A Recovery-Oriented Care ApproachWeighing the Pros and Cons of a Newly Built Mental Health FacilityCatherine Clark Ahern, MA, BSc; Peter Bieling, PhD, CPsych; Margaret C. McKinnon, PhD, CPsych; Heather E. McNeely, PhD, CPsych; and Karen Langstaff, MHSc

The current study adopted a recovery-oriented care approach by emphasizing patients’ perspectives and experiences regarding changes to a newly built mental health facility. The inpatient entrance, or “portal,” intended to balance the aims of recovery-oriented care with minimizing risk. A mixed-methods study of the por-tal’s pros and cons was conducted, according to four themes: (a) autonomy versus inconvenience; (b) safety and security versus stigma; (c) unit door versus portal operat-ing costs; and (d) privacy versus community integration. Focus groups engaging with patients (N = 39) indicated that the design effectively supported recovery-oriented care. Patients did not find the portal to be stigmatizing or triggering and valued the safety and privacy it created, and visitors also generally had a positive experi-ence. Survey responses (N = 101) from portal users were also positive about the new design. The study findings suggest that the pros outweighed the cons of the new design. [Journal of Psychosocial Nursing and Mental Health Services, 54(2), 39-48.]

© 2016 Ahern, Bieling, Langstaff, McKinnon, & McNeely; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International (http://creativecommons.org/licenses/by/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article, for any purpose, even commercially, provided the author is attributed and is not represented as endorsing the use made of the work.

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ABSTRACT

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The recovery-oriented care model is increasingly becoming a widely accepted standard of care

for mental health services (Gilburt, Slade, Bird, Oduola, & Craig, 2013) and is based on the principles of hope, empowerment, self-determination, and responsibility (Mental Health Commis-sion of Canada, 2012). Recent national guidelines have recommended extend-ing this model from individual care to an institutional level, asking that individuals with lived experience co-design policies and procedures (Men-tal Health Commission of Canada,

39Journal of Psychosocial nursing • Vol. 54, no. 2, 2016

2015). However, the best way to act on this type of directive remains unknown (Grol & Wensing, 2004), particularly in inpatient settings (Kidd, McKenzie, & Virdee, 2014). One possibility for

implementing this standard of care is by engaging patients as co-creators of health care through their engagement in mental health services decision making (Calami-nus, 2013; Schwartz et al., 2013).

The purpose of the current study was to adopt a recovery-oriented care approach by emphasizing patients’ perspectives and experiences to study and manage the change to a newly built mental health facility. Engag-ing patients for their contributions is particularly important when, as in the case of the current facility, the novel and unique design features have generated debate among hospital ad-ministrators, care providers, and other building users.

BACKGROUNDThe somewhat controversial issue

arose in the context of St. Joseph’s Healthcare Hamilton’s (SJHH) newly built West 5th facility—a 305-bed, tertiary-care, inpatient mental health hospital that is integrated with out-patient mental health, diagnostic, and medical services. The newly built environment was developed using a clinically informed, patient-centered design to improve the quality and safety of care (Karlin & Zeiss, 2006), stemming from the best evidence and a participatory approach that included many stakeholder groups (e.g., staff, patients, community mem-bers, funders) (Karlin & Zeiss, 2006; Perkins, 2013). Among the most in-novative, but also potentially con-troversial, features of the new facility are the interdependent inpatient en-trance, or “portal” (Figure 1), and a unique transitional security zone, or “galleria,” where many amenities for patients are located (Figure 2). The portal restricts movement between a fully publicly accessible outpatient area and an inpatient area that in-cludes both the galleria and 14 inpa-tient units (Figure 3). These design features were intended to balance the aims of supporting patients’ autonomy (e.g., by having unlocked inpatient unit doors) and integration with the community while minimizing risk and protecting patients’ privacy (Dvoskin et al., 2002; Eggert et al., 2014). By contrast, the original 1950’s-era fa-cility was readily publicly accessible, except for the inpatient units, which

Figure 1. Blueprint of the inpatient entrance (i.e., the portal).

