David Cummins: G'day and welcome to the AHDC podcast series Health Design on the Go. I'm your host, David Cummins, and today we are speaking to Nicole Eadie, an architect from Darwin, who has national experience of working in mental health projects across Australia, working at DWP Australia for over nine years, Nicole has designed some of the most innovative mental health standalone hospital projects up to 70 million across Australia.

I'm excited today to discuss mental health design with Nicole and understand more about the importance of design for people who require these facilities.

Welcome Nicole. Thank you for your time to be here.

Nicole Eadie: Thanks, David. I'm excited to join you.

David Cummins: Mental health facilities is such a huge array of patients, whether you are teenagers or kids, whether you are older women, acute rehabilitation, there's such a huge plethora of an array of people with needs. How does an architect hit that balance for such a different array of specialties within one facility?

Nicole Eadie: I think really it's about understanding what the demographic of the hospital will actually be. So what you'll find across Australia is that there's often specialist facilities.

So it's really unlikely that you would have a drug rehabilitation ward within the same area as you would, for instance, have a youth or teenager-specialised mental health facilities.

The needs are quite diverse, and so it's not really possible to make things multi-functional in that way. So what you end up finding is that a unit might have for instance, a non-acute level of care, which is people that are needing to go into an in-patient environment for three weeks voluntarily all the way through to your more acute levels that are usually tied to your public hospitals and to your emergency departments and admission systems.

So what we find is that, if you do need to provide multiple ward types, not dissimilar to a normal hospital environment, you would be designing them as particular areas and making sure you're providing dignity of privacy between a youth's area versus an adult mental health facility.

David Cummins: Yeah, that's really, really interesting point.

So, knowing that some people in mental health hospitals may be mentally unstable or may need some specialist equipment or specialist treatment, how do we find the balance of patient safety versus respect versus privacy versus compassion, empathy, but also making sure that they're able to function in such a space as well?

It's quite a task to get the balance between all those areas, is it not?

Nicole Eadie: Absolutely.

And the other part of it as well is that you've also got to tackle the problem of infection control as well, because fundamentally there's still a hospital and so they need to be licensed under the AusHFG (Australasian Health Facility Guidelines).

So when you throw that into the mix as well sometimes your infection control factors aren't really conducive to good design from a mental health perspective. I suppose to sort of circle back to your question in terms of how you balance the needs of safety versus all the other factors, safety is the number one in mental health in-patient ward.

So not necessarily talking about your community facilities, like intervention areas that you might be Victoria at the moment is setting up those community health hubs and regional centres, those sorts of areas, you can allow yourself to lower the risk parameters, but in an actual hospital environment, people are there because they've reached a point where they're not necessarily able to act in a way that is in their own best interest in terms of their physical safety.

So the way we tend to talk about it is in three spaces. So harm to self, harm to others, harm to your environment, or destructive behaviour is the other way that people often talk about a third one.

A harm to self is relatively obvious when you're talking about mental ill health, but you are trying to eliminate in design many of the things that make a space pleasant.

So you can't necessarily have things hanging on the walls, battening and things like that all needs to be flushed so you don't create ligature points because unfortunately people will look for ways to create hanging points within their environment to follow through on that self harm factor.

And I suppose harm to others is usually talking about your health staff. So we know that in normal health environments, there is unfortunately a lot of abuse that happens with your nurses and doctors that is compounded in a environment for patients that have mental ill health.

What we are trying to do is eliminate the ability for people to have projectiles, to be able to pick up chairs potentially and throw them around the room, and all of these factors in terms of your patient's risk profile versus what you actually intervene depends on the type of facility.

So in a non-acute environment, which is usually when maybe the patient has been having really bad depressive episodes and is self-admitted for three weeks, you can usually stand to pull back some of those interventions that you might do, and the tolerance from the hospital operations will be higher.

So maybe you don't necessarily have to have your full piano gear type hinges on doors and things like that in every single environment. They may only reserve that for the higher risk areas like laundries, bedrooms, ensuites.

Whereas if you're talking in a public setting, which has acute care, which is usually unfortunately when a person has presented to an emergency department, due to a act of self-harm, and that they've been transferred to a public facility, those types of environments, the tolerance for anything that constitutes a risk is very, very low.

So the way that we actually implement that in design is usually completely flush finishes to eliminate ligature hanging points. Usually anti tamper screws because patients will attempt to get in behind power points and access to electronics.

You can't ordinarily have any kind of acoustic tiles in your ceiling, and things like that, so you also get reverb problems within these types of spaces as well. So how you start to deal with that is quite specialised and highly specific to the patient demographic you're designing for, and the risk tolerance of the hospital operator.

