This multi-method, multi-case study was a philosophically pragmatic and realist inquiry into how the physical habitat/material environment supports or hinders the creation of therapeutic safety in acute inpatient mental healthcare facilities.
The literature review indicated that trust is integral to therapeutic relationships but acts of trust were unlikely without manifest organisers and signifiers of trustworthiness. The Constructing Trust Model that emerged from the review postulated that the Environmental Determinants of Care, comprised of physical, social and symbolic elements, moderated therapeutic trust in the development of safety. The Determinants were incorporated into James Reason’s (1995) Swiss Cheese Model of Accident Causation to illustrate how environments emphasizing surveillance and technical safety do not create therapeutically safe environments but introduce latent error, leading to patient harms such as violence, seclusion and sanctuary harm.
Four sites were purposively selected for participation in the study. Initial site visits were made to three newly commissioned facilities and data were collected using key informant interviews, document and artefact analysis. Alterations were made at the fourth site, including: acoustic dampening, wall murals, gardens, increased circulation space, new colour scheme, and new outdoor furniture. Data collection also included focus groups, a safety climate survey, spatial data, incident data and seclusion data. The frequency and duration of seclusion was reduced during renovations. Staff reported consumers found the work a welcome distraction, providing hope that a poor environment would be much improved. On completion staff reported reduced patient agitation, increased patient satisfaction, and fewer incidents of vandalism. Seclusion practices, however, soon reverted. Funding was not provided for changes to address environmental problems known to be linked to seclusion use, that is, overcrowding and social density.
Three major findings emerged in the cross-case analysis. Firstly, participants held dichotomous beliefs about safety. I labelled those who viewed safety as arising from the control of concrete hazards requiring custodial environmental designs, ‘Risk Warriors’, and those who considered trusting relationships the precursor to safety, requiring environments signifying care, trustworthiness and refuge, ‘Trust Advocates’. Secondly, at all four facilities decision-makers did not follow the advice of Trust Advocates and introduced unintended risk into the care system, creating the latent conditions for iatrogenic harm. Thirdly, collocation of acute inpatient mental healthcare facilities on general hospital sites encouraged the cultural dominance of Risk Warriors, leading to an over-emphasis on surveillance and the control of risks, to the detriment of trust development strategies and therapeutic safety.