Gender is routinely pitched as a key determinant of vulnerability for staff and residents on acute mental health inpatient units. Since the 1960's mixed gender units have become more prominent in Western health systems, yet questions remain around the configuration of these units, including how to ensure emotional and physical safety of those living and working in them.This paper draws on a large study of the lived experiences of 42 staff and 43 service users from different acute mental health units in New Zealand. We conducted thematic analysis of interview data from four units with diverse architectural layouts to identify key themes central to decisions around gender and spatial design.it goes beyond gender emphasized that there are many other non-gender attributes that influence vulnerability on the unit.Key themes emerged around gender-related trauma histories, safety perceptions and vulnerabilities, accommodation of gender-diverse and non-binary mental health service users, and gender-specific needs and differences. A further theme, of While findings emphasize the need for safe places for vulnerable people, trauma-informed care, access to staff who “understand,” and recreation that is meaningful to the individual, we question if the dilemma of gender-separation vs. gender-mixing is an outmoded design consideration. Instead, we argue that a flexible, person-centered approach to provision of care, which values autonomy, privacy, and safety as defined by each service user, and that promotes choice-making, obviates a model where gender accommodations are fore. We found that a gender-exclusive narrative of vulnerability understates the role of other identifiers in dynamics of risk and vulnerability, including age, physicality, past violence, trauma history, mental unwellness, and substance use. We conclude gender need not be a central factor in decisions around design of prospective built unit environments or in occupational and clinical decisions. Instead, we suggest flexible spatial layouts that accommodate multiple vulnerabilities. Until the 1960's, psychiatric inpatient facilities in New Zealand were segregated by sex . The shiA considerable body of research exists on the gendered aspects of life in adult acute mental health facilities , 4, 7–13Literature specific to service user and staff perspectives on gender separation and mixing in acute mental health settings exists, but there are caveats to the depth, translational capacity and scope of some of this research. Most studies explored attitudes within contemporaneous units of different setups , 48–50. However, there are limitations to current understandings of gender and issues of gender-separation or mixing in the acute mental health setting. A proclivity for service users to endorse the therapeutic milieu to which they were admitted–and hence familiar with–was sometimes shown , 41, 52,Experiences of staff and residents in the mental health unit are frequently described in terms of being traumatic , 60. A hThere is increasing interest in the experience and accommodation of gender-diverse service users within the mental health system , 69–72. There is little research around the New Zealand experience, with the only substantive literature identified being a Master's thesis . From a This paper aimed to answer the research question: “What are gendered experiences on the acute mental health unit, and what are the spatial implications for unit design and model of care?”. Using data from a large multisite qualitative project exploring New Zealand staff and service user experiences of acute mental health facility design , this stThis paper reports on a qualitative analysis of interview data collected during a 3-year study to understand the built therapeutic and social environment of New Zealand's adult acute psychiatric inpatient facilities. As part of this we were interested in the socio-political organization of space on the units. In the current analysis, we focused on the gendered experiences of service users and staff in four mental health inpatient units. Gendered experiences are those by which the gender of interviewees, or their perceptions of gender as it impacted other parties, is relevant to their experience on the unit, and to perceptions of the unit environment and social milieu.http://www.ANZCTR.org.au/ACTRN12617001469303.aspx. The study protocol assured the participating hospitals that they would net be identifiable in the research results.As part of the initial development of the primary study, consultation with Otago Ngāi Tahu Research Consultation Committee was initiated, as per University of Otago criteria, to involve indigenous Māori in a review of the research proposal. The ethics application (17/CEN/94) was reviewed and approved by the Central Health and Disability Ethics Committee. Locality consent was granted by the four participating District Health Boards. The study protocol is available in the Australian and NZ Clinical Trials Registry (ACTRN12617001469303): Data collection involved multiple site visits to inpatient units across New Zealand between 2017 and 2019 by GJ, a social scientist, to conduct interviews and collect other data on unit design. Four inpatient facilities, ascribed here as Unit A, B, C and D, were selected out of a sample frame of all 20 publicly funded mental health units in New Zealand. Case facilities were selected for diversity, in terms of building age, condition, design and location. The first four units prioritized for inclusion on this basis agreed to participate. All units were publicly funded, mixed gender inpatient units, which admitted acutely unwell adults between the age of 18 and 65 for short term care.Posters and study information sheets were displayed in the main circulation areas of the units and in the staff room prior to and during the study, and the principal investigator worked with the management and senior staff to promote the study and