Impact of the design of adult mental health inpatient facilities on healthcare staff: a mixed methods systematic review

Abstract

Objectives

Mental health inpatient facilities are increasingly focusing on creating therapeutic, person-centred care environments. However, research shows that this focus may have unintended consequences for healthcare staff. Designs that do not pay attention to staff needs may risk contributing to stress, burnout, job dissatisfaction and mental exhaustion in the work environment. This systematic review aims to identify and synthesise current research on the design factors of adult mental health inpatient facilities that impact healthcare staff.

Design

A mixed method systematic review was conducted to search for empirical, peer-reviewed studies using the databases CINAHL, Embase, PsycINFO, PubMed and Web of Science from their inception up to 5 September 2023. The Joanna Briggs Institute’s critical appraisal checklists were used to assess the methodological quality of the eligible studies. Data were extracted and grouped based on the facility design factors.

Results

In our review, we included 29 peer-reviewed empirical studies that identified crucial design factors impacting healthcare staff in adult mental health inpatient facilities. Key factors included layouts providing optimal visibility, designated work and respite areas, and centrally located nursing stations. Notably, mixed perceptions regarding the benefits and challenges of open and glass-enclosed nursing stations suggest areas requiring further research. Facilities in geographically remote locations also emerged as a factor influencing staff dynamics. Additionally, although only supported by a limited number of studies, the significance of artwork, sensory rooms for respite, appropriate furniture and equipment, and access to alarms was acknowledged as contributory factors.

Conclusion

Through the synthesis of existing research, this review identified that the design of mental health facilities significantly impacts staff well-being, satisfaction, performance and perception of safety. Concluding that, in order to create a well-designed therapeutic environment, it is essential to account for both service users and staff user needs.

PROSPERO registration number

CRD42022368155.

Strengths and limitations of this study.

• This is the first systematic literature review to identify and assess the impact of the design of mental health inpatient facilities on healthcare staff.

• The review uses a robust systematic methodology and provides transparency through compliance with reporting standards and the quality assessments of the studies.

• The review included only empirical, peer-reviewed research in English. Therefore, it is possible that high-quality literature, both in other languages and unpublished, was missed due to this limitation.

Introduction

Optimal mental healthcare is rooted in person-centred principles, with a focus on recovery and trauma-informed care.¹ When integrated into the design of mental health inpatient facilities, this patient-focused approach is intended to enhance the therapeutic environment, making it more conducive to patient (service user) recovery.² However, while the design focus must be to benefit service users, emerging evidence suggests some elements may also have unintended consequences for healthcare staff users.^{3 4} The functionality and layout of the ‘workspace’ within healthcare settings play a pivotal role in how staff experience the work environment.⁵ If these designs focus too heavily on service users while overlooking staff requirements, it might inadvertently increase stress, burnout, job dissatisfaction and mental exhaustion.^6–8 Such adverse work-related outcomes can, in turn, result in higher staff turnover, absenteeism, decreased service user satisfaction and lower organisational commitment and productivity, ultimately compromising service user quality of care and safety.^{6 8} This evolving understanding of potential adverse impact on staff highlights the need for an approach to facility design that balances the needs of all facility users, including service users and healthcare staff.^9–11

While existing literature reviews already cover the service user perspective in mental health facility design, there is a lack of synthesis of current research focusing on healthcare staff. A similar literature review is already available for general healthcare facilities.¹² However, the applicability of the evidence to mental health inpatient settings remains debatable. This is due to the unique treatment and recovery specifications for mental illness, which require specialised designs to minimise the risk of self-harm and suicide or reduce environmental stimuli.¹³ Addressing this lack of knowledge is essential given the importance of staff health and well-being and their role in supporting service user satisfaction and the therapeutic process. This review aims to synthesise existing research on the design factors of adult mental health inpatient facilities that are important to staff or impact their well-being, safety, performance and satisfaction. This review contributes to the healthcare staff’ perspective towards developing evidence-based design guidance on the requirements for mental health inpatient facilities that consider both service user and staff needs.

Methods

This systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.¹⁴ A protocol for the review was registered with PROSPERO. A deviation from the protocol was made to reflect the use of an alternate critical appraisal tool for assessing the methodological quality and risk of bias of the eligible studies. A mixed method review that included the combination of qualitative and quantitative research was adopted to provide a more comprehensive analysis than reviewing each method separately, thus obtaining a more robust and broader account of the topic, especially in this area where there is a paucity of research.

Patient and public involvement

Patients or other members of the public were not involved in this study.

Search strategy

This systematic literature review was commissioned by NHSScotland Assure and the Scottish Government to inform the development of the ‘mental Healthcare Built Environment (mHBE) Quality and Safety Assessment Tool’. As such, the research team received the specific review aim and inclusion criteria based on these needs. A systematic search was conducted using CINAHL (Ebsco), Embase (Ovid), PsycINFO (Ovid from 1967), PubMed and Web of Science (Core Collection) from their inception up to 5 September 2023. The reference lists of the final included studies were hand-searched for further relevant publications. Search terms were developed by the lead author (LR-L) with advice from the principal architect (SG) and input from the commissioning team and then reviewed by a librarian. Search terms were based on the population (eg, healthcare staff), intervention/phenomenon of interest (eg, facility design, architecture) and context (eg, mental health inpatient settings). Subject headings were used where available. Results were limited to English language only. Search strategies are provided in online supplemental file 1.