Figure 2. Photograph of the transition zone (i.e., the galleria).

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were universally and consistently locked. These novel and unique de-sign features added significant ex-pense and had far-reaching design im-plications for the entire hospital. For example, access to outdoor spaces by patients residing on the second floor requires leaving the unit, and access to some allied and medical health services (e.g., dentist) requires all pa-tients to be able to leave their units. Although the stakeholder groups who participated in the hospital’s design were hopeful about the transformative potential of these innovative features, their newness created unanticipated challenges.

Soon after opening in 2014, the hospital’s leadership received feed-back that users were having difficulty adjusting to this significant change in design. Visitors to inpatient units now had to identify themselves at the portal before going to the specific units to see a loved one, and security personnel were now participating in the decision to let a patient in or out through the portal. As a result, many options were considered to manage the change in design, including re-moving the portal and effectively re-turning to the security design of the old facility. However, before any op-tion was selected, a decision was made to gather feedback from users and evidence of the impact of the design features in an effort to maintain a re-covery-oriented approach at all levels of care (Livingston, Nijdam-Jones, Lapsley, Calderwood, & Brink, 2013). Consequently, an ongoing existing pre- and post-occupancy evaluation of the West 5th facility was expanded to include a specific sub-study of the por-tal and galleria (Ahern, McKinnon, Bieling, McNeely, & Langstaff, 2015).

This smaller study, outlined here-in, compares the pros and cons of the portal and galleria based on four themes developed in collaboration with key stakeholders, particularly unit managers (Figure 4) and draws on a mixed-methods approach. The first theme is autonomy versus incon-venience, where patients’ autonomy is

enhanced by the inpatient zone yet creates an inconvenient process for visitors to access the inpatient units. The second theme is safety and security versus stigma, where the more obvious security presence might increase stig-ma by further associating criminality with mental illness. The third theme is unit door versus portal operating costs, where the costs of locking all inpatient unit doors are compared to the cost of operating the portal. The fourth theme is privacy versus community integration, where patients are integrated with the community to enhance transitions out of the inpatient setting.

METHODA mixed-methods approach was

taken to gain both users’ perspectives and experiences of the design fea-tures and their impact on the quality of care. Methods included six focus groups (N= 39 participants), a survey (N = 101 respondents), interviews

(N = 14), observations (72 hours), and a review of hospital records, which emphasized patients’ perspec-tives and experiences to better inform the decision-making process (Van Tosh, 2013). This approach was se-lected because the novelty of the fa-cility design meant that there was no baseline comparator and because of the complexity of the related issues and implications for care. Ethics ap-proval was obtained from the Hamil-ton Integrated Research Ethics Board.

Focus GroupsSix groups were conducted with

patients from the Forensic Psychia-try Program (n =2), Schizophre-nia and Community Integration Service (n = 2), Acute Psychiatry (n = 1), and Concurrent Disorders Program (n = 1), as this approach has been proven helpful for gain-ing perspectives of other redevelop-ment projects (Malagon-Maldonado,

Figure 3. Security zones and therapeutic pass levels (TPLs) created by the unit doors and portal.

41Journal of Psychosocial nursing • Vol. 54, no. 2, 2016

2014). A focus group was conducted with family members of patients in the Seniors Mental Health Program because many patients in this pro-gram are non-verbal. Patient partici-pants were offered a $5 coffee gift card for participating and were asked to complete a consent form, assuring the anonymity of their responses. Every effort was made to support meaningful engagement to ensure patients’ per-spectives were faithfully represented. This representation included having a skilled facilitator lead the group, in-viting unit staff to remain and offer support, and taking notes instead of using a recording device. The facili-tator (C.C.A.) described the consent process, explained the reasons for the design features, and summarized the criticisms of the portal and galleria. This approach seemed to be success-

ful, as patients engaged with the top-ic, and consensus or near consensus was reached at each session. At the end of each session, an informal poll was taken about whether the portal should remain or be removed.

