The Physical Environment

Abstract

Many readers will have worked in facilities that were once state-of-the-art in design, but have become unfit for the purpose. Capacity to modify the physical environment of a psychiatric unit in response to changing clinical need or practice is essential. The Walker Unit differs from adolescent units at other locations because of its larger internal footprint and greater secure outdoor space. Substantive modifications to the Walker Unit over time have included requisitioning of space to create a learning centre, modification of some bedrooms to create a parent retreat, the establishment of a sensory room, and repurposing of the seclusion area to become a de-escalation suite. The chapter will describe the physical environment of the Walker Unit referenced to Australasian Health Facility Guidelines, and current best practice.

Introduction

The Australian Health Facility Guidelines stipulate that inpatient mental health units for young people require “a conscious balancing of the requirement to provide an effective therapeutic environment for acute mentally ill young people with the need to provide them and their families’ visitors and staff with a pleasant, spacious light filled, comfortable and homely facility” (Australasian Health Infrastructure Alliance, 2016). Domestic style furnishings and décor should be homely not custodial, and in shared spaces should be movable to make adjustments for activities.

The environment should support the provision of safety and privacy of young people, allow for spaces where individual therapy can be conducted confidentially, group therapy and educational activities can be conducted for larger groups and recreational activities can be planned and undertaken. The environment should have capacity to offer smaller containing zones that can be used to separate young people experiencing distress, away from the wider patient group to prevent what Sergeant (2009) describes as the “Domino effect” where distress spreads among young people. These containing areas should enable distraction and sensory modulation activities to take place and reduce the noise created during distress from affecting the wider ward area. In situations where there is an event of behavioural disturbance such as aggression, the ability to move the wider group of patients to a different area where the programme can continue, reduces the need for physical restraint.

History

The public announcement that an adolescent unit would be established on the Concord Centre for Mental Health campus was made when the Centre was partially built (see Fig. 2.1). The ward allocated for this purpose was originally intended as an adult extended care unit. As such, considerable modification to the design was required from the outset to accommodate the needs of mentally unwell adolescents. Fortunately, some of these modifications were made while the original build was in progress. For example, the areas labelled “Arts and Crafts” and “Group Room” in Fig. 2.2 were redesigned to accommodate the Learning Centre, while the area labelled “Activities” became the Art Therapy space. Subsequent modifications have been made to respond to the need for structural improvement, repurposing of space, privacy, infection control, and Occupational Health and Safety (OH&S) concerns.

Fig. 2.1

Phase of build at the time the ward was repurposed from an adult extended stay unit to an adolescent high severity longer-stay unit

Fig. 2.2

The Walker Unit floor plan at the time of commissioning

The responsibility for facility planning first rested with the health district’s Director of Child and Adolescent Mental Health Service (CAMHS), the nursing unit manager of an existing adjacent medium severity adolescent mental health unit, the principal of the school providing learning centre support to the unit, and the Mental Health Facility Planner. They worked from the floor plan illustrated in Fig. 2.2. The Director recalls the challenge of trying to imagine from the floor plan how the unit would look in real life, as 3-D imaging was not available to the team. After commissioning responsibility for facility planning, it was transferred to the unit’s newly appointed nursing unit manager and psychiatrist director, supported by the CAMHS and Mental Health Service executives.

Modifications

Since the Walker Unit opened in 2009, there has been extensive modification to address clinical risks and to ensure that the environment is both therapeutic and safe. The original fit out of the building posed a number of safety hazards. For example, fire extinguishers were placed in common areas, where they could have been used by an assaultive patient as weapons. Bedrooms contained items that could be misappropriated for self-harm, such as exposed metal screws in the light fittings and metal strips under the doors. Once identified these hazards were removed and replaced.

As the clinical programme evolved, use of the available space within the unit changed. For example, the adoption of trauma informed care principles has altered greatly the way in which the seclusion area is used. Originally used for time out, and sometimes the emergency administration of medication, it now forms part of a suite of low stimulus options for young people who are emotionally and behaviourally not regulated.

A quality project as well as a needs analysis were conducted over a two year period from 2012–2014 incorporating physical environment, practices and policies through several Plan, Do, Study, Act (PDSA) cycles. An inventory and stocktake of what we had and what we required and wished for was discussed through several planning meetings. The design of several spaces such as the development of the parents retreat room and sensory spaces were envisaged and planned for future implementation.

Since the original building was completed, there have been a number of capital work adaptations:

• 1. Creation of a parent retreat room, including en-suite bathroom and overnight facilities such as a sofa-bed, within an accessible bedroom and en-suite.

• 2. Extending an interview room and creating a purpose built sensory room.

• 3. Changing a high secure bedroom into a quiet room and then into a staff resource room.

• 4. Adding secure doors to the main corridor and opening up two bedrooms to create the High acuity POD, which includes a bedroom, en-suite and living area that can be securely maintained as a containment area.

• 5. Creating a purpose built musical instrument store in the space where music therapy is undertaken.