Inclusion criteria

Population

Healthcare staff of adult mental health inpatient facilities who provide care for service users. This includes, but is not limited to, clinical professionals, nurses and allied health staff. No restrictions were placed on age, ethnicity, length of service or level of qualifications.

Type of intervention(s)/phenomena of interest

The qualitative component of this review considered studies that explored staff experiences and perceptions of the facility design. The quantitative component of the review considered studies that investigated the impact of the design of adult mental health inpatient facilities on one or more staff outcomes. Facility design in the context of this review refers to the dimensions of the physical environment as defined by Harris et al¹⁵: (1) architectural features (relatively permanent characteristics, such as the spatial layout of a hospital, room size, window placement); (2) interior design (less permanent elements, such as furnishings, colours, artwork, etc); and (3) ambient features (eg, lighting, noise levels, temperature, and odours).¹⁵

Outcomes

The review examined the impact of the design of mental health inpatient facilities on staff outcomes, such as job performance, satisfaction, safety and well-being. This extended to the components of these outcomes, such as morale, stress, anxiety, depression, self-esteem, burnout, efficiency, turnover, absence, and incidents or injuries.

Setting

The review considered studies conducted in adult mental health inpatient settings, including acute and long-stay services, intensive psychiatric care units (IPCU) and forensic units (low and medium secure). Studies were excluded if they primarily targeted child and adolescent, geriatric and learning disability inpatient settings, and emergency departments. However, if these settings were part of a broader sample that met our inclusion criteria, they were considered for inclusion.

Type of studies

The qualitative component of the review considered studies that included, but were not limited to, designs such as action research, case studies, descriptive analysis, ethnography, grounded theory, narrative approaches and phenomenology. For the quantitative component, experimental, quasi-experimental and observational study designs were considered. Mixed method studies were included if data from the quantitative or qualitative components could be clearly separated. The review only included empirical, peer-reviewed studies in English.

Study selection

Results from the literature search were uploaded into EndNote V.20, and duplicates removed. Two reviewers (LR-L and JK) screened studies against the inclusion criteria by reading the title and abstract (first screening) and assessing the full text of eligible studies (second screening). Both reviewers conducted each stage of the screening independently. Disagreements or omissions were discussed at each stage until a consensus was reached. A third reviewer (LN) made the final decision when a consensus agreement could not be reached. The excluded studies and their reasons for exclusion in the second screening are provided in online supplemental file 2.

Critical appraisal

In assessing the methodological quality of the eligible studies, we used the Joanna Briggs Institute’s (JBI) critical appraisal checklists for qualitative,¹⁶ analytical cross-sectional¹⁷ and quasi-experimental studies.¹⁸ Each checklist item was assessed as ‘yes’, ‘no’, ‘unclear’ or ‘not applicable’ (NA). To ensure a fair assessment, we adopted an approach where any question marked as ‘not applicable’ was excluded from the total possible score for that specific study. A ‘yes’ response was scored 1; both ‘no’ and ‘unclear’ responses were scored 0. The final quality score of each study was derived from the number of ‘yes’ responses out of the total applicable items. For mixed methods studies, the qualitative and quantitative elements were appraised separately. While some publications in the review explored healthcare staff and service user experiences within a single study, the methodological quality assessments and data extraction focused only on staff-related data. Studies that were eligible for inclusion were assessed by the lead author (LR-L), and the second author (JK) conducted a 30% check of the appraised studies.

Data extraction, transformation and synthesis

Data were extracted by the lead author (LR-L) and included, where available, the source (authors and year), country, study design, participants (number and their characteristics), type and description of the inpatient facility, phenomenon of interest/intervention, methods, outcome measures, findings, limitations identified by the authors and the design factor investigated or reported in the studies. The convergent integrated approach, adhering to the JBI methodology for mixed methods systematic reviews, was used for data synthesis.¹⁹ Following the methodology, quantitative data was converted into ‘qualitised data’ and assembled with qualitative data. Assembled data was then pooled together and grouped according to facility design factors. Key results from quantitative studies and the quantitative component of mixed methods studies can be found in online supplemental file 3. A summary example of the ‘qualitising data’ process relates to staff perceptions of respite spaces.²⁰ In the study, while the raw quantitative data indicated numerical ratings—with importance scoring at 6.25 and effectiveness at 4.45 (t-value of 9.10)—the ‘qualitised’ interpretation highlighted that staff valued a dedicated respite space but had reservations about its current effectiveness.

Results

Study inclusion

The initial search generated 4100 records across all the databases, of which 1496 were duplicates. Additional screening of reference lists identified eight more studies. The PRISMA flow diagram is reported in figure 1.¹⁴ A total of 29 full-text studies were included in the final review. See online supplemental file 3 for a breakdown of the characteristics of all included studies.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart. This diagram illustrates the stages of the systematic review process, detailing the quantity of records identified, included and excluded, along with the rationale for each exclusion.

