The Physical and Psychosocial Environment’s Influence on Patients’ and Staff’s Perceptions of Person-Centered Care in Forensic Psychiatry

Special Article - Forensic Medicine

Austin J Forensic Sci Criminol. 2016; 3(2): 1051.

The Physical and Psychosocial Environment’s Influence on Patients’ and Staff’s Perceptions of Person-Centered Care in Forensic Psychiatry

Eirini Alexiou RN1,2, Alessio Degl’ Innocenti2,3, Anette Kullgren RN4, Hanna Falk RN4,5 and Helle Wijk4,6,7*

1Department of Forensic Psychiatry, National Board of Forensic Medicine, Sweden

2Center for Ethics, Law, and Mental Health (CELAM), University of Gothenburg, Sweden

3Forensic Psychiatric Clinic, Sahlgrenska University Hospital, Sweden

4Institute of Health and Care Science, University of Gothenburg, Sweden

5Department of Psychiatry and Neurochemistry, University of Gothenburg, Sweden

6Department Quality Assurance, Sahlgrenska University Hospital, Sweden

7University of Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Sweden

*Corresponding author: Helle Wijk, Institute of Health and Care Sciences, The Sahlgrenska Academy at Gothenburg University, Box 457, 405 30 Gothenburg, Sweden

Received: August 18, 2016; Accepted: September 26, 2016; Published: September 29, 2016


Objective: We sought to investigate the impact of the psychosocial and physical environment on patients’ and staff’s perceptions of the care atmosphere, quality of care and possibility to perform person-centered care at three forensic psychiatric facilities in the county of Västra Götaland in Sweden.

Background: In order for a forensic psychiatric care environment to be adaptable to face the needs of the patients, a person-centered approach is needed. Person-centered care regards the patient as a person with unique experiences, desires and preferences that must be taken into account when care is provided. This requires a sufficiently flexible staff to accommodate these individual conditions and an environment adapted for individual needs.

Methods: Participants were patients over 18 years of age sentenced to compulsory forensic psychiatric treatment, and health care professionals at the wards of the aforementioned facilities. Data were obtained by employing structured questionnaires.

Results: Overall, 58 patients (72% were men) with an age range of 18 to 69 years, and 239 staff members (43% were men) with a mean age of 45 years, participated in the study. Although the staff estimated their possibility to provide person-centered care as rather high this didn´t correspond with the patients’ assessment of perceived ward atmosphere as person-centered. There was a difference in assessed person-centered ward atmosphere between urban and rural facilities in favor of the urban hospital (p<0.01).

Conclusion: The results of this study indicate that patients’ and staff’s perceptions of person-centered care in forensic clinics are highly susceptible to factors in the physical and psychosocial environment.

Keywords: Person-centered care; Environment; Ward atmosphere; Forensic psychiatry; Rural; Urban


It is well known that the physical environment has a huge influence on patient rehabilitation by providing support for declining functional capabilities and strengthening preserved resources. An environment that maximizes safety and security as well as awareness and orientation, supports functional abilities, facilitates social contact, provides privacy, gives opportunities for personal control, regulates stimulation and provides the possibility for continuity is supposed to characterize a secure and safe caring environment [1]. The main purpose of a forensic psychiatric facility is to act as a place for improving health and promoting recovery for the patients with the aim to them re-entering society. It can be presumed that the physical environment has an impact on patients’ rehabilitation in forensic psychiatric care, just as it has in other medical disciplines such as general psychiatry, geriatrics and oncology [2]. Nevertheless, most facilities in forensic psychiatric care are designed and constructed with a traditional institutional layout with single-bed rooms located alongside long double-loaded corridors with the priority placed on their effectiveness as workplaces for staff rather than on habitability for patients [3]. Patients in forensic psychiatry care are unique persons who have been referred by the courts for assessment or who have been declared as being not criminally responsible or unfit to stand trial by the criminal justice system. The majority of these individuals are in need of secure in-patient care and assistance over long periods of time, which poses great demands on the healthcare environment.