Those two things do tie back into really understanding what your model of care is, and you should be gaining that understanding through really intensive user group sessions with the hospital that you're designing for.

David Cummins: I've noticed in a few new mental health facilities around Australia, the use of no doors in bathrooms or ensuites. Do you mind just talking about that from a privacy point of view versus safety point of view?

I suppose it goes back to your point of safety is a number one priority, but how does that sort of work and what does the research say about that?

Nicole Eadie: Yeah, absolutely.

So in a hospital that we've designed recently, it was discussed really early days about whether or not we are going to have doors within the ensuites. We have been able to remove them from our design.

Typically the no doors to ensuites is reserved for your higher levels of care. So those acute settings, like I discussed before, this hospital is actually a non-acute environment, so it's quite unusual to remove the doors because in those environments, we're trying to afford the patient a higher level of privacy.

And so what we needed to do is develop in conjunction with the health department and the hospital operator, how to actually overcome that so that we were creating and striking a balance between those two things.

So essentially what we ended up doing was arranging the on-suite design in a way that essentially you cannot actually see into the ensuite until you are fully within the room.

Now that does sound counterintuitive when you're talking about mental health in an acute setting because it's likely that you're going to be wanting to see into the ensuite, in case an incident has occurred there, but in a lower care setting, it is actually more important to afford the person privacy within that quite private environment.

So what we actually ended up doing was with the health department, we brought them into a 3D environment and did a walkthrough of all the typical bedrooms and non suite designs, and actually showed them how those site lines would work and how we were affording privacy.

It was very much a joint effort between us and the hospital. We presented how the physical implications were realised and then the hospital themselves talked through their different procedures that they were going to go through.

So they developed a particular doorknob policy, the way that we designed the doors had privacy vision panels that were operated from within the bedroom as opposed to outside of the corridor, which is typical, and those things all fit back into a design that felt a lot more like a hotel room, than a hospital environment.

And it also meant that we could afford, we could avoid some of the proprietary ensuite doors, which are often made out of foam and look very, very institutional and speak to the patient, that they're in an environment where you don't trust them.

And what we want to do is have safe interventions that are invisible. The problem that we have in mental health design so often is that we make a space safe, but it screams to that patient... "you can't be trusted, we think that you have no autonomy, no agency", and it really dumbs down and condescends the patient and makes them feel worse in some ways.

And what we're trying to do, through our design at least, is create environments that are empowering and not knocking somebody back. This intervention that we've done with the 'no doors' we got approval for that by agreeing to go through a really rigorous post-occupancy review 12 months after completion.

That hasn't happened yet, but the reviews from the patients at the moment is that they do feel like they have privacy and they do feel like they have dignity. And some of them have stayed in hospitals that have the other door types, which are not an ideal scenario and have commented that, yeah, they're really happy with the design outcome.

David Cummins: I know you talked about nurses and staff for that user group process, but was it hard to get consumers on that journey and investigate and discuss with consumers?

Because obviously people are at different mental states and different heightened awareness, so was there any real consumer feedback or just more based on research and nursing experience?

Nicole Eadie: I would say that from our perspective, I suppose there's lots of different ways that you can do that consumer engagement process, because it's quite a sensitive area.

Often the clinicians naturally are very protective of the people in their care and they don't necessarily want to expose them to architects who may say the wrong things that aren't necessarily as sensitive.

And so from my perspective, I've been thinking about this a lot recently, and actually I think it's more important that the clinicians have that back and forth with the patients and consumers then it's for us to have face-to-face time because so much of health design and mental health design specifically is about how the environment ties into your model of care or how the operations are actually managed.

And so they have the best understanding of that. The clinicians and nurses are the experts and where just stepping in to facilitate an environment that allows them to operate at the way that they need to.

Generally speaking, we do have opportunities to talk to consumers, but it's quite limited and I don't necessarily see an issue with that.

David Cummins: Yeah, that makes sense.

So we've talked about the importance of good design. Generally speaking, bad design can lead to bad operations in non-acute hospitals, but in this situation, bad design can actually lead to death.

So I'd say it's probably one of the main areas which can lead to a higher death rate than other departments. I think I'm comfortable to say that.

You talked about post-evaluation assessment on your projects, but you've built so many projects in the past. Is there examples that you are aware of, not necessarily on your projects where a death has occurred from bad design and what happens then?

Do we have to retrofit? Does the law have to be changed? Does BCA have to be shown to you? Report, like there must be examples in the past of things that haven't worked.

So what happens then?