The majority of the studies were conducted in the UK (n=9),^21–29 followed by the USA (n=8).^{20 29–35} Other studies were spread across Australia (n=5),11 29 34 36 37 Sweden (n=3),^{3 38 39} Canada (n=3),^{4 29 40} Brazil (n=1),⁴¹ New Zealand (n=1)⁴² and Denmark (n=1).¹⁰ It is important to note that one publication included the USA, Australia, Canada and the UK,²⁹ while another included the USA and Australia,³⁴ with the above analysis accounting for each of these countries. Studies were published between 1989 and 2022. While some studies in the review contained data from settings that fell outside our inclusion criteria, they were still considered as they were part of a larger sample that met our criteria for inclusion. This included one study containing data from geriatric facilities,⁴³ two from older persons’ mental health units,^{28 36} three from child and adolescent mental health units^{28 31 38} and one from emergency and outpatient facilities.²⁹

The 29 studies encompassed qualitative (n=19), quantitative (n=8) and mixed methods (n=2) study designs. In three studies initially classified as mixed methods, one component was excluded from the review due to the lack of applicability. Consequently, these studies were considered only for their qualitative or quantitative component and were not classed as mixed method studies.^{23 38 43}

Methodological quality

Tables 1–3 summarise the methodological quality of the included studies. All studies were included in the review regardless of their methodological quality. However, some methodological issues were identified.

Table 1.

Critical appraisal of eligible qualitative studies

Study	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Score
Björkdahl et al38	U	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	7/10
Brennan et al21	U	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	8/10
Butler et al22	U	Yes	Yes	Yes	Yes	NA	NA	Yes	No	Yes	6/8
Csipke et al23	U	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	7/10
Curtis et al24	U	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	7/10
Curtis et al25	U	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	7/10
Forsyth and Trevarrow44	U	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	7/10
Jenkin et al42	U	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9/10
Johnson and Delaney30	U	Yes	Yes	Yes	Yes	No	U	Yes	Yes	Yes	7/10
Kalantari and Snell40*	Yes	Yes	Yes	Yes	Yes	No	No	U	No	Yes	6/10
McPhaul et al31	U	Yes	Yes	Yes	Yes	Yes	No	No	No	Yes	6/10
Molin et al3	U	Yes	Yes	Yes	Yes	Yes	U	Yes	Yes	Yes	8/10
Novotná et al4	U	Yes	U	U	Yes	No	No	U	Yes	Yes	4/10
Oates et al27	U	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9/10
Pink et al36	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	8/10
Shattell et al33	Yes	Yes	Yes	U	Yes	No	No	Yes	Yes	Yes	7/10
Shattell et al32	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	8/10
Shepley et al34	U	Yes	Yes	Yes	Yes	No	No	Yes	No	Yes	6/10
Simonsen and Duff10	U	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	7/10
Tyson et al*11	U	Yes	Yes	Yes	Yes	No	No	No	No	Yes	5/10
Wilson et al37	U	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	7/10

Q1 - Is there congruity between the stated philosophical perspective and the research methodology?

Q2 - Is there congruity between the research methodology and the research question or objectives?

Q3 - Is there congruity between the research methodology and the methods used to collect data?

Q4 - Is there congruity between the research methodology and the representation and analysis of data?

Q5 - Is there congruity between the research methodology and the interpretation of results?

Q6 - Is there a statement locating the researcher culturally or theoretically?

Q7 - Is the influence of the researcher on the research, and vice-versa, addressed?

Q8 - Are participants, and their voices, adequately represented?

Q9 - Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body?

Q10 - Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

*Qualitative component of a mixed methods study.

NA, not applicable; U, unclear.

Table 2.

Critical appraisal of eligible cross-sectional studies

Study	1	2	3	4	5	6	7	8	Score
Haines et al26	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8/8
Sousa et al41	Yes	Yes	Yes	Yes	NA	NA	Yes	Yes	6/6
Kalantari and Snell40*	Yes	Yes	Yes	Yes	NA	NA	Yes	Yes	6/6
Sheehan et al28	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8/8
Shepley et al29	U	Yes	Yes	Yes	NA	NA	Yes	Yes	5/6
Shepley et al20	Yes	Yes	Yes	Yes	No	No	Yes	Yes	6/8

Q1 - Were the criteria for inclusion in the sample clearly defined?

Q2 - Were the study subjects and the setting described in detail?

Q3 - Was the exposure measured in a valid and reliable way?

Q4 - Were objective, standard criteria used for measurement of the condition?

Q5 - Were confounding factors identified?

Q6 - Were strategies to deal with confounding factors stated?

Q7 - Were outcomes measured in a reliable way?

Q8 - Was appropriate statistical analysis used?

*Quantitative component of a mixed methods study.

NA, not applicable; U, unclear.

Table 3.