Any healthcare environment consists of physical, psychosocial and cultural dimensions, which individually and collectively contribute or withhold patients’ well-being by capitalizing or preventing particular strengths while reducing or increasing limitations [4]. In recent years, a stronger research focus has been placed on considering the relationship between the physical healthcare environment, patient well-being and staff work-satisfaction [5], emphasizing how poorly designed environments are a risk, inhibiting functioning and social well-being [6]. In 1973, Lawton and Nahemow developed an ecological model of environmental fit that has provided a theoretical background for understanding the need for environmental adaptions in order to match individual abilities. This model suggests that an individual’s behavior and well-being is a result of the interaction between the complexity of personal abilities and their adaptation to the environment. Optimal fit occurs when someone’s capacities are consistent with the demands and opportunities within that person’s environment. However, if the demands of the environment exceed or undercut the person’s abilities, there is a person-environmental incongruity. This concept is well in line with the ratings included in the generic quality-assessment protocol that measures good caring environments and their ability to accomplish safety and security, by focusing on orientation, functional abilities and personal control [1].

Patients in forensic psychiatric care who have sufficient and adequate resources at their disposal, and who learn how to use them, can gradually develop a strong sense of coherence. Resources that are bound to individual capacity can be summoned within people, but these can also be found in their immediate physical and psychosocial environment which is of great importance in a forensic psychiatric health care environment that aims to be supportive, habitable and safe [7]. Within the context of forensic psychiatry, person-centered care emphasizes the individual’s right to define what steps need to be taken in order to achieve health and well-being in the process towards rehabilitation and re-integration into society. Person-centered care environments are known to acknowledge the respective resources, needs, personality, preferences, habits, and cognitive, sensory, and physical limitations of each patient [8].

There is little evidence on the effects of person-centered environments in forensic psychiatry found in the literature, although there have been several approaches presented of how to change the environment in forensic psychiatry to meet the needs of the patients. A growing body of research suggests that the environment should not only support patients’ functional abilities and physical activity but should also provide them with a sense of control and independence [9]. Disruptive behaviors are prevalent in most forensic psychiatric long-term care facilities. For example, about 70% of residents suffer from insomnia or disturbed sleep [10]. Furthermore, environmental factors that may contribute to sleep disturbance include limited sunlight exposure, large amounts of time spent in bed, lack of physical activity, and nighttime noise [11].

Finally, the characteristics of a traditional environmental design in forensic psychiatric care may contribute to confusion and disorientation, such as monotony of architectural composition and lack of reference points [12], long corridors with many doors and lack of windows or lack of access to windows. One study, for example, has shown that different aspects of the environment in forensic psychiatry - such as the unit layout, supportive features and finishes, reduced noise, as well as access to outdoor spaces and sensory stimulation - may be linked to better outcomes, including improved sleep, better orientation, reduced aggression and disruptive behavior, increased social interaction, and increased overall satisfaction and well-being [13].

In view of the above disparity, we sought to investigate the impact of the psychosocial and physical environment, and subsequent architectural interventions, on forensic psychiatric care outcomes. There is a specific need to demonstrate that person-centered forensic psychiatric environments have an impact on the quality of care in light of the high costs that the authorities have invested in health care facilities recently. Additionally, we aimed to study the effect of the working environment and other staff-related parameters, such as competence and experience, on the delivery of person-centered care. In this first scientific report, the specific aim is to present baseline data of the three forensic psychiatric facilities in the county of Västra Götaland, Sweden; one urban and two rural. In order to confirm or reject our preconceptions–that a poorly designed environment has a negative influence on patients’ and staff’s perceptions- we provide a systematic description of (1) ward atmosphere, (2) quality of care, and (3) staff possibility to perform person-centered care before relocation.


This study was conducted at the three forensic psychiatric clinics in the western part of Sweden in the county of Västra Götaland; one urban, and two rural facilities. The environment matched on all design features at the three forensic psychiatric clinics. The design faced both latent implicit and explicit architectural drawbacks according to architectural evaluation documented in a local report [14] and existing evidence based literature in this field [4]. These included that standardized traditional single-patient rooms, called ‘back-to-back’, were laid out on both sides of a hallway; a lack of individual bathrooms; a deficient ventilation system; lack of windows and controllable lighting and temperature; lack of access to the natural environment and daylight exposure, neither through a nature window view or by gaining access to gardens with seating areas; poor placement of handrails; and inappropriate door openings and furniture heights.