recruit participants. This required frequent daily visits to the units over 7–10 days, with repeat visits over a 2-month window for some units where recruitment was more challenging.Recruitment involved invitation of staff across the range of disciplines on the unit, with the aim of including several nurses, and ideally one of each from the other professions on the unit; care assistants, social workers, occupational therapists, psychiatrists, cultural advisors and pharmacists. Staff within the priority occupations for interview then self-selected to be interviewed and were interviewed in their work time. Much of this was organized verbally by conversations between the lead investigators and the staff involved.As per ethics approval, a list of service users who were assessed by their lead clinician as competent to consent, well-enough for the interview, and potentially interested in participating, was provided to the lead investigator, GJ. With the help of senior staff on the ward, the principal investigator went onsite to find the listed individuals and arrange interviews with those who agreed to participate in the study, interviewing service users who provided written consent. On a number of occasions some service users changed their mind about participating in the research by the time the interview could be arranged: several decided they no longer wanted to participate, so the recruitment period was extended until enough participants had been interviewed.Due to resource constraints a decision was made to cap the number of interviews on each ward to 20, allowing 10 with each of the staff and service user groups, although more were interviewed in reality.Interviews lasted 30–90 min, were audio recorded and transcribed verbatim. All but 10 took place in a private room on the unit in a face-to-face setup, with the remainder conducted by phone.a priori, insofar as exploration around gender on the unit was sought. A broadly deductive approach enabled discovery of gender-related themes, while answering a defined research question. This said, our approach assumed a dynamic relationship between the findings and the research questions. We employed thematic analysis, as described by Braun and Clarke , who then met with SM and SEP to discuss the data. Relevant extracts of the data were then prioritized for further analysis. The research agenda was to an extent d Clarke , which id Clarke , with std Clarke . SectionData on the spatial organization of the units were collected and documented through photographs and architectural plans of unit layouts. Interview transcripts, which were anonymised and are reported here in a codified form, indicate: the ward , their position as mental health service user (MH) or staff (S), their gender , their Ethnicity (indigenous Māori or non-Māori), and their interview number. For example, A_MH_M_NM_4 = Unit A, Mental health service user, Male, non- Māori, participant 4 (of service user group in Unit A).As shown in The relevant spatial aspects of the units' designs in terms of gender are shown in Five central themes, common to both staff and service users, were identified as relevant to the exploration of gendered aspects of social life on the unit as influenced by the spatial layout:Gender-related trauma preceding admission.Gender-related perceptions of safety and vulnerability on the unit.The accommodation of gender-diverse and non-binary service users.Gender-specific differences and needs.Non-gender attributes that may influence risk and vulnerability on the unit.1. Gender-related trauma of service users preceding admission to the mental health unit was consistently reported or conjectured by staff and service users. This was notable across all four units, and reported most often by women service users, and by staff. Many service users described gender-related trauma as both observation of others, and as self-observation.Service users often interpreted their mental distress, and that of their peers, through a traumagenic lens.The most common pre-admission traumas discussed by participants related to violence toward women, inflicted by men. As well as preventing sexual violence on the unit, a repeatedly voiced reason for gender separation by staff was a recognition of trauma histories by women and the importance of ensuring their emotional safety:Many of the women that come through, have had situations of abuse in their lives. And surely to God we can keep them separate from the guys. (A_S_M_NM_8)And we have also had a vulnerable woman that had been raped and things like that that don't like being around men. So, it's easier to keep the two apart. (C_S_W_NM_1)Some women were keenly aware of the potential trauma histories of other women. One woman framed the trauma of a fellow female service user's experience of rape as a consequence of women's vulnerability in a patriarchal society:She's gone through a significant amount of pain. And what it is, is pain that being a female in a male-dominated world, and not having people that understand the implications of rape. (B_MH_W_M_1)Some women service users described post-traumatic difficulties co-habiting with men on the unit, which contributed to feelings of discomfort and lack of safety:if say you're a female who's been through trauma, the last thing you want to do is be in a closed room with men. (A_MH_W_M_2)However, while male to female sexual violence is undoubtedly more common, men also talked about vulnerability to trauma–as one male service user reflected on his own trauma preceding admission:I'd like to say - hey you know things happen, you know. Things have happened in my life, like I've had all this trauma deep, deep, deep, deep, deep down (A_MH_M_NM_4).Staff were cognisant of the inherent difficulties of accommodating service users with past experiences of gendered violence (violence by the opposite gender) in a mixed unit setting:Many have been traumatized by the opposite gender, and