Critical appraisal of eligible quasi-experimental studies

Study	1	2	3	4	5	6	7	8	9	Score
Christenfeld et al43	Yes	U	U	Yes	No	No	Yes	U	U	3/9
Degl' Innocenti et al39	Yes	Yes	U	No	Yes	Yes	Yes	Yes	Yes	7/9
Southard et al35	Yes	Yes	U	No	Yes	U	Yes	Yes	Yes	6/9
Tyson et al*11	Yes	Yes	Yes	No	Yes	U	Yes	Yes	Yes	7/9

Q1 - Is it clear in the study what is the ‘cause’ and what is the ‘effect’ (ie, there is no confusion about which variable comes first)?

Q2 - Were the participants included in any comparisons similar?

Q3 - Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?

Q4 - Was there a control group?

Q5 - Were there multiple measurements of the outcome both pre and post the intervention/exposure?

Q7 - Were the outcomes of participants included in any comparisons measured in the same way?

Q8 - Were outcomes measured in a reliable way?

Q9 - Was appropriate statistical analysis used?

*Quantitative component of a mixed methods study.

NA, not applicable; U, unclear.

Qualitative studies

Based on the assessment criteria (table 1), 21 studies were scrutinised, which included the qualitative segments of two mixed methods studies.^{11 40} Out of these, 76% achieved a quality appraisal score between 7 and 10.3 10 21–25 27 30 32 33 36–38 42 44 Only one study scored as low as 4 out of 10.⁴ A 100% demostrated congruity between the research methodology and the methods for data collection (question 3), and data representation and analysis (question 10). Nevertheless, certain areas raised ambiguities: the philosophical perspective (question 1) was addressed affirmatively in just four studies32 33 36 40; the cultural or theoretical framework of the researchers (question 6) was evident in five studies3 21 27 31 42; and the reciprocal impact of the researcher and the research subject (question 7) was acknowledged in merely two studies.^{27 42}

Cross-sectional studies

On assessment using the criteria in table 2, six cross-sectional studies were appraised, including the quantitative segment from one study.⁴⁰ Two analytical studies scored the highest,^{26 28} while another scored 5 out of 8.²⁹ Three studies were purely descriptive cross-sectional. In these studies, the questions related to confounders were deemed not applicable (questions 5 and 6). While we recognise that addressing confounders (even merely acknowledging them) is not directly relevant to descriptive studies, we consider this as a limitation. Two of the three descriptive cross-sectional studies scored 6 out of 6,^{40 41} and one 5 out of 6.²⁹ Except for one study,²⁹ all studies clearly defined their inclusion criteria (question 1). Additionally, all studies consistently met the criteria for questions 2, 3, 4, 7 and 8, underscoring the thoroughness of their methodologies.

Quasi-experimental studies

Four studies were scrutinised based on the assessment criteria (table 3), including the quantitative segment of one mixed methods study.¹¹ Three of these achieved a quality appraisal score of 6 out of 9.^{11 35 39} Only one study scored as low as 3 out of 9. Notably, unlike the others, this study was the only one that included a control group.⁴³

Themes

The synthesis of results is organised under distinct thematic categories that embody the core components of healthcare facility design and functionality, including visualisation and safety, workplace and equipment, spaces for respite and comfort and ambient features and aesthetics.

Visualisation and safety

Designs that enable visibility on the ward

Seven studies evidenced the critical role ward design layouts play in shaping staff perceptions of safety and the effectiveness of service user observation.3 25 28 30 31 33 42 A recurring theme across six qualitative studies was the challenge posed by ward layouts that do not support clear visibility, impeding the ability to monitor service users effectively but also contributing to heightened feelings of vulnerability among staff.3 25 30 31 33 42 A consensus from five of these studies revealed staff’s dissatisfaction with layouts characterised by oddly shaped wards and rooms laden with blind spots and corners.25 30 31 33 42 Supporting this finding, another qualitative study highlighted the merits of open ward designs. Staff members perceived open layouts as safer, citing fewer corners and obstructions, providing a better overview of the unit as a whole.³ A cross-sectional study further solidified this perspective on the preference for open designs, which found that working in wards without corridors was associated with higher staff satisfaction levels compared with those with corridors.²⁸

Nevertheless, the discourse on ward design extends beyond layout. Features such as glass partitions, which enhance visibility across the courtyards into the rooms, and single-floor wards, has been highlighted as beneficial for staff maintaining a safer environment.²⁵ Conversely, the same study identified potential safety hazards such as walls separating an office from a dining room, specific furniture arrangements and closed doors intended for energy-efficient heating—all of which block the lines of sight.²⁵ Large wards also emerged as problematic for service user observation across three qualitative studies.^{11 30 34} The expansive nature of these larger spaces is more likely to incorporate obstructive nooks and crannies, making clear views of service users challenging.³⁰ Additionally, another study highlighted staff concerns related to the potential expansion of unit size if incorporating single-bedded rooms, suggesting this could further complicate supervision and potentially endanger staff.³⁴

Building on these insights, findings from a before and after study revealed that transitioning from an older, more compact ward to a newer, more spacious one with a distinct observation wing led to increased emotional exhaustion and diminished personal accomplishment among staff. However, this change in environment did not impact job satisfaction. Through follow-up interviews, it was identified that the increased space made locating other staff and service users difficult, with observation impinged. Additionally, the combined effect of the larger space and separate observation wing contributed to feelings of isolation among the staff.¹¹