SurveyIndividuals who stopped at the se-

curity desk between July 7 and July 19, 2014 (N = 101), were invited to complete an anonymous survey about their experiences and were offered a $5 coffee gift card, following quality improvement methodologies (Ortiz, 2014). The survey was developed for visitors, but no one wanting to par-ticipate was refused. Reasons identi-fied for using the portal were used to group respondents into patients (com-ing to receive care) and visitors (e.g., family members, friends, community

workers) (Table). Regular West 5th staff did not complete the survey as they rarely use this entrance.

InterviewsKey informant interviews were

conducted with directors and managers to obtain a clear under-standing of the original vision and purpose behind the design, following qualitative methods that have been used by others (Wood et al., 2013). In their unique roles, directors and managers had received formal and in-formal feedback about the portal and galleria and were well versed with the issues. They were able to review and confirm the pros and cons identified in the current study as being the most relevant issues relating to the impact of the portal. Interviews were audiore-corded and transcribed, but given the unique position of each participant, no guarantee of anonymity could be provided (i.e., there is only one man-ager for each unit and four directors across all of SJHH’s Mental Health and Addictions Program).

Naturalistic ObservationsObservations were performed to

compare the quality and nature of the interactions of individuals talk-ing to the inpatient entrance security staff against the interactions of indi-viduals talking to Public Affairs staff at the welcome desk, following the methodology of other facility evalua-tions (Edgerton, Ritchie, & McKechnie, 2010; Tyson, Lambert, & Beattie, 2002). A trained observer spent 20 hours at three locations (i.e., public side of the inpatient entrance, inpatient side of the inpatient entrance, and informa-tion desk). For each interaction, the observer recorded the duration, types of participants, number of partici-pants, and nature of the interaction. The nature of the interaction was scored as positive, negative, or neutral on a digital scoring sheet. Each cat-egory had a clear set of descriptions that had to be met so as little as pos-sible was left up to the observer’s sub-jective judgement. The observer also

Figure 4. Pros and cons by theme of the newly built mental health facility portal and galleria. Note. S = survey; FG = focus group; Q = queuing time observation; ULOA = unauthorized leaves of absence; I = interview; O = naturalistic observation; D = administrative data; SMH = Seniors Mental Health.

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made subjective field notes immedi-ately after each observation period.

To measure the amount of time it takes individuals to pass through the portal, 8 hours of security footage were reviewed over a single, arbitrarily se-lected day (i.e., May 28, 2014, 8:00 a.m. to 4:00 p.m.). Time for each ob-servation was recorded from arriving at the portal on the outpatient side to completing the transit to the inpa-tient side. Observations included 225 stops at the security desk (112 used the turnstile, 88 used the sally port, and 25 remained on the public side).

Observations of the amount of time staff spent managing the locked door of a unit took place over 1 week (i.e., September 22-26, 2014). Over the week, 12 hours of observations were made during 2- or 3-hour intervals that timed how long it took staff to let patients in and out of the unit. For patients who were arriving, the time taken from the sound of the buzzer to the time the nurse had resumed his/her previous activity was recorded. For patients who were leaving, the time taken from when the nurse left the care desk to the time he/she re-turned and resumed the previous ac-tivity was recorded.

Hospital RecordsPatients’ access to the various secu-

rity zones is determined by their clini-cal care team. Each patient is given a therapeutic pass level (TPL), which corresponds to a specific security zone (Figure 3). A snapshot of all pass lev-els was taken from the whole hospital on October 2, 2014, from each unit’s communication boards to determine the number of individuals with each TPL, as well as to capture all of the qualifiers (e.g., time limits, accom-paniment requirements). These data were drawn directly from the units, so the data were in real-time, reliable, and detailed. Data from the hospital’s Observation, Seclusion, Restraint and Application (OSRA) database for the duration of the study were also re-viewed. These data are less detailed because the OSRA database only re-

cords pass level (not qualifiers) and is not as reliable (i.e., it is an imperfect system of entry and upkeep).

