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Evidence-Based Design Has a Sustainable Positive Effect on Patients' Perceptions of Quality of Care in Forensic Psychiatry

A 3-Year Follow-Up Study

Wijk, Helle, RN, MSc, PhD1,2; Degl' Innocenti, Alessio, MSc, PhD3,4; Kullgren, Anette, RN, MSc1; Alexiou, Eirini, RN, MSc, MD, PhD3,5

doi: 10.1097/JFN.0000000000000226
Original Articles

ABSTRACT This prospective longitudinal study aimed to assess the sustainable effect on patients' assessment of ward atmosphere and quality of care at three forensic psychiatric clinics relocated to new facilities built with the latest evidence-based healthcare environment design to support recovery. Baseline data were collected in the old facilities and during three follow-ups after relocation, between 2010 and 2016. Of 74 patients who gave informed consent to participate, 58 patients (100%) answered the questionnaires at baseline, with 25 patients (43%) completing them at Follow-up 1, 11 patients (19%) at Follow-up 2, and seven patients (12%) at Follow-up 3. This study provides evidence that the mean values of patients' perceptions of care quality in these forensic psychiatric facilities increased when moving to new buildings and were stable up to 3 years after relocation, which was statistically significant in the domain of secluded environment (p < 0.05). The sample size at Follow-up 3 was small, and thus the results are limited, which indicates that further research is needed to confirm the findings.

Author Affiliations: 1Institute of Health and Care Science, Sahlgrenska Academy, University of Gothenburg;

2Department Quality Assurance, Sahlgrenska University Hospital;

3Center for Ethics, Law, and Mental Health, Sahlgrenska Academy, University of Gothenburg;

4Gothia Forum for Clinical Trials, Sahlgrenska University Hospital; and

5Forensic Psychiatric Clinic, Sahlgrenska University Hospital.

The authors declare no conflict of interest.

All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals.

Correspondence: Alessio Degl' Innocenti, MSc, PhD, Gothia Forum for Clinical Trials, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden. E-mail:

Received April 24, 2018; accepted for publication November 4, 2018.

The physical environment can influence a patient's health and is often mentioned as an important factor to support person-centered care and patients' daily lives. However, the quality of the physical environment is rarely evaluated, and knowledge is sparse in terms of how well the environment meets the needs of the patients. The healthcare environment can be described as an integration between the physical environment and the psychosocial environment, where the latter can be characterized as being part of a person-centered approach that influences well-being and health (Edvardsson, Sandman, & Rasmussen, 2006). Aligned with this approach, person-centered care is characterized by consisting of equal encounters between carers and patients to address the patients' offending behavior, where the patient is treated as a person and a partner in the care process while being supported by the physical and psychosocial environments (McCance, McCormack, & Dewing, 2011; McCormack, Karlsson, Dewing, & Lerdal, 2010). A person-centered approach to care sets the person's view about his or her life situation and condition at the center of care. The patient narrative is the person's personal account of his or her illness, symptoms, and their impact on his or her life. It captures the person's distress in an everyday context. In contrast, medical narratives reflect the process of diagnosing and treating the disease in an objective manner (Ekman et al., 2011). In relation to the recognition of the importance of person-centered care, Elf, Fröst, Lindahl, and Wijk (2015) highlight that it is surprising that the impact of the physical environment on a person-centered approach is often neglected.