Nursing station design

The review included several studies reporting positive and negative staff experiences of two main nursing station designs—open and glass-enclosed—and their subsequent influence on staff satisfaction. Within the glass-enclosed designs, staff reported discomfort from being constantly observed by service users, leading to feelings of intimidation and perceived loss of privacy.¹⁰ Conversely, the same study reported staff satisfaction, noting that this design allowed them to observe service users unobtrusively without needing direct engagement.¹⁰ However, another study reported that the glass-enclosed design was viewed as less favourable by staff as they felt under constant demand, even when engaging in non-clinical tasks, increasing workplace stress.³⁷

Delving into open nursing station designs, the views were varied. Some studies highlighted concerns about compromised confidentiality^{32 40} and potential threats to staff safety.^{32 34 40} On the contrary, others favoured the design for enhancing service user awareness, responsiveness, better visualisation^32–34 and improved staff–patient relationship.³⁴ Digging further, nurses familiar with both designs found an open station design especially challenging due to their limited availability to communicate confidential information with other staff and the frequent service users interruptions, negatively impacting their work efficiency.³² Another study focused on a post-occupancy evaluation of an open nursing station, which also incorporated highly effective passive security measures, showed a ‘wait-and-see’ attitude from staff regarding their safety. However, the authors reported that claims of compromised safety lacked empirical backing.⁴⁰ Supporting this perspective, a study investigating the transition of a nursing station from enclosed to open design found no increase in patient aggression toward staff post-renovation.³⁵ Conversely, other findings favoured open designs, with staff emphasising that enclosed stations could lead to patient mistrust, occasionally escalating to violent reactions like breaking windows. Moving away from such enclosed designs was associated with improved staff–patient relationships.³⁴

Interestingly, several quantitative studies suggest that nursing station designs, whether open, glass-enclosed or entirely closed, do not impact staff satisfaction,^{28 40} or their perceptions of the therapeutic milieu.³⁵

Nursing station location

The location of the nursing station, especially in relation to the ward’s primary social spaces, consistently emerged as a theme across six studies.3 4 10 28 30 31 One study stressed the importance of proximity to key patient areas such as the dayroom for maintaining oversight and safety, irrespective of the nursing station’s design.³⁰ Another study highlighted that when strategically positioned between the dayroom and courtyard, glass-enclosed nursing stations optimised observation capabilities and enhanced the staff’s sense of control.¹⁰ On the other hand, a new three-story facility design presented observational challenges when nursing stations were placed on alternating floors.⁴ Another study emphasised that the nursing station’s design and position in relation to the dayroom facilitated patient–staff interactions and observations, though the study did not delve into specifics of the design type.³¹

Further resonating with the theme, two other studies delved into the benefits and limitations of centrally located nursing stations for staff. First, in one study, a central location of the unit office was associated with a perceived decrease in safety risks among staff, attributing it to a more expansive corridor view.³ Contrarily, a cross-sectional study that investigated the ability to observe the bedroom doors from a central point did not find an association with staff satisfaction with the physical environment.²⁸

Facility location

The geographical location of the mental health inpatient facilities and their connectivity to the main hospital emerged as an overarching theme across several studies.24 27 28 37 An urban-focused study identified that poor transportation and lighting intensified staff feelings of isolation, echoing old semi-rural asylums.²⁴ Another study found the geographical remoteness of high-security hospitals to be a key determinant in staff recruitment and retention, with factors such as affordable housing, closeness to educational institutions and commutes being decisive.²⁷ Furthermore, staff perceived a mental health unit’s physical and cultural disconnect from its main hospital as negatively affecting their work routine.³⁷ Contrarily, a cross-sectional study found that connectivity to a main hospital did not necessarily translate to higher staff satisfaction with their work environment.²⁸

Workplace and equipment

Workspace

The importance of staff having suitable and designated working spaces was identified across six studies.3 4 21 23 33 41 First, a study identified that ward redesign, which involved a reduction in working space for meetings and discussions, negatively affected nurses’ job satisfaction.³ Another study pointed out that spaces like ‘quiet’ rooms, intended for patient use, were sometimes used for staff purposes, such as ward rounds and handovers, impeding staff’s efficiency and engagement with patients.²¹ The findings from three studies suggest the importance of providing staff with adequate space for private interactions with service users.^{4 23 33} Among these, one study highlighted the challenges associated with using open cubicles for meetings with service users, suggesting they hindered confidentiality and job performance, primarily due to the increased time spent seeking suitable alternative private locations.⁴ This research further documented that the lack of dedicated staff spaces for tasks, such as paperwork storage and filing, had a negative impact on well-being.⁴

Two studies tackled the importance of the workspace size. One reported staff dissatisfaction due to inadequate space for fitting enough computers.³ The other conveyed concerns about the small size of the nursing station, with participants describing it as overcrowded, especially during shift changes, which created feelings of claustrophobia and negatively impacted their job performance.⁴ Building on the qualitative evidence, one quantitative study provided corroborative data. The study reported an association between unsuitable workplaces for the tasks and inadequate physical space to perform the work with a self-reported severe risk of illness.⁴¹