At the conclusion of the study, a summary of the findings (Figure 4) was presented at the Mental Health and Additions Leadership Forum, which not only included inpatient manag-ers and directors, but a wider group of participants, including hospital execu-tives and outpatient and community-based managers (approximately 40 attendees). Participants at that presen-tation were invited to provide written comments and complete an informal survey at the end of the forum.

RESULTS AND DISCUSSION BY THEME

Overall, results from the vari-ous methods generally support keep-ing the portal operating as intended

(Figure 4). All but two of 39 patients agreed it should be kept based on the informal polls taken at the end of each focus group. The overall experience reported on the survey was positive (Table). Managers and directors were supportive of the vision for the space that requires the portal, which is un-derstandable because many had sat on committees responsible for reviewing and selecting architectural designs, as noted by one manager: “The building was built so that the sickest of the sick would have more freedom, and I don’t think we can lose sight of that.” They believed in the vision but also under-stood why, now that the new facility was operational, there were concerns about how to manage this novel de-sign. Of 14 interviews with managers and directors of the West 5th campus, one was undecided, one was opposed,

TABLE

VISITOR AND PATIENT RESPONSES TO SURVEY (N = 101)

Survey Item Respondent nMean

Score (SD)a

Overall experience Visitors 82 1.3 (0.8)

Patients 19 2.1 (1.4)

Wait time Visitors 82 1.3 (0.5)

Patients 19 1.9 (1.0)

Knowledge of staff Visitors 81 1.4 (0.6)

Patients 19 1.7 (1.1)

Friendliness of staff Visitors 80 1.7 (1.1)

Patients 19 1.6 (0.8)

Importance of tracking visitors Visitors 80 1.2 (0.5)

Patients 19 1.3 (0.6)

Ability to keep out unwanted visitors Visitors 81 1.4 (0.7)

Patients 19 1.9 (1.1)

Comfort with giving name Visitors 81 1.2 (0.6)

Patients 17 1.5 (1.0)

Pleasantness of facility design Visitors 81 1.7 (0.9)

Patients 19 2.1 (1.3)

Note. Visitors comprise family members, friends, community workers, and lawyers. Not all respondents completed the entirety of the survey; however, all available responses were included in the analysis. a1 is the highest possible score, 5 is the lowest possible score.

43Journal of Psychosocial nursing • Vol. 54, no. 2, 2016

and the remaining 12 participants favored keeping the portal. Their impressions were consistent with the findings, described below, that weigh the pros and cons of the novel and unique design features according to the four themes.

Theme 1: Autonomy Versus Inconvenience

The creation of the three se-curity zones by the portal was in-tended to safely advance patients’ self-determination in keeping with a recovery-oriented approach to care (Gilburt et al., 2013). As one man-ager explained:

People who were previously confined to a unit that ended at the front door can now go out and have a space they can walk in, which is still behind a se-cure perimeter. I think that has greatly enhanced the client experience.

This statement is particularly true for those who are at risk for leaving without authorization. In the old fa-cility, such individuals would never have been able to leave their units, even accompanied by staff because they were too great a flight risk.

The increased autonomy for pa-tients created by the three security zones emerged in the key informant interview as being an improved qual-ity of care for those individuals who would otherwise be confined to their units. As one manager explained, “It [Zone 2] creates a safe yet normal-ized environment to help patients prepare for community integration.” For example, one long-term patient is, for the first time since coming to the hospital, able to get a can of soda for himself. This task increases his independence and physical activity, thereby supporting his recovery and improving his quality of life.

TPLs allow patients various degrees of independence, making it possible to quantify this increased autonomy. Use of different TPLs varies widely by program and two data sources were used to explore this issue (i.e., OSRA database and communication boards snapshot). The OSRA data do not

capture any of the ways that TPLs are used as a therapeutic tool, which al-lows for conditions and exceptions. The database only captures patients’ maximum TPLs (1 = not allowed off unit; 2 = unit and galleria; 3 = unit, gal-leria, and public side; 4 = offsite). The OSRA data show only an average of 15% of patients with TPL 2 between April and October 2014. Conversely, the data garnered from the unit com-munication boards snapshot capture a range of TPL exceptions and condi-tions, including individuals who have:

l accompanied Level 2 (i.e., likely flight risk and would not be able to leave the unit without the portal);

l escorted (1:1) or accompanied (3:1) Level 3 (i.e., allowed past the por-tal, but only when a staff member has the time to go as well); or

l Levels 3 and 4, but with time re-strictions (ranging from 30 minutes to several hours).