Forensic psychiatry in Sweden provides compulsory care for patients who have committed a criminal offense but who lack criminal responsibility because of a mental disorder and are deemed to be a danger to public safety. The main purpose of a forensic psychiatric care service is to act as a setting for improving health and promoting the recovery of the patients with the aim of supporting them to reenter society as well as addressing offending behavior (Degl' Innocenti et al., 2014). The most common diagnoses (59%) among this population are schizophrenia, and schizotypal and delusional disorders (Degl' Innocenti et al., 2014). In the county of Västra Götaland, Sweden, three new forensic psychiatric facilities have been constructed using the opportunity for improvement provided by the field of evidence-based design (EBD; Hamilton & Watkins, 2009; Shepley & Pasha, 2017) with the aim of improving the physical environment to promote a person-centered approach. The concept of EBD has been introduced to ensure the provision of high-quality physical environments that best support a patient's well-being and recovery. EBD relates to the process of drawing on the best available knowledge from research and practice to inform the planning and design of buildings to best meet their function. It has increasingly been used in the planning and design of healthcare facilities with the goal of achieving the best possible patient and staff outcomes (Ulrich et al., 2008). Inherent EBD is an interdisciplinary approach that requires an integration of evidence from various disciplines and multiple perspectives, including representatives of architecture, building construction, and healthcare (Elf et al., 2015). A central part of EBD is to begin by defining the needs of the user of a clinic (e.g., forensic psychiatric patients) in relation to evidence from research and practice.

The design of many hospitals is influenced by EBD. Including EBD in the construction of new hospitals has been shown to increase patient safety and patient satisfaction and to reduce the costs of delivering care (Ulrich et al., 2008). A database has been established in the United Kingdom to compile evidence of the various factors within the control of architects that can make significant differences to patients' satisfaction, quality of life, treatment times, levels of medication, displayed aggression, sleep patterns, and compliance with treatment regimens. One study (Ulrich, 1984) showed, for example, the effect of views through windows on the rate of recovery from surgery. The physical healthcare environment is also a part of the staff's workplace and has an effect on job satisfaction and the staff's sense of well-being, which in turn has been shown to influence the ward atmosphere in terms of performance, productivity, and the quality of care provided (Lundstrom, Pugliese, Bartley, Cox, & Guither, 2002).

Hospitals are complex systems, and it is difficult to isolate the impact of a few single factors, such as patients' perceptions of the environment. Although the quality of patient care and patient well-being remain the primary objective (Cutler et al., 2006; Ulrich et al., 2004) for staff working in hospitals, the care atmosphere and the psychosocial work environment are also important factors believed to contribute to the quality of care provided and the well-being of patients. To what extent these factors contribute to care and well-being of the patient is, however, unknown.

The traditional institutional layout, which is used in most forensic psychiatric clinics, consists of long double-loaded corridors with single-bed rooms. This layout is designed primarily to be an effective workplace for staff rather than to be habitable for patients (Haglund, von Knorring, & von Essen, 2006). The characteristics of these traditional environmental design features in forensic psychiatric clinics may contribute to confusion and disorientation through the lack of reference points and because of the monotony of architectural designs and composition, such as long corridors, multiple doors, and lack of windows (Passini, Pigot, Rainville, & Tetreault, 2000). In contrast, when constructing new-generation clinics, attempts are made to integrate noise reduction, to adapt furnishing to personal preferences, and to provide access to both natural daylight and outdoor environments to stimulate the senses, according to EBD (Alexiou, Degl' Innocenti, Kullgren, & Wijk, 2016). Adopting an EBD approach in forensic psychiatric clinics has been linked to better outcomes, such as a reduction in aggression and disruptive behavior, improved sleep, improved orientation, increased social interaction, and an increase in the general sense of well-being (Drahota et al., 2012). This means that adopting an EBD approach contributes to creating hospitals that help patients to recover in a safe environment. As such, the implementation of new methods for health care, such as building new facilities to achieve better patient outcomes in terms of decreased recovery times, is dependent on the physical environment of the healthcare architecture in which the health care is provided. Thus, making sensitive decisions about healthcare architecture is critical because they will affect people and work processes for many years and demand a long-term financial commitment from society (Elf et al., 2015).

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The specific environmental changes implemented in the three new physical facilities, designed to support patient recovery and activities, were influenced by EBD and comprised access to gardens, nature window views, and a quiet environment. Furthermore, supportive features and finishes were integrated into the physical environment, for example, appropriate access to equipment, such as job training or weight training, a private bathroom in every room, artistic decoration, and sensory stimulation, each of which may increase the patients' perceptions of the unit having a person-centered atmosphere.