Office equipment

Office equipment—its availability, functionality and accessibility—emerged in three studies as a factor affecting staff efficiency and well-being.^{21 31 41} Staff expressed concerns that office equipment, such as computers and photocopiers, were often insufficient, impacting their ability to carry out their tasks efficiently.²¹ This scarcity not only complicated everyday activities and information sharing but heightened stress levels, especially in the context of the intensive administrative demands on wards.²¹ Expanding on this finding, a quantitative study identified an association between inadequate equipment to carry out tasks and staff self-reported severe risk of illness.⁴¹ Another study indicated that even minor issues, such as faulty phones for service users, could lead to significant operational disruptions and tension at nursing stations when service users needed to use the phone there.³¹

Furniture

The implications of furniture on staff well-being and performance were reported in three studies.^{21 31 41} One highlighted potential safety risks associated with certain furniture choices, with staff raising concerns about furniture being potentially used as weapons or to hide contraband.³¹ Expanding on this notion, the issue of insufficient seating options, particularly easy chairs relative to the patient count, was identified as a barrier to effective group activities, leading to additional challenges and frustrations for staff aiming to provide the best care.²¹ These findings are supported by a cross-sectional study that identified an association between inadequate workplace furniture and staff’s self-reported severe risk of illness.⁴¹

Spaces for respite and comfort

Staff respite spaces

The need for staff-designated respite spaces emerged as an overarching theme in five qualitative studies.3 4 20 34 36 These spaces, both in their availability and adequacy, were considered by staff as important,^{20 29} impacting their well-being,^{4 36} and job satisfaction.³ For instance, the lack of these spaces meant that staff had to use other rooms, such as conference rooms for rounds and shift handovers, or share the communal spaces with service users when eating and taking breaks.^{3 4} Findings from another study suggested that diverse staff respite spaces may be necessary for different purposes, such as socialisation or quiet time.³⁶ In this study, a lounge was renovated and equipped with amenities such as a television, couches and microwave. While some perceived it as crucial for its community-building potential, others felt it did not suit those seeking a quiet space due to the noise and disorder in the room. This led them to seek out inadequate spaces for quiet or restoration that were out of sight of service users, such as the medication room.³⁶

Supporting the importance of these spaces, a cross-sectional study identified that staff perceived respite spaces in their current facilities as less effective than what they considered necessary. This difference was statistically significant, indicating a real disparity between what staff believe is essential and their experience of the current space.²⁰ On the contrary, another cross-sectional study found a statistically non-significant association between having a sitting and eating area with staff satisfaction with the physical environment. This conflicting evidence could be related to variables not controlled in the study, such as the design and condition of these areas.²⁸ Finally, the findings from a survey suggested that when considering staff respite amenities, staff outdoor spaces, dedicated entrances and exercise rooms were more valued by staff compared with counselling and nap rooms. These preferences were not just marginal; they were statistically significant.²⁹

Sensory rooms

Two studies explored how staff experienced sensory rooms within mental health facilities.^{38 44} Drawing from qualitative data, one study observed that sensory rooms in nine units indirectly enhanced job performance—ie, an improvement in service user’s well-being and self-care was perceived by staff, which made their job easier and helped to increase their focus on patients’ self-management strategies and nursing interventions.³⁸ The other study noted that sensory rooms, initially intended for service users, served as sanctuaries for staff under stress, offering them space to decompress, manage anxiety and refocus after intense incidents.⁴⁴

Ambient features and aesthetics

Lighting

The impact of lighting on how staff experience the work environment and their perceptions of safety emerged as a theme across three studies.^{3 26 31} Among them, one found that giving staff the ability to control lighting enhanced their work experience, particularly in areas such as the office and medicine room compared with the previous automatic system.³ In another study, staff in various mental health centres expressed discomfort due to what they described as ‘inadequate lighting’ during night-time checks.³¹ While the specifics of what constituted ‘inadequate’ were not detailed, there was a shared sentiment that lack of adequate illumination might correlate with instances of patients becoming violent towards staff.³¹ Similarly, a cross-sectional study highlighted the importance of brightness levels in wards. Though again, exact details on what defined ‘brightness’ were not provided, the general consensus was that appropriate brightness levels contributed to the staff’s sense of safety.²⁶

Homelike environments

Comparing renovated facilities with the previous designs, which were redesigned to resemble more homely environments, one study revealed improved staff morale and reduced the time spent on patient care and support staff activities, such as medication supply, charting and communication.⁴³ Additionally, another study observed an enhanced sense of safety and a more domestic atmosphere among staff.³⁹ Interestingly, this study also found that these outcomes appeared to correlate with the staff’s educational level and experience in forensic mental health.³⁹ However, it is challenging to attribute these impacts solely to the homely environments, as the renovations also included other design changes, such as offering more privacy or better control of the environment. These changes could have benefited service users’ recovery, subsequently impacting staff. Moreover, potential shifts in organisational procedures, staffing and treatment methods associated with the renovations might have played a role.