By capturing some of the complex-ity of how the TPLs are used, 25% of the patient population is shown to benefit from the portal and galleria.

The most persuasive results come from the focus groups. Patients admit-ted to the hospital were encouraged to freely express their thoughts about the physical surroundings. Although they acknowledged the inconvenience of going through the portal, they valued being able to access the galleria and having the autonomy of leaving the units without having to wait for a staff member to unlock the unit doors. As one patient explained:

It’s [the portal] one of the best fea-tures of the hospital. It’s annoying to wait and takes longer than you want, but really it takes only 45 seconds to 1 minute and means you can leave. At [another site], you’re locked on the unit. Here, you can go in the in-between space…that’s huge.

Being able to access the galleria (Figure 2) was valued by many par-ticipants. Patients enjoyed being able to leave the unit to go for walks, so-cialize, use the computers, visit the clothing store, and get coffee and snacks at the café. One patient espe-cially appreciated the proximity of the gymnasium, saying, “I love the gym; I love being able to do something physical…. It’s an amazing feature.” Patients’ only criticism was that the hours for many of the amenities are not long enough, making some un-available at certain times.

Surprisingly, even patients who could freely cross to the public side valued the portal and galleria, empa-thizing with fellow patients who were not yet able to do so, with one patient stating, “It’s kind of like having a re-ally big unit.” The qualitative findings are supported by the survey results.

The additional process of going through the portal may be an incon-venience to visitors, such as family members, community-based service providers, and external professionals (e.g., lawyers, social workers), who have to go through one or two ad-ditional steps to gain entry into the units. At the portal’s security desk, visitors are asked for their name and are registered as visitors. Based on the key informant interviews, some

The increased autonomy for patients

created by the three security zones emerged in the key informant interview

as being an improved quality of care for those individuals

who would otherwise be confined to their

units.

44

viewed this process as an onerous, unnecessary step that seems like so-cial control, even stigma. For others, being asked your name seems like a sensible and expected step for some-one visiting a loved one in a con-trolled environment, especially in an increasingly security-conscious world. The latter position was supported by the survey results, as most individuals were comfortable giving their names at the security desk (Table).

The family members from the Seniors Mental Health Behavioural Unit felt the least favorably about the portal because it makes it more dif-ficult for them to visit. In addition, their family members do not ben-efit from the portal because their unit doors must remain locked because of some patients’ symptoms (e.g., wan-dering due to dementia). However, family members noted that they enjoy bringing their loved ones to the galle-ria and expressed appreciation of the portal from a safety perspective, in terms of keeping out individuals who

do not have a “legitimate” reason to be in the unit.

Patients who are able to leave the inpatient side (i.e., those with TPLs 3 or 4) must show their identity card at the security desk (Figure 1). Patients then swipe their cards and indepen-dently use the turnstile upon return to the unit. Regular West 5th physi-cians, staff, volunteers, and clinical (i.e., residents) and non-clinical (i.e., graduate and undergraduate) students carry identification badges to enter

and exit the inpatient side through a number of access points, not just the portal.

Field notes from the naturalistic observations indicate that certain se-curity staff members provided better customer service, such as smiling, us-ing a warm tone of voice, and apolo-gizing for wait times. This variability depended largely on the personality of the individual, not whether he or she was hospital staff or a contracted security guard. However, with the exception of one or two individuals, most guards provided professional, courteous service, suggesting no par-ticularly adverse consequence of hav-ing to speak to a security staff member before accessing the inpatient area.

Findings suggest that having to go through the portal is only a minor in-convenience for visitors and patients who are able to leave the inpatient side. Observations showed that it takes an average of 1 minute, from the moment a visitor approaches the por-tal, to getting on the other side. The

majority of visitors responded posi-tively about the wait time (Table).