Previous research implies that employing EBD in planning living units to prevent crowding and other stress-producing environmental conditions is important. For example, one study showed that a poorly designed clinic, one that creates crowding, is noisy, and has other stressful features, can intensify stress during rehabilitation, thereby worsening aggressive behavior and working against the quality of treatment outcomes (Ulrich, Bogren, & Lundin, 2012), for example, the length of recovery times. Stress-reducing models developed for psychiatric clinics include the physical environment as a variable influencing stress, placing emphasis on reducing the stress resulting from crowding or high-bed occupancy rates, which calls for the need of the possibility to withdraw to privacy in single rooms (Kumar & Ng, 2001; Nijman, 2002; Nijman, aCampo, Ravelli, & Merckelbach, 1999). The fact that stressful events can trigger aggression and violence in patients with psychiatric problems was shown in a study conducted by Sariaslan, Lichtenstein, Larsson, and Fazel (2016), where exposure to all examined triggers was associated with an increased risk of committing violent crime in the week after the exposure by patients with a history of psychosis. In addition, poor physical environment features can have a severe impact on care quality and can reduce opportunities for providing person-centered care in forensic psychiatry, and patients' perceptions of person-centered care are highly susceptible to factors in both the physical and psychosocial environments (Alexiou et al., 2016).

We assume that the physical environment is one crucial element of a person-centered approach. Findings from a linked study examining staff's perceptions of the relocation from traditional forensic psychiatric care facilities to new EBD premises (Alexiou, Wijk, Ahlquist, Kullgren, & Degl' Innocenti, 2018) show that the staff's assessment of a person-centered ward atmosphere in the new facilities was sustained over time. This prospective longitudinal study aims to assess the sustainable effect on patients' assessments of ward atmosphere and quality of care at the same three forensic psychiatric clinics relocated into new facilities by using two patient-related outcome instruments. Instead of simply comparing the effect of the relocation before and after, we have chosen to follow up on the impact of EBD over a time span of 3 years to assess whether any effect was sustainable.

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All patients at the three participating forensic psychiatric clinics in the county of Västra Götaland in the western part of Sweden were informed about the study and asked whether they were willing to participate. The patients' responsible doctors provided them with information about the study, and a patient informed consent form was signed by both the patient and the doctor before data collection took place. Data were collected prospectively between 2010 and 2016: before (baseline) and three times after relocation of the forensic psychiatric clinics to new buildings, namely, after 6 months (Follow-up 1), after 1 year (Follow-up 2), and after 2 years (Follow-up 3).

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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 general psychiatric unit, length of current admission, and compulsory care during current admission. Crucial factors in the physical environment for supporting a person-centered approach before and after relocation are displayed in Table 1.



The two following questionnaires were selected because they targeted the main focus of the study (the environment) and the target group (inpatient psychiatric forensic care) and were developed for use in Sweden. The Person-Centered Climate Questionnaire–Patient version (PCQ-P) was administered; this is a validated patient-reported outcomes instrument designed for evaluating the extent to which a climate (i.e., the physical and psychosocial environments) 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 three related domains: safety (10 items), everydayness (four items), and hospitality (three 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 being welcoming and the sense of perceiving the care and treatment as exceeding expectations. The items are rated on a 6-point 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 (Edvardsson, Sandman, & Rasmussen, 2008, 2009). The PCQ-P enables the description and comparison of environments, the exploration of correlates between person-centeredness and patient outcomes, and/or the measurement of the results of various interventions. In Edvardsson et al.'s (2008) psychometric study, it was shown that the three domains explained 65.1% of the total variance and also that the PCQ-P shows satisfactory goodness of fit in confirmative factor analyses. Content and construct validity were estimated to be satisfactory by Delphi assessment and item analysis. Cronbach's alpha was satisfactory for the total scale (0.93) and also for the three subscales: safety (0.94), everydayness (0.82), and generosity (0.64; Edvardsson et al., 2008). Reliability and internal consistency for the instruments are shown in Table 2.