Artwork and colour

The choice of colours and the presence of artwork in mental health facilities have been shown to influence staff experiences. For example, one study demonstrated that artwork positively influenced staff’s perceptions and interactions with their work environment.²² This study investigated the experiences of 32 staff members on the inclusion of primarily abstract and nature-related wall paintings in an IPCU, which professional artists created in collaboration with inpatients. Staff reported that the artwork gave them hope, physically and mentally expanded space and created a calmer environment.²² Another study identified that staff satisfaction was improved by using different colour tones across the unit—vibrant and saturated in treatment areas for service users with learning and social disabilities and warmer and more soothing colours in communal areas and bedrooms.⁴⁰

Wayfinding

A post-occupancy evaluation found that implementing wayfinding strategies, including a distinct colour scheme combined with ‘super-graphic’ pictograms and recognisable icons indicating paths to key destinations, improved staff satisfaction. It also led to a reduction in staff dependence on wayfinding directions when compared with previous staff experiences.⁴⁰

Alarm displays

The issue of lack of access to alarms was reported in two studies in relation to increased security risks.^{3 42} In another study, staff perceived that the lack of alarms in bedrooms and bathrooms could make initiating an emergency response challenging.⁴

Discussion

This systematic review examined and appraised existing literature to identify the design factors of adult mental health inpatient facilities impacting healthcare staff. Results showed evidence that some design factors notably influence staff and how they experience and perceive the physical and work environment. First, findings indicated that designs that offer good peer-to-peer visibility and facilitate service user observation improve staff satisfaction and enhance their sense of security and ability to keep the unit safe. This may be achieved through open-plan designs devoid of corridors and other obstructions, providing clear lines of sight. The configuration of units and thoughtful furniture arrangements further minimise blind spots, ensuring optimal observation and interaction. Larger wards, however, can introduce challenges, particularly with the potential for more obstructive nooks and corners, emphasising the importance of careful design in spacious environments to maintain visibility and security.

Second, the findings established the importance of staff-specific respite spaces in enhancing well-being and satisfaction. When such spaces are missing or inadequate, staff adapt other areas or share common spaces with service users. The evidence suggests that the nature of these areas should be diverse, offering a mix of communal places for socialisation and quieter spaces for personal downtime. Furthermore, feedback from staff showed a strong preference for outdoor areas and exercise rooms, underlining the importance of a strategic approach to facility design.

Third, the findings indicated the importance of designated working spaces of the right size and furnishings tailored to various tasks, from one-on-one encounters to individual work and meetings. Such spaces enhance job satisfaction and performance, while their absence can compromise confidentiality, hinder overall job performance and increase staff risk of illness. However, we do not know from the studies whether these working spaces should be multifunctional. Interestingly, an overarching theme in these studies is the reduced staff workspace attributed to designs that emphasise client-centred care aimed at facilitating staff-service user interaction outside of clinical spaces. Additionally, the functionality and availability of office equipment play a critical role. Insufficient or malfunctioning equipment increases stress and disrupts operations, underscoring the need for sufficient resources in these settings.

Further, the review emphasised the importance of nursing station designs and their location in the unit. Staff experiences of glass-enclosed and open nursing stations were mixed. Both types were seen as positive in that they improved the service users’ visual oversight, ensuring their safety. On the other hand, they were associated with increased work interruptions, staff privacy violations and compromised service users’ confidentiality. In addition, open station designs presented staff concerns over their safety. As for location, staff favoured being close to essential patient areas, such as the dayroom, to ensure continuous oversight and security. A recurring observation in studies on nursing station designs was the lack of clarity about additional workspaces in the unit. This ambiguity regarding supplementary areas leaves it unclear where staff might conduct their tasks, hold private conversations or take breaks. When faced with spatial constraints, the central nursing station may inadvertently become a multipurpose area, and if it is not entirely enclosed, this could potentially compromise staff privacy, confidentiality and quality of care. The need for clarity in the literature is paramount to inform the best nursing station configurations that benefit both staff and service users, especially given the preference service users have expressed for open nursing stations.32 33 45 46 In addition, there is a need for comprehensive, controlled studies that compare incidents involving staff before and after design alterations to nursing stations.

While the importance of design layouts, staff working and respite spaces, and the design and location of nursing stations cannot be understated, other design elements deserve consideration, even if they are less frequently emphasised in the literature. This encompasses aspects such as the facility’s location and its implications for recruitment, the uplifting influence of homely environments on staff morale and the role of artwork, colour choices and wayfinding strategies in enhancing staff satisfaction. Other key components include the positive impact of appropriate furniture on staff well-being and efficiency, the use of sensory rooms for relaxation, and the essential role of efficient alarm systems. Notably, most qualitative studies included in this review predominantly presented negative staff experiences of the facility design. Each facility’s unique design, typology and operational dynamics could influence these perspectives. There is a need for more comprehensive research that does not solely focus on drawbacks but also identifies the positive aspects of the design of these facilities.