Data collection, measures, and outcomes

All patients and staff at the three clinics were informed about the study and asked if they were willing to participate. The staff was informed by the researchers, both orally at a general meeting and by written information. After given informed consent they were asked to fill in the questionnaires. The same procedures were followed for the patients, with the exception that they were informed at their specific unit. Data were collected prospectively between 2010 and 2011 and before the intervention of relocating the forensic psychiatric clinics to the new health care buildings.

For patients, demographic data included age, gender, place of birth, education, employment history, marital status, place of residence before admission to the forensic psychiatric clinics, previous admission to a psychiatric ward, length of current admission, and compulsory care during current admission. For members of staff, demographic data included age, gender, education, current profession, and professional experience within the field of forensic psychiatry.

In the patient group, perceived ward atmosphere was measured using the patient version of the Person-Centered Climate Questionnaire (PCQ-P) which is a patient-reported outcomes instrument designed for evaluating the extent to which a climate (i.e., the physical and psychosocial environment) is perceived as being person-centered (i.e., supporting the person by placing his or her needs and expectations at the center of care). The instrument comprises 3 related domains; safety (10 items), everydayness (4 items), and hospitality (3 items). The domain of safety is related to experiences of being safe in the environment; the domain of everydayness is related to the environment as having an everyday tidy character; and, finally, the domain of hospitality is related to the feeling of welcoming and the sense of perceiving the care and treatment as exceeding expectations. The items are rated on a 6-grade Likert scale, ranging from “I disagree completely” to “I agree completely.” The questionnaire is sum scored, and scores can range between 17 and 102, with higher scores indicating a more person-centered climate [15,16]. Quality of care was measured using the Quality in Psychiatric Care questionnaire (QPC), which is a patient-reported outcomes instrument designed to measure the quality of care from a patient perspective [17]. The instrument contains seven related domains; encounter (8 items), participation (8 items), discharge (3 items), support (4 items), secluded environment (2 items), secure environment (3 items) and specific questions about the forensic clinic (6 items). The last 6 items have been developed for use in forensic psychiatric settings with an emphasis on legal matters surrounding such settings [17]. It included questions about whether the patients have been informed about their rights, or have received help to contact the Administrative Court and their lawyers, as well as questions about the involvement of staff and doctors in treatment and crime processing. The items are rated on a 4-grade Likert scale, ranging from “I agree completely” to “I disagree completely”. The overall score is calculated as the mean of the individual item scores which can vary between 1 and 4. Higher scores indicate lower quality of care from a patient perspective.

In the staff group, perceived ward atmosphere was also measured using the staff version of the Person-Centered Climate Questionnaire (PCQ-S). The instrument comprises 3 related domains; safety (6 items), everydayness (4 items), and community (4 items). The domains of safety and everydayness have previously been described. The domain of community involves possibilities to keep previous social contacts and to establish a new social context in the environment. The items are rated on a 6-grade Likert-scale, ranging from “I disagree completely” to “I agree completely.” The questionnaire is sum scored, and scores can range between 14 and 84, with higher scores indicating a more person-centered climate [15,16]. Person-centered care was measured using the Person-centered Care Assessment Tool (P-CAT) which is a self-reported outcomes instrument designed for evaluating the extent to which staff perceived they have a possibility to provide personcentered care and to which degree environmental factors support them in their work [18]. The instrument consists of 13 items that are rated on a 5-grade Likert scale, ranging from “I disagree completely” to “I agree completely.” The questionnaire is sum scored, and scores range between 13 and 65, with higher scores indicating more personcentered care [15,16]. Reliability and internal consistency was good for the majority of the instruments and acceptable for the dimension of hospitality in the PCQ-P. The instruments, along with their respective dimensions and Cronbach’s alpha values, are presented in Table 1.