Quality of care was measured using the Quality in Psychiatric Care questionnaire (QPC). This is a validated patient-reported outcomes instrument designed to measure the quality of care from a patient's perspective (Schröder, Larsson, Ahlström, & Lundqvist, 2010). The instrument contains seven related domains: encounter (eight items), participation (eight items), discharge (three items), support (four items), secluded environment (two items), secure environment (three items), and specific questions about the forensic clinic (six items). The last six items have been developed for use in forensic psychiatric settings with an emphasis on the legal matters surrounding such settings (Schröder, Ågrim, & Lundqvist, 2013). This instrument includes questions on whether the patients have been informed about their rights or whether they have received help to contact the Administrative Court and their lawyers as well as questions about the staff and doctors' involvement in treatment and crime processing. The items are rated on a 4-point Likert scale, ranging from “I agree completely” to “I disagree completely.” The overall score is calculated as the mean of the individual item scores that can vary between 1 and 4. Higher scores indicate lower quality of care. The QPC has excellent internal consistency (α = 0.96; Schröder et al., 2010). The loadings on the factors are as follows: encounter = 0.87, participation = 0.90, support = 0.86, discharge = 0.88, secluded environment = 0.81, and secure environment = 0.77. These factors explain 76.4% of the variance (Schröder et al., 2010). The QPC for use in forensic psychiatric settings has large similarities with the original QPC for patients in general psychiatric care, has good psychometric properties, and can be used as a self-report instrument in low-, medium-, and high-security forensic inpatient units to investigate the quality level and to improve the quality of care (Schröder et al., 2013).

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First, we analyzed incomplete data using expectations maximization algorithm. Most of the items in the PCQ-P are phrased so that a strong agreement indicates a positive quality. However, all of the items in the QPC scale are phrased in the reverse. To make these items comparable with the PCQ-P items, we reversed the value of the scores so that a higher overall score indicated better quality of care.

Descriptive statistics were calculated for all variables. Because of the small sample size, it was not possible to perform a repeated-measures analysis of variance, so scale scores were therefore analyzed using one-way analysis of variance. Furthermore, pairwise comparisons of the scale scores, among baseline and Follow-ups 1, 2, and 3, were performed by using Fisher's least significant difference test. Comparisons of the patients' overall scale scores between gender, nationality, and patients having or not having previous care experience, as well as between patients having or not having knowledge of the treating physician, diagnosis, and legal representative, respectively, were performed by the calculation of Student's t test. All reported p values were based on two-sided tests and compared with a significance level of 5%. The correlation between other patient characteristics, such as literacy level and previous care experience, was examined by using Fisher's least significant difference test. To measure the strength of the linear relationship between patient ages, length of current admission, and scale scores, we calculated the Pearson correlation coefficient. The SPSS statistical software package (Version 20; SPSS, Chicago, IL) was used for all statistical calculations.

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This study was approved by the research ethics committee at the University of Göteborg, Göteborg, Sweden (Dnr 671-10). This includes the protocol and the obtaining of written informed consent from all participants before their inclusion in the study.

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Demographics and Sample Characteristics

Of 74 patients who gave informed consent to participate, 58 patients (100%) answered the questionnaires at baseline, with 25 patients (43%) completing them at Follow-up 1,11 patients (19%) at Follow-up 2, and seven patients (12%) at Follow-up 3. Approximately two thirds of the participants at each time point were men, and the age range varied from 18 to 69 years (n = 58, SD = 1.1). The age group of 18–29 years (n = 20) represented 34% of all patients, whereas the proportion of patients over 60 years old was about 2% (n = 1). The vast majority of the patients reported having had a previous experience in general psychiatric care (67%) and were, at the time of the study, under compulsory forensic psychiatric care (70%). Finally, 72% of the patients were Swedish.

