According to patients and family members, four environmental attributes were recognized as being central to promote healing and coping: (a) therapeutic; (b) supportive of functional independence; (c) facilitative of social connections; and (d) provision of a sense of safety and security (Figure 1).
For all participants, the physical environment of a psychiatric unit was perceived as an important element of healing, a vital part of the therapeutic process. Patients and family members defined therapeutic as “positive” and “home-like.” One family member depicted a therapeutic milieu as being quiet and calm, with low stimuli, while at the same time providing positive stimulations.
A home-like environment was viewed as welcoming to family presence and having a positive psychological effect. Features such as warm color, comfortable furniture, and domestic decor were regarded as stress-reducing. In contrast, institutional design such as long, straight hallways, with parked wheelchairs and patients calling out, were experienced as “depressing.” One patient’s daughter explained:
I just want to feel safe from emotional outbursts. The environment can affect my mood when I leave. If it’s dark and gloomy, it affects my mood poorly. It’s important to feel my dad is in a positive home-like environment.
Participants indicated that tranquil, calm surroundings were more conducive to healing. In particular, features of the natural world such as the patio, sunlight, fresh air from outdoors, flowers, and plants were noted to be calming and refreshing, as well as stimulating. For example, one patient stated: “It’s terrible to be stuck in here all the time. I like to go out to get fresh air, to see the spring flowers, the trees and greenery, very pretty out there.”
Patients and family members expressed feeling distressed dealing with common negative stimulations, such as noise from confused patients calling out, multiple alarm systems (e.g., doorbells, chair/bed alarms), and overhead announcements. One patient reported that the calling out of other patients made her feel scared; another patient expressed empathy and feeling distressed and helpless. A third patient expressed fear for her own dignity should her illness progress.
Supportive of Functional Independence
A supportive environment was interpreted as being accommodating to limitations of older adults and maximizing their ability to maintain as much independence as possible in bathing, grooming, eating, and dressing. In contrast, obstacles in the environment that restricted optimal function were observed to include toilets with no doors; long, cluttered hallways with stretchers, wheelchairs, and other equipment; inadequate space to move around safely; and inconvenient or lack of storage for clothing and other personal toiletries. Among all of the complaints, the bathroom was the most problematic, as described in the following field note:
Patient Linda struggled to maneuver her walker in the close confines of the washroom and became increasingly frustrated. “Why do they make the washrooms so small? Could you please help take this thing [walker] out of here? I’ve dropped my brush and now I can’t reach it.” Linda struggled to hold her nightgown, toiletries, and a towel. “This is ridiculous! It would help if the place was bigger and if there was a shelf or drawer to put my things in.” For Linda to safely return to her bed, she required assistance to move several objects out of the way. As Linda remarked, “It’s like an obstacle course in here.”
Patients and family members also believed that long corridors, identical looking rooms, and frequent room changes were confusing and obstructive for independent way-finding. Patients frequently complained about confused patients going into the wrong bed or wrong room. Patients depended on nurses’ help for things such as finding the dining room or returning to their own room due to the lack of effective directional clues or signage in the environment. One patient told us that the nurses took her to areas within the unit and it bothered her, as she preferred doing things for herself. When asked why she needed nurses to escort her, she explained, “There are no signs to show me the way to the dining room or my bedroom. I know my room number, but unless I’m right outside my door, I don’t know where it is.”
Facilitative of Social Connection
Patients and family members perceived social connection as feeling connected to others through having things to do with other patients and staff. Explicitly, the use of music was observed to have profound effects around the unit. Patients, including those who were severely impaired, expressed their enjoyment and appreciation of the music as it evoked positive emotions, humor, and memories. This is evident in the following field note:
A young volunteer came in to play classical music. A patient connected to an intravenous machine tapped her index finger along to the music while another’s feet were pattering with the rhythm as she stared out the window. A gentleman, looking delirious, invited me to sit beside him. As the music played, the tempo got faster, he became more elated, moving his fingers blissfully, pretended he was playing piano. He reached to my side to tap the high and low piano keys, dancing his feet, clapping his hands, playful and creative in making funny faces, very animated, raising his eyebrows, shaking his body, moving his head…. Once the volunteer left, the room returned to the hospital mode—the IV machine was beeping, the TV was turned back on; people had their heads down.
Physical elements in the environment that facilitate positive social interactions can contribute to supporting personhood. For instance, patients and family members frequently mentioned how much they enjoyed having access to the outdoor patio and patio furniture, which offered an opportunity to connect with the outside world. Patients and family members also expressed their appreciation of the offered activities (e.g., baking, music, access to books, personal conversations, craft-making) as these met individual preferences and provided a sense of purpose, contribution, capability, and normalcy. Essentially, in the interviews with patients, there was a strong theme of wanting more opportunities to engage in meaningful activities and reduce boredom and loneliness. Comments such as “the days are very long here because there is not much to do” were mentioned often. One patient explained how activities and chores on the unit promoted her self-esteem and well-being: “I love to help out sorting paper because I can...it makes me feel capable.”