Description of Current Ward Physical Environment

The Walker Unit is a large inpatient unit offering 11 bedrooms, 6 of which are located off a secure corridor, a number of lounge areas, three outdoor courtyards, a sensory room, art room and de-escalation suite all surrounding a central nursing office, secure kitchen and dining area. The unit contains a two-roomed Learning Centre, parent’s retreat room, and two interview rooms. Managing risk and supporting safety is a key feature of the physical environment. Safety checks are undertaken by staff before young people enter the unit to ensure an environment free from items that can be used to cause harm. Delaney et al. (2018) describe inpatient CAMHS units as providing an “aseptic” environment free from fixtures and furnishings that can be used for the purpose of self-harm; some of the modifications made at the Walker Unit are depicted below (Figs. 2.3, 2.4 and 2.5). All windows have thickened secure glass, all doors accessing the ward area have viewing windows to prevent young people absconding when doors open. A duress alarm system works throughout the unit spaces.

Fig. 2.3

Adaptations made to improve safety

Fig. 2.4

Adaptations to improve safety

Fig. 2.5

Adaptations to improve safety

Separating Spaces

The Walker Unit was designed so that it could function as two separate zones. When a young person needed a more secure space to support their safety and privacy away from other young people, it was common practice to move either the young person or the wider group into the other zone. However, when the second side was used to support an individual, access to some facilities was compromised. In 2021, capital works were undertaken to create a “High acuity POD”. This area can now be locked off from the rest of the unit, provide a living and dining space, bedroom and en-suite bathroom and securely contain a young person with lesser restrictions on space for the wider group. This POD space is located by the parent retreat room and has secure access to a courtyard. This space provides containment for acutely unwell young people on admission to the Walker Unit. When this space is not required for containment, it is kept open and offers a third lounge area and seating area that can be used to provide group or family therapy.

Single Bedrooms

Each young person has their own bedroom with shared single use bathrooms. Each bedroom contains a tamper-proof bed preventing a hiding place for contraband, fixed shelving, desk and bedside table and a magnetic locked cupboard. The bedrooms have blinds between the window panes so no curtains, which could provide ligature fixtures, are required. Six of the bedrooms are accessed via a secure corridor adjacent to the nursing station allowing for close observation. In the secure corridor, the bedroom doors are fitted with a window with integrated blinds that can be operated from the outside to enable regular checking on the young people’s wellbeing. Bedrooms in the secure corridor can have their doors removed to prevent barricading by a young person who may attempt being unsafe. The use of single bedrooms and bathrooms allow for capacity to accommodate gender diverse young people without having to make obvious environmental adjustments, supporting both their needs and confidentiality. Young people are encouraged to bring in bedding and decorations from home to make their room feel homely and inviting. Bedrooms are locked during the hours of the therapy programme, but can be accessed on request as needed.

Multipurpose Spaces

The main lounge and dining area provides space for all young people and staff to eat meals, run group activities, hold community meetings and farewell events at discharge, and run school assemblies. It is within view of the nursing station. The other ward areas; interview rooms, art room, sensory room and de-escalation suite routinely are spaces used for individual therapy sessions, smaller family meetings or supporting individuals experiencing difficulties away from the busier area offering more privacy and reduced sensory stimulation.

Outdoor Spaces

There are three courtyards available at the Walker Unit, offering access to a trampoline, basketball rings, exercise bike, rowing machine and punching bag. One courtyard is specifically designed as a sensory garden, with musical instrument fixtures, artificial grass, water sprinklers, orange and lime trees and a sand pit (see Chap. 13). All the courtyards have modified designs that include anti-climb fencing and walls. Access to a courtyard is supervised by staff and duress sensors can detect alarms in these areas. As with the internal spaces, frequent environmental searches must take place in the courtyard to remove items that could be used to self-harm with such as broken glass or sharp objects. During the warmer months, each Friday lunch, the unit has a barbeque and all the staff and young people dine together outside.

Staff Presence and Availability

Engaging young people in meaningful activities, learning centre or programme activities, or relaxing and social recreational activities in the evening is central to being able to observe young people’s behaviour and the dynamics amongst the wider group so as to provide support or intervention when required. In a large space such as the Walker Unit, the ability to plan activities with young people and manage the space, so that staff can observe and engage does include the ability to close the space down and open spaces in a planned way to account for the needs of the young people.

If We Knew Then What We Know Now

• 1. Outdoor space should be well maintained, plants and bushes trimmed to allow clear view underneath to prevent hiding of contraband items. Outdoor spaces should be well lit so they can be used in evenings when it becomes dark as a space to offer a variety of de-escalation activities.

• 2. Consider having spaces available that can be closed into more private, containing space, to be able to support young people in distress away from the wider unit population. Distressful noise can contribute to a cascade effect, disturbing other young people and triggering distress.

• 3. Have the capacity to close the wider areas of a unit down in the evening, as part of the night time routine and focus activities in fewer spaces.

Conclusion

The physical environment of an adolescent inpatient unit is a constantly changing one. Several modifications and improvements have been made to the Walker Unit to address risk and safety, which have necessitated in minor capital works and changing practices. The balance of being a therapeutic space versus safety and containment is always a challenge, however, just as young people learn from practical experience, so do the staff adapt with ongoing practical solutions.