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Scale Score Analysis

Scale scores for perceived person-centered care and care quality for patients are presented in Table 3. Patients at Follow-up 3 had higher QPC total score and higher mean scores in all the following domains of the QPC compared with baseline and Follow-ups 1 and 2: encounter (mean = 2.83 vs. 2.50, 2.74, and 2.52, respectively; p = 0.39 and 0.55, respectively), discharge (mean = 3.00 vs. 2.48, 2.31, and 1.88, respectively; p = 0.25 and 0.31, respectively), support (mean = 2.76 vs. 2.50, 2.48, and 2.45, respectively; p = 0.56 and 0.94, respectively), secluded environment (mean = 3.57 vs. 2.48, 2.56, and 3.20, respectively; p < 0.05), secure environment (mean = 3.04 vs. 2.54, 2.94, and 2.66, respectively; p = 0.14 and 0.39, respectively), and specific questions for forensic department (mean = 2.86 vs. 2.62, 2.75, and 2.68, respectively; p = 0.53 and 0.83, respectively). Although the mean scores at Follow-up 3 were higher compared with those at baseline and Follow-ups 1 and 2 in all the abovementioned domains, only the mean differences between Follow-up 3 and baseline (mean = 3.57 vs. 2.48, p < 0.05) and between Follow-ups 3 and 1 (mean = 3.57 vs. 2.56, p < 0.05) in the domain of secluded environment were found to be statistically significant. On the contrary, the mean scores in the domain of participation remained rather stable over time (mean = 2.69 vs. 2.70, 2.71, and 2.24, respectively; p = 0.95 and 0.16, respectively).



A similar picture was revealed by the comparison of the PCQ-P everydayness domain scores: measures performed at Follow-up 3 and baseline and at Follow-ups 1 and 2 (mean = 4.35 vs. 3.79, 4.20, and 3.67, respectively; p = 0.31 and 0.32, respectively). These results are in contrast to the scale scores, both in the remaining domains of the PCQ-P and in the total score, where after a temporary decrease at Follow-up 2, an increasing trend was revealed at Follow-up 3 with the scale scores, although these were lower than those measured at baseline and those measured at Follow-up 1. The above results are presented in Table 4.



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Correlations Between Patient Characteristics and Scale Scores

The correlations between patient characteristics such as gender, literacy level, nationality, previous care experience, length of care, level of satisfaction, knowledge of the treating physician and diagnosis or legal representative, and scale scores were not found to be statistically significant. Table 5 shows a moderate negative correlation between specific questions for forensic department (r = −0.33, p ≤ 0.05) and participation (r = −0.28, p ≤ 0.05), and years of age. This indicates a weak trend that age decreases the patients' perceptions of quality of care received. No other correlations between scale scores and years of age were found to be significant.



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Improving and sustaining the quality of care in hospitals is a challenge. The patients' experiences of the quality of given care can provide important feedback to enable staff to direct quality improvement efforts to areas where they are most needed. Yet, patient experience is often marginalized in favor of aspects of care that are easier to quantify, for example, waiting time (Beattie, Lauder, Atherton, & Murphy, 2014). Measurements, however, are difficult to take, interpret, and compare, and no single measure can capture the multitude of facets and outcomes of modern, complex healthcare systems.

This study investigates sustainability of EBD in forensic psychiatry in patient-related outcomes. The main findings were seen in the patients' perceived quality of the psychiatric care provided (i.e., the QCP) with evident stability from baseline through the three follow-ups. Moreover, this study revealed a sustainable increase related to the patients' assessment of having access to a secluded environment up to 3 years after relocation. This confirms the need for patients in forensic psychiatry to have the possibility for both privacy and socialization when needed, which is in line with models indicating that the physical environment is a variable influencing stress if there is no room to withdraw to privacy (Kumar & Ng, 2001; Nijman, 2002; Nijman et al., 1999). In a study by Alexiou et al. (2016) with the same population, it was found that, 1 year after the relocation of a forensic psychiatric population, patients' perceptions of person-centered care were highly susceptible to factors in the physical and psychosocial environments. Apparent by the study performed by Alexiou et al. (2016), patients' perceptions of the unit atmosphere and the quality of the received forensic psychiatric care are influenced by attributes in the physical environment, such as the possibility to withdraw to a secluded environment.