Theme 2: Safety and Security Versus Stigma

The portal was intended to manage safety and security without compro-mising autonomy (Eggert et al., 2014). One of the most important goals of the new design was to protect patients who were vulnerable to individuals participating in illegal activity (e.g., dealing drugs). The portal was envi-

sioned as a deterrent by having a secu-rity guard ask for names before issuing a visitor pass. The portal also acted as a second safety net for patients leav-ing their units without authorization. If patients leave their units without permission, they can more easily be found and brought back, without re-quiring a report to the police, as is the case of patients in the forensics pro-gram or involuntary patients. Finally, having visitors check in at the portal serves to generate a record of who has entered the building in case of an emergency (e.g., a fire).

As one key informant explained, the drawback to these safety and se-curity measures is that they may be seen to increase the stigma of mental illness by further associating mental illness with criminality. Another con-cern is that the experience of going through the sally-port of the portal could be unpleasant or even trigger-ing for patients who have been incar-cerated or otherwise traumatized from being enclosed.

It is difficult to quantify the ben-efits of the facility design to safety and security because these are largely preventive measures, and measuring them would depend on estimating ad-verse events that were prevented. Se-curity staff at the portal have a list of individuals who would be turned away if they requested access to the inpa-tient side.

Patients, managers, and visitors are generally positive about the increased levels of safety and security made pos-sible by the portal. In focus group discussions, most patients expressed feeling safer with the restricted ac-cess into the facility. As one patient stated, “I would prefer the [portal] doors remain for safety reasons.” An-other patient commented, “I like see-ing visitor badges and knowing that the visitor belongs here, as opposed to someone who has just wandered in and shouldn’t be here.” Another pa-tient noted, “Security makes me feel safe; I like that they know what’s go-ing on.” The portal also provides pa-tients with a sense of ownership of the

Findings suggest that having to go through the portal is only a minor inconvenience for visitors and patients who are able to leave the inpatient side.

45Journal of Psychosocial nursing • Vol. 54, no. 2, 2016

space. Patients were glad that security could discourage unwelcome visitors from entering the facility.

One patient appreciated how the portal keeps patients from leaving the facility without authorization, stating, “When there’s only one security barrier, sometimes it’s not hard to slip past it when you’re not supposed to. Two secu-rity barriers makes it a lot harder.” An-other patient observed that when she was more severely ill she was guaranteed safety and privacy until she recovered.

One manager also recalled that, in the old facility, unwelcome visi-tors would come to the unit doors and demand to clinical staff, sometimes forcefully, that they be allowed to see a particular patient. This would be dis-ruptive at best, or occasionally result in an aggressive incident. These con-versations now happen away from the unit doors between the visitors and security staff, which better protects patients from these stressful events that may adversely affect their recov-ery and frees clinical staff to focus on their work.

From the survey, both patients and visitors felt that tracking visitors was important (Table).

On the other hand, the stigma as-sociated with mental illness has sig-nificant repercussions for those living with mental illness (Corrigan, Druss, & Perlick, 2014). Reducing this stigma was a core vision to designing the entire West 5th facility, including creating the transitional zone with the portal. As one manager explained, “It [the portal] means that many units can have doors that now can be open-ing and welcoming.”

Patients did not express any con-cern about the possible implications of the portal to stigmatizing attitudes or the experience of going through it it-self. As one patient explained, “They [security] see your card is you and buzz you through; it’s like going into an of-fice. No big deal…for what it’s trying to do.” Several individuals expressed reservations about the actual experi-ence of going through the portal, with it being confusing and unpleasant, but only for the initial few times.

Responses to the survey question about providing personal information to security staff reinforced that most individuals are generally accepting of modern security measures. They also rated the security personnel’s friend-liness above average (Table), indicat-ing that the security staff ’s roles are important and professionally executed and not particularly stigmatizing.