we're forcing them right into each other's faces. (A_S_W_NM_4)This observation was notably non-specific as to the gender dynamic at play. Men and women could assume roles as victim or perpetrator. Provisions to better attend to the needs of individuals with trauma histories were noted by a number of staff. These included gender separation, surveillance, alternative restraint practices, and talk therapies. Both women service users and staff recognized the possibility of re-traumatisation for individuals by being in the unit environment. One staff member, on being asked why a unit had attempted to separate females from males, explained how the lack of space on the unit and mixing of genders exacerbated the traumagenic effects of the environment:forcing patients like this, all in crisis, into a little wee TV room on top of each other, males and females together, where many have been traumatized by the opposite gender, and we're forcing them right into each other's faces. And I think their ability to settle and resolve, to settle their mental state, is reduced and takes a lot longer, because of the way that our ward's set up. It actually re-traumatizes them. (A_S_W_NM_4).One way of reducing this re-traumatisation and providing for the needs of trauma-impacted individuals is the use of ‘flexi' spaces. These featured in Unit D with a mixed gender layout, where a separate pod or bubble of 2–3 bedrooms , are located in between the open and closed wards (with doors that can be opened either the high needs ward or the open ward by staff as needed). This effectively accommodates a small group of service users who are in a vulnerable place or stage of their wellbeing.A lot of our female clients have had trauma in the past…, and so we do try to take that on board when we can. So we do have areas called flexi areas where they can be nursed away, not necessarily in female-only spaces, but they can be nursed away from the [male participants on the] ward. (D_S_W_M_5)Some facilities provided women's lounges, for example, Unit B. However, this differential treatment did not go unnoticed by some male service users who felt this was unfair:The only thing that annoys me, is the fact that there's a women's lounge and not a man's lounge. The women have a place to go to get away from the men, but there's no place where the men can get away from the women. (B_MH_M_NM_9)An alternative design strategy was suggested by one staff member, with common areas set up with ‘little nooks and crannies, that people can sit and chill' (C_S_W_NM_1). While not explicitly relevant to gender needs on the unit, satisfying service users' need for space and choice-making may attenuate feelings of vulnerability and unsafeness. Staff and service users were aware of lack of space in the communal areas of some of our case units, as well as seating limitations:At the moment there's not enough tables and chairs for patients (C_S_W_NM_1).One staff member suggested the policy goal in acute mental health care settings of using human restraint (hands on immobilization of the service user) instead of seclusion, was particularly problematic and traumatizing for those already suffering from histories of abuse:They're trying to push zero seclusion by 2025 and have only physical restraints. So what about the people that had been raped and abused? They don't want hands on, they'd rather a room to themselves. (D_S_W_NM_2)Some staff were cognisant of the fact that gender of the person/s doing the restraining is also likely to be a factor of significance to the person restrained and their specific trauma history, and that this could retraumatise them. The staff member (D_S_W_NM_2) highlighted the need to recognize within-group differences in preferred treatment options.2. Gender-related perceptions of safety and vulnerability on the unit were described by both service users and staff. Often, these perceptions were used to justify the need for gender separation on the unit. Issues of safety concerned both the welfare of service users and staff. Recognition of safety issues had implications for the recruitment and rostering of staff, utilization of occupational or diversional activities to mitigate agitation and violence, and the use of unit design to facilitate safe spaces for service users to commune and to sleep.Women service users were most likely to voice concerns about unit safety. While it was not always explicit that safety concerns and incidents of unit violence followed a male-on-female configuration, women expressed concern for other women.I wouldn't wish that upon anyone … regarding the safety to think that it was okay to go in there [in the unit], especially if it was my granddaughters or my daughter. (C_MH_W_NM_5)Again, feelings of unsafeness were sometimes linked to the mixed gender unit layout. Staff and service reported that at times men entered women's bedrooms. A service user on the gender mixed Unit D, commented on the lack of gender separation of bedroom areas:Right next door, there's a guy in there, yeah. It's just not safe. (D_MH_W_M_7)Staff described some of the men on the unit in pejorative terms, as “predatory,” “philandering” and “violent.” The potential for danger where these men are in mixed gender units was noted by a staff member:We're managing aggressive, aggro males, that have used drugs, and have no belief that they're unwell, with your grandmother. (B_S_M_NM_3)In this, gender was just one of multiple vulnerabilities and risk factors identified by staff perceived to affect safety.Sometimes male-on-female violence was determined to be a result of a dynamic of unwellness, while some staff saw elements of opportunistic intent. The gender mix of staff on shift was seen as relevant to the incidence of premeditated assaults in some cases:When you saw this guy come along and he knew he's gonna be violent and you could see the guy looking around counting, doing a headcount, and thinking ‘is it