Although this study did not assess specific features at the facilities that could increase the possibility for the patient to withdraw to a secluded environment, it is still interesting to compare the results from this study with those of one conducted by van der Schaaf, Dusseldorp, Keuning, Janssen, and Noorthoorn (2013). In contrast to our group of forensic patients, their study was conducted with a general psychiatric population; however, they found that, when patients were only provided with access to large general outdoor spaces, in combination with a large number of patients in the building, this increased the risk of negative perceptions of isolation. This negative perception decreased when the patients were offered more private space per patient in addition to access to general outdoor spaces, together with a good overview of the unit. This finding is in line with our results, where the new buildings provided the patients with an increased overview, that is, a better line of sight of the unit, in addition to more private space per patient, which was assessed as a positive perception by the patients in having the opportunity to withdraw to a secluded environment when needed. An explanation for our finding could be that an overall high visibility of a clinic gives the patients an opportunity to choose where to withdraw to and where to socialize. In addition, bigger units can be divided into smaller units, as they could in the buildings in this study, where the units could be divided into two modules by locking two doors if needed.

In a systematic review (Dijkstra, Pieterse, & Pruyn, 2006) conducted to determine the effects of physical environmental stimuli in healthcare settings on the health of patients, predominantly positive effects were found for sunlight, windows, odor, and seating arrangements. Inconsistent effects were found for nature sounds, spatial layout, television, and multiple stimuli interventions. In general, both the size and direction of effects seem highly dependent on the characteristics of the patient populations and healthcare settings, and a conclusion from Dijkstra et al. (2006) is that studies that manipulate several environmental stimuli simultaneously clearly support the general notion that the physical healthcare environment affects the well-being of patients, but that conclusive evidence is still very limited and difficult to generalize. Thus, our study appears to contribute to this research field in a mixed way; the patients' perceptions of the quality of the care they received appeared to be positive, and at the same time, their perceptions of seclusion appeared to be more positive after relocation relating to higher scores in the instrument.

The strength of this study is, to our knowledge, that this is the first study to examine the long-term patient outcomes of clinic relocation in forensic psychiatry. Furthermore, we followed the same patients from the old facilities, to the new facilities, and for 3 years after relocation. A limitation of adopting this 3-year follow-up strategy is that the sample size at Follow-up 3 was small and thereby the results are limited by placing a bias on those who completed the questionnaires. This high attrition over time reflects the situation in forensic psychiatric care where the patients' psychiatric illnesses and psychiatric symptoms make them reluctant to participate in studies. However, considering a cross-sectional approach, to manage the attrition, repeated measures were performed to accomplish robust follow-ups. Another limitation is that we cannot rule out whether only patients with a higher positive perception answered the questionnaires or that social desirability played a role in the patients' assessments. Most design changes to physical environments involve and influence multiple environmental factors at the same time. This creates complexities and confounding factors that blur the independent effect of the specific environmental factor of main interest (Ulrich, Berry, Quan, & Parrish, 2010; Ulrich et al., 2008). This is the case in the current study, where we cannot indicate the specific design features associated with quality of care. However, our results show that patients' positive perceptions of the ward atmosphere and quality of care are sustainable after relocation to an EBD setting. This has not been explored before in a forensic psychiatric population.

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This study provides evidence that patients' perceptions of quality in given forensic psychiatric care increased and remained stable up to 3 years after relocation to new facilities constructed in accordance with available EBD. Moreover, this study revealed that patients perceived a higher degree of having access to a secluded environment up to 3 years after relocation, confirming earlier knowledge of the needs of patients in forensic psychiatry to withdraw to privacy and to socialize with others when they feel strong enough. The sample size at Follow-up 3 was small, and thereby the results are limited and challenging to generalize. However, EBD was found to have a sustainable positive effect on patients' perceptions of quality of care in these forensic psychiatric clinics. Therefore, nurses in forensic psychiatry, as well as patients, should be involved when constructing new facilities as well as when considering the impact of the physical environment on patients' perceived care quality in everyday practice. Further research is needed to confirm the findings in other samples drawn from forensic psychiatry.

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Evidence-based design; forensic psychiatry; relocation; sustainability

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