This review points out certain essential design factors from a staff perspective. However, there seems to be a tension between some of these findings and the emerging design trends of recovery care models. These newer models promote a collaborative therapeutic environment, which may inadvertently diminish dedicated spaces specifically designed for clinicians and their activities.⁴ As evidenced by this review, these spaces notably impact well-being, job satisfaction and overall efficiency.^{3 4 36} With a global shortage in mental health staff and their critical role in patient recovery,⁸ the need for staff-designated working and respite spaces becomes evident. The Department of Health in England has already acknowledged this need, offering guidelines on specific rooms and amenities essential for staff.⁴⁷ Nevertheless, given the diverse characteristics of mental health facilities—from their location to design—further research is required to determine the optimal space required for staff to work and unwind.

Simultaneously, it is worth noting that many design elements, while vital to staff, also resonate with service users. For instance, amenities like gyms and natural spaces, though crucial for staff breaks,²⁹ are also valued by service users for their contribution to well-being.⁴⁸ The topic of open layouts draws attention to these shared experiences. Staff appreciate open designs for the safety they provide to everyone in the unit, a feeling shared by service users who prioritise safety and seek environments that offer a sense of security.⁴⁹ A potential challenge of these open designs is that the layout and scale might not be perceived as homely as traditional facility design with corridors. However, we are limited in what we can interpret from these spaces due to a lack of information in the studies, including detailed descriptions, floor plans and photographs. There might be a balance by designing domestic-sized open-plan units, with smaller clusters of patient bedrooms designed around a central open staff space.

Additionally, the review highlighted that the isolated location of mental health facilities impacts staff recruitment and retention, leading to feelings of isolation.^{24 27} Concurrently, service users associated such remote locations with societal stigma.⁴⁸ Though for distinct reasons, both groups agree that these facilities should not be overly isolated. The broader visibility of these units becomes pivotal, not just for societal acknowledgement but also for enhancing workplace perceptions and recruitment. Supporting this, a study conducted in New Zealand revealed that mental health units are, on average, three times farther from main hospital amenities than acute general units.⁵⁰ Other features identified by this review as being positive for staff have also been identified to benefit service users, such as the incorporation of artwork,^{22 51} homelike environments,⁵² and sensory rooms.⁵³

Study limitations

The review findings challenged our expectations in terms of depth and breadth. For example, the richness of the evidence and the quantity of the included studies supporting the findings did not allow a sufficient exploration of the topic; instead, they were based on thin and superficial data from a low number of studies, leading to broad, mainly descriptive findings. Furthermore, we expected to find publications on other design factors such as outdoor spaces, exterior views, noise or natural light - factors that have been identified as impacting healthcare staff in a similar literature review conducted for general healthcare facilities.¹²

In addition, the quality of the studies was variable, mostly of moderate quality. Most quasi-experimental studies did not include a control, the samples were different pre-assessment and post-assessment, and in most cases, they failed to acknowledge potential confounders associated with the interventions. Studies that claimed to conduct a post-occupancy evaluation lacked baseline data that allowed for comparisons to evaluate the effectiveness of the interventions. Qualitative studies most frequently failed to discuss issues related to reflexivity and triangulation or response validation to check the credibility of the findings, and the sampling was purposive. In the mixed methods studies, the number of participants for each component—quantitative survey data and qualitative interviews—was unclear. In addition, there was no justification for using mixed methods, and the reasoning for integrating the qualitative and quantitative components was not adequately addressed.

We also found limited quantitative research, especially related to single interventions, although this was not surprising; research in this area often investigates the effectiveness of designs ranging from simple renovations to a complete relocation to new facilities, where a package of interventions takes place simultaneously. This made it challenging to compare qualitative data, where staff expressed their experiences and perceptions of specific design factors. Furthermore, the generalisability of the results was limited due to several reasons. First, ward designs varied between studies, and second, each study measured the effect of the intervention on a different outcome or used different outcome measures. Therefore, more quantitative pre–post redesign/relocation studies are needed that measure the same outcomes and use standardised outcome measures to allow comparisons and better understand the impact of the interventions. These studies should be methodologically rigorous, have controls and report potential confounders associated with the intervention that could influence the results, such as variations in organisational procedures, treatment and staffing. Randomised control trials would also be beneficial to understand the impact of specific design factors on staff. Also, well-conducted mixed methods research, where qualitative inquiries follow-up quantitative data findings. This will make interventional studies more meaningful by providing further descriptions of findings. More rigorous qualitative research should also be conducted that explores staff experiences of the physical and work environment on defined outcomes. Importantly, future research should be methodologically better defined and more rigorous, paying particular attention to the setting characteristics, the sampling and the risk of researcher bias.

Conclusion

This systematic review consolidated current research on how the design of mental health inpatient facilities affects healthcare staff. It emphasises the pressing need for dedicated work and respite areas for staff. While recent designs emphasise patient-focused care, the undeniable influence of these spaces on staff well-being makes their incorporation imperative. Additionally, the design specifics and strategic placement of nursing stations are vitally important. With staff expressing reservations about open nursing stations and service users favouring them, more research is essential to find a middle ground prioritising safety, efficiency and a supportive therapeutic environment. Notably, several design features vital for staff, such as open layouts for heightened safety, community-integrated facilities, sensory rooms, homely environments and the inclusion of artwork, also align with service users’ preferences. The complex relationship between facility design and mental healthcare delivery calls for ongoing research, especially in less explored areas, to provide facilities that benefit service users and staff equally.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Not applicable.