Spaces that offer activities not only were supportive in promoting social engagement, but they contributed to maintaining personhood by supporting the patients’ sense of identity. Performing non-medical tasks and participating in small talk in social spaces were found to offer patients an opportunity to reminisce about their past and share their life experiences with others. This helped create a feel of at-homeness, as well as an experience of being connected and respected. A patient proudly described the decades he spent working as a housekeeper and how he went on to own a housekeeping company. Another patient described her experience of sharing her life story:
Julie [a rehabilitation staff member] helped me find my old house and advertising company on the computer. We did business with people all over the country and we were successful. It’s just nice to have the portfolio. I’m not gonna go to work or anything, it’s just that I could tell people what I have done, what kind of business I was in.”
Safety and Security
The feeling of personal safety and security was found to be important in reducing distress and supporting healing. The lack of private patient rooms caused much distress for many patients and family members. One patient, Nora, and her husband described their emotions when they found a male patient in her bed:
A man was in my room, sitting on my bed touching everything. I told him to get out and he refused. I was scared and mad. They [staff] couldn’t get him out. They had to call security. I was so upset. I feel my privacy has been violated. They gave me pills to calm down but I couldn’t sleep all night.
Sharing rooms with other patients was observed to evoke feelings of frustration. Patients did not wish to disturb others and did not wish to be disturbed. Sharing rooms with cognitively impaired patients caused further distress, and at times, led to use of physical and chemical restraints.
From our observation, there was a desire from patients to have staff in proximity and/or the ability to quickly call staff for help when needed. When patients who were unable to move themselves were left on their own to call out, fellow patients and visitors reported feeling distressed, sad, and helpless. Further, minimized clutter, continuous access to handrails on both sides of hallways, benches for rest, and even flooring were important environmental strategies for fall prevention and patient safety.
These findings provided a better understanding of how the physical environment of an acute geriatric psychiatry unit supported or hindered care. Drawing on the evidence from the literature and patient and family views, the authors developed a reference model (Figure 2) that captures the four identified themes and possible environmental interventions that may contribute to a positive healing environment.
Reference model. Suggested environmental strategies to support older patients and their families.
Discussion and Implications for Nursing
The results of the current study highlight the unique perspectives of older adults with mental health conditions and their family members on their acute hospitalization experiences. Analysis of their experiences is consistent with research that indicates the physical environment plays a significant role in supporting safety and quality of care. However, further research in the area of acute geriatric psychiatry is needed. Given the rapid growth of the aging population, more patient and family involvement in research and design of hospital environments will be necessary to make acute care environments age-friendly and responsive to mental health needs of older adults.
Understanding the relationship between the hospital environment and experience of patients and family members has important implications for nursing practice. By increasing the knowledge of the key aspects of the physical environment of hospitals, gerontological nurses can help create care environments in acute hospitals to meet the needs of the aging population in a more person- and family-centered way. Although each of the themes can be viewed separately, these environmental attributes are interconnected in many ways. For example, patients and family members may consider safety as an element of the therapeutic aspect, as well as supportive of functional abilities. The good news is that implementation of one intervention may contribute positively to more than one of these attributes. For example, providing Nora with a private room would enhance patient privacy and reduce disruptions and noise, which may be agitating and disturb sleep. A single room would also give her a sense of safety and security—appropriate stimulation that promotes recovery.
Making improvements to the physical environment may be considered valuable, but daunting. However, not all environmental interventions are expensive or require huge capital. For example, music, an inexpensive intervention, can encourage social engagement (McCloskey, 2004). In the current study, music had a powerful impact on the psychosocial experience of patients. Other implements such as plants, gardens, paintings, and artwork can also easily retrofit existing environments. Expensive interventions or those that require unit reconfiguration (e.g., single private rooms, outdoor spaces, open communal areas) continue to be important, as they have been shown to provide privacy and reduce violence (Kumar & Ng, 2001) and should be advocated for and taken into consideration when planning new buildings or renovating existing structures. Using creativity, nurses can develop innovative ideas to make a patient- and family-centered care environment possible. For example, a small indoor therapeutic “garden room” could be created, as going outdoors may not be feasible for some frail older adults. For social environment, personalized name tags and event calendars are helpful orientation clues. Sources for therapeutic activity kits can be found at http://consultgerirn.org/resources/?tt_request=theraAct.pdf in the “Try This®” series.
Essentially, the stories told by the study participants suggest that staying on a locked acute psychiatric unit leads to feelings of fear, helplessness, and lack of autonomy. A predominant element consistently emerged that seems to mediate negative feelings: “The nurses are very good.” Again and again, patients and family members described the relationships they had with nurses as key to their acute care experience. It was the relational work that helped patients and family members feel they were cared for and respected. Future research should further investigate how the physical aspect of the hospital environment may underpin the attitude and behaviors of nurses in caring for older adults. Caring for older adults with mental health needs, along with complex comorbidities and functional challenges, involves immense emotional work and stress; therefore, appropriate environment and adequate support are essential. Furthermore, the hospitalization experience of patients can be affected by multiple factors, including individual symptoms relating to illness, expectations of care, and previous experience. Future studies need to investigate the dynamics and interactions of these factors and how they shape the experience of patients.
The authors recognize that the small sample and exploratory nature of the study limit the generalizability of the results. However, given the prevalence of older adults and the rise in dementia and other mental health needs in acute care hospitals, many of the current study’s findings and recommendations may be applicable to other acute care units.