Theme 3: Unit Door Versus Portal Operating Costs

As a publicly funded institution, SJHH’s leadership have a responsibil-ity to ensure the public receives good value for health care dollars. There are always financial considerations for any decision, and this holds true to the role and value of the portal. The design is complete and the portal built, so setting these capital and start-up costs aside, the study researchers compared the dif-ferent costs of operating or not operat-ing the portal. In an interview, security supervisors estimated that it requires one additional full-time staff member to operate the portal (i.e., provide visi-tor passes and answer questions).

However, the portal also creates costs savings because many units can now have their doors unlocked, or even open, resulting in clinical staff spending less time opening unit doors for patients and visitors (of 13 operat-ing units, four are routinely and two are occasionally left unlocked). On these units, patients and visitors can come and go as they please. On units that remain locked, individuals who do not have an activated SJHH iden-tification badge (e.g., patients, visitors, staff from other hospital sites) must be allowed on or off the unit by a unit staff member. Observations showed that approximately 2.5 hours of nurs-ing time per day are used to manage the door on a locked unit. Not only is this labor-intensive, there is the additional adverse effect of being disrupted (e.g., interruptions in conversations with pa-tients).

Overall, the cost of an additional security staff member is minimal com-pared with the cost savings of un-

KEYPOINTSAhern, C.C., Bieling, P., McKinnon, M.C., McNeely, H.E., & Langstaff, K. (2016). A Recovery-Oriented Care Approach: Weighing the Pros and Cons of a Newly Built Mental Health Facility. Journal of Psychosocial Nursing and Mental Health Services, 54(2), 39-48.

1. The recovery-oriented care model, emphasizing hope, empowerment, self-determination, and responsibility in care provided by mental health service practices, is being used to inform mental health facility design.

2. One of the newest recovery-oriented mental health facility designs is a secure transition zone between the inpatient and public areas created by a secure entryway (or portal).

3. Four principle pros and cons of these new features were identified: (a) autonomy versus inconvenience; (b) safety and security versus stigma; (c) unit door versus portal operating costs; and (d) privacy versus community integration.

4. Results showed that the pros outweighed the cons for each theme, except for the privacy versus community integration, where neither position was more supported.

5. By using a recovery-oriented model of care to guide the facility design and evaluation of that design, the hospital leadership chose to keep the portal operating as intended.

Do you agree with this article? Disagree? Have a comment or questions?Send an e-mail to the Journal at jpn@healio.com.

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locked units. As a general estimate (based on interviews with security managers and observation data), the dollar costs associated with both op-tions are approximately equal: $100,000 each (5,827 hours of security staff = ~$104,832; 1,820 hours of provider time = ~$91,000). Therefore, keeping the portal is justified from a financial perspective.

Theme 4: Privacy Versus Community Integration

The facility was designed to support patients’ privacy and sense of owner-ship and control over the spaces they are using. However, the facility was also intended to support integration with the surrounding community to foster patients’ independence and re-engagement in the community. Both of these priorities are in keeping with recovery-oriented care (Ballard, 2008). These priorities were managed by build-ing a flexible perimeter that would al-low a large section of the galleria to be opened to the public. As of yet, this sys-tem has not been used, and the findings suggest that it may not be necessary.

Patients value the galleria and the amenities it offers. They are not against it being more accessible to the pub-lic; however, some patients expressed a preference for increased privacy. As one patient explained, “It is a check-point for us to get out, but it’s a check-point for them to come in as well, and people can’t roam the hospital.” On the other hand, according to another key informant, there has not been much demand to have community partners use this space. Ultimately, if the de-mand for access to the inpatient side increases, it would be possible to ad-dress this issue. For the time being, pri-ority is being placed on keeping access to the inpatient side more restricted to protect patients’ privacy and sense of ownership over the space.