Nicole Eadie: I've definitely been given examples from others in the industry of things happening. You know, There was a hospital I believe that was designed and then they went and put a bridge over a highway directly adjacent to it.

And, you know, things happen because of that co-location and there's not a lot that you can do about it when it comes to things like that because the boundary of your site is where you have the influence, if that makes sense.

And you can't actually stop people leaving that hospital environment. People do have agency and they are entitled to be able to leave depending on where they're at with their patient journey.

And that's quite confronting as well because the sighting is not necessarily up to us as architects often, that's decided by where a hospital for potentially physical health is best to be located, not necessarily one for mental health, because they're often located in similar areas.

I've also had, from a just personal experience, not related to mental health design, but when I was at university one of the students had a really bad exam result and died by suicide adjacent to one of the libraries and they did do a design intervention after that, quite similar to how we would design a courtyard for a mental health hospital.

Now they put up barriers that were three meters high and you kind of limited the use of that outdoor rooftop courtyard space, but it does become necessary in these public environments.

I think the question relates not only to mental health hospital design, but a broader context as well, in terms of how we actually help our community in those early intervention times.

 I do think I feel a lot of responsibility there. I had a moment last year where I was thinking about exiting the health sector completely because as we were going through the construction process, every time you had to have that argument, and our contractors were great, but you're still having these arguments about whether something's actually necessary.

"Are you sure? Nicole, are you sure that we actually need to put anti-tamper screws here? Are you sure that we need to silicone every single joint that exists in the hospital"? I am sure, but it is frustrating and, there are times when you think, oh, "maybe I am being unreasonable".... but then you think back to what the consequences are of designing something poorly.

And unfortunately, patients who are experiencing mental health, they're just looking for an opportunity for the environment that they're within, to be designed badly, to harm themselves. And that's a big responsibility and it's something we have to very much take seriously.

From my perspective, I have friends and family that have stayed in in-patient units before and I just think back to what I would want an architect to do for them. And I try to advocate as much as possible for a safe environment whilst balancing the aesthetic parts of it, which also play into the success of an in-patient unit.

David Cummins: It is a balancing act.

That seems to be a common theme throughout this conversation, I think if we come back to our number one priority of patient safety and care then that's a good guide for all of us.

I have . Spoken to a few mental health clinicians and one thing, especially with the older facilities, because you've been lucky enough to design a lot of new ones, with the older facilities where they are in literally in the basements with no windows with very small rooms, very, very 1960s, 1970's facilities.

They're listening to this going, "oh wow, you're so lucky you've been able to design something new". But for retrofitting, especially old departments, what are some tips that designers can do or hospitals, on a limited budget, try and enhance mental health patients in that environment, which is restricted by infrastructure and by money.

Nicole Eadie: I've been involved in one extension and one refurb and a retrofit I suppose, depends how you classify all of those. But I think what it's about is creating communal spaces potentially maybe the . Bedrooms themselves can't necessarily be resolved in a way that you would, in a newer facility that has less constraints, but you're often able to create environments that are a lot more conducive to best practice care.

So what you'll find in older facilities is that a dining room, for instance, may be in it's own little room or space, and so you are very much cutting off the access to natural light by having it in the older way, whereas there may be ways to take advantage of courtyards, because often even the older facilities tend to have really beautiful courtyards I've found.

Moreso I think than the newer ones, I think that now we tend to prioritise consult rooms and interview rooms a little bit more than maybe garden spaces, which again, balance act of can you provide your care in an indoor environment or in an outdoor environment.

But if you can take advantage of putting your communal spaces, like living rooms, et cetera, group rooms and things alongside those existing courtyards. I think that gives you a lot of opportunity to create a really pleasant environment.

David Cummins: Yeah, there's so much research to support biophilic benefits. We've got a podcast series about it coming up. I a hundred percent agree, do what you can and try and get as much connection to nature as possible where you can.

I think it's a great idea. Thank you so much for your time. I'm so glad you haven't given up on the profession. I'm a big, big fan of your designs. I think some of the facilities have made around Australia are absolutely phenomenal. So credit to you and to DWP.

It's very obvious that you put a lot of effort into your evidence-based research to support your findings and to support your thoughts so therefore, when some people are challenging it, you're actually supported by evidence, just not opinion.

 I think that's an absolute credit to you, to DWP and to your profession. So thank you so much for your time. I think you're phenomenal and look forward to seeing more designs with you in the future.

Nicole Eadie: Yeah. You're most welcome, David.

Thank you so much for having me on.

David Cummins: You have been listening to the Australian Health Design Council podcast series, Health Design on the Go. To learn more about the AHDC, please connect with us on LinkedIn or our website.

Thank you for listening.