worth me being assaulted? No, too many men' … And if you've got mainly female nurses, that's just how they get their needs met. (C_S_W_NM_11)vulnerability to violence is not gender or sexuality specific:Notably, some staff viewed service user violence on the unit as enacted by ‘any gender' (B_S_M_NM_6). Further, a staff member suggested that It doesn't make any difference these days, does it, as far as sexual preferences and things, so anyone could be at risk gender-wise. (B_S_W_NM_8)This staff member appears to describe the increasing understanding that non-heteronormative identities and sexual orientations indicate vulnerability that goes beyond a simple gender formulation. Violence in New Zealand impacts lesbian, gay and bisexual , as wellA staff member also commented that in their view, some unwell service users “cannot distinguish” between men and women, when lashing out in response to psychosis-related threats “They're just danger, danger” (D_S_W_NM_1).Staff accounts of gendered safety issues on the unit sometimes invoked the narrative that women were more vulnerable when unwell, and that sexual activity and sometimes assault of women could be a result of illness-related hypersexuality, specifically as a symptom of mania presentations. In these accounts, women were more often seen as the vulnerable parties in sexual assault, while men were more often seen as perpetrators, though disinhibition and diminished comprehension of events were speculated:People become sexually disinhibited as well: I guess maybe someone who's manic, or if it's a bipolar disorder, or being psychotic. People can do things that they wouldn't necessarily do when they're well. (B_S_W_NM_9)Sexual relationships between service users on the ward were talked about as a common occurrence that raised important issues of sexual safety. A number of staff said they discouraged romantic and sexual relationships between service users on the unit because of the nature of the environment and the vulnerability of those in it.We don't encourage it. Because I mean ... You're meeting in a place that you know... you're both put here. You didn't both decide to come here to meet up. (B_S_M_NM_4)Other staff expressed concerns about how they could support people's autonomy while also keeping them safe:So I'm thinking about the safety of both [parties], but its the individuals'choices at the end of the day. (A_S_M_NM_9)Staff worried that service users might not be well-enough to give informed consent, that a power imbalance might exist between those “at different points in their recovery,” and that unwell service users might make sexual decisions they later regretted.A lot of these guys are mentally unwell ... they're vulnerable.... some of them don't really know what they're doing. (A_S_W_M_1)Service users did not share the staff view on forbidden romance on the unit, explaining that relationships established on the ward could be meaningful and long term.I met a girl here in 2014. We dated for a year and a half up until March or May 2015. (A_MH_M_NM_5)But accounts also provided some hints of impulsivity around relationship decisions, as can happen outside the mental health unit.And this time last week I met a woman here and we're actually planning to get married (A_MH_M_NM_5)Staff expressed discomfort and uncertainty around how best to manage these romantic relationship situations. They described a culture of not openly discussing the sexual and relational needs of service users. There was the sense that it was a complex issue, one that was often dealt with by pretending it did not exist, but this led to additional risks.There are no signs up about um, you know, how you can keep yourself safe [sexually]. And we've got a lot of vulnerable people here (D_S_W_NM_3)Some staff raised the matter of sexual frustration amongst some of the service users in the unit:If a male or even a female … is staying in a ward for a long long time … and we talked about their needs. What about their sexual needs?' (D_S_W_M_8)‘When this issue was raised with management its was however ignored:Nobody answered me of course, and I didn't expect an answer (D_S_W_M_8)3. Accommodation of gender-diverse and non-binary service usersUnderstanding the needs and accommodations of gender-diverse and non-binary service users is also relevant to attitudes about the separation or mixing of genders on the unit. Discussion related to these issues was found in staff interviews, and in comments from a transgender service user who identified as a woman:it could be more welcoming and better suited, especially for the gay and lesbian [and] trans community as well. (A_MH_T_NM_1)When asked about her attitude toward gender separation of bedrooms on the unit, she expressed reservations about full gender separation, explaining that it need not be “necessarily, like, segregated,” but responded positively to the notion of some separate spaces for people (like her) who identify as women:It would be nice just to have a separate area where people like myself could just chill out and connect in some way and support each other (A_MH_T_NM_1)The service user account suggested that gender-diverse populations are sometimes initially misgendered or allocated bedrooms in corridors with the non-identified gender:I was with nearly all men, down the corridor, and then I was moved into, where it's mostly women, where I identify as (A_MH_T_NM_1)Staff had varying levels of understanding of the accommodation needs of gender diverse service users. Some staff members said that the service user should elect the type of unit “where they would prefer to be.” Others considered this to be a decision for the “government and ministries,” or spoke of the thorniness of gender logistics as “such a hot topic these days.”The provision of unisex toilets was suggested as a good design strategy by some staff:If they could be unisex, I think that's a bit better for people who have concerns