Leadership Forum FeedbackAttendees who provided feedback

on the study at the Leadership Forum included directors and managers, as well as others in leadership positions,

such as nurse educators and program evaluators from the Mental Health and Addictions Program. The re-sponse at the Leadership Forum was one of generally pleasant surprise that patients were enthusiastic about the impact of the portal on their experi-ences, based on the informal survey (n = 21) taken at the end of the fo-rum. As one attendee noted, “The re-sponses from patients were most mov-ing…that they understood the vision and were prepared to live with the portal to improve their peers’ lives.” Most attendees preferred to keep the portal and galleria, and those who did not were persuaded by the results shown above presented at the time. Of the nine individuals whose opinions were changed by the presentation, all changed to either yes or not sure from not wanting to keep it. One individual remained unconvinced of the value, even after viewing the findings, stat-ing, “Good idea for now but depends on value for money.” The remaining 11 individuals came to the meeting being convinced of keeping the portal and remained so, as captured by this comment: “Thanks, really helpful to have data. Always felt it was needed; however, appreciate now having data for rationale to keep it [the portal].”

CONCLUSION AND IMPLICATIONS FOR NURSING PRACTICE

The various methods presented combine to inform an overall picture of the impact of the portal and gal-leria on the four themes that capture the most salient controversies about the design. Results suggested that the pros of keeping the portal outweigh the cons (Figure 4) for each of these themes despite the unexpected chal-lenges associated with the novel and unique design. In particular, there was surprising consensus among focus group participants that they preferred to continue operating the portal as it exists, but with adjustments to make the experience of using it easier and more pleasant. With several units now able to unlock or even open their doors, autonomy is increased and sav-

ings and convenience are being real-ized.

The study also demonstrated how prioritizing patients’ perspectives and experiences in decision making can effectively help manage hospital-level change. As a result of the findings from the current study, researchers are evaluating how to make passage through the portal a more positive ex-perience for everyone.

A recently published guideline on providing recovery-oriented care recommends that organizations draw on lived experience of consumers in the co-design of policies and proce-dures (Mental Health Commission of Canada, 2015). This viewpoint is a reasonable extension of person-centered, recovery-oriented care by frontline staff, as it is a successful ap-proach in inpatient settings (Barton, Johnson, & Price, 2009). Yet, how to extend this standard of care to policy and procedure decision mak-ing remains unknown. In the current example, patients’ perspectives and experience were central to study the novel and unique facility design, in keeping with recovery-oriented prin-ciples (Gilburt et al., 2013). By using a recovery-oriented care approach to manage this significant change, pa-tients’ perspectives and experiences have allayed lingering concerns and there has been a greater acceptance of the portal and galleria design. The outcome of the current study was that SJHH leadership were guided by pa-tients’ perspectives and experiences to continue operating the portal as de-signed, albeit with minor adjustments.

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Ms. Ahern is Research Study Project Man-ager, Dr. Bieling is Psychologist and Director, Mental Health and Addictions Services, Dr. McKinnon is Psychologist, Mood Disorders Program and Clinical Neuropsychology Ser-vice, Dr. McNeely is Clinical Neuropsychologist, and Ms. Langstaff is Chief Planning Officer, St. Joseph’s Healthcare Hamilton, Hamilton, On-tario, Canada. Dr. Bieling is also Associate Pro-fessor, Dr. McKinnon is also Associate Co-Chair, Research, and Associate Professor, and Dr. Mc-Neely is also Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Cana-da. Dr. McKinnon is also Homewood Senior Sci-entist, Homewood Research Institute, Guelph, Ontario, Canada; and Dr. McNeely is also Train-ing Director, Clinical Psychology Residency Program, McMaster University, Hamilton, On-tario, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

© 2016 Ahern, Bieling, McKinnon, McNeely, & Langstaff; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International (http://creativecommons.org/licenses/by/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article, for any purpose, even commercially, provided the author is attributed and is not represented as endorsing the use made of the work.

Address correspondence to Catherine Clark Ahern, BSc, MA, Research Study Project Manager, St. Joseph’s Healthcare Hamilton, 100 W. 5th Street, Hamilton, Ontario, Canada L9C 0E3; e-mail: catherine.ahern@gmail.com.

Received: July 29, 2015Accepted: November 9, 2015doi:10.3928/02793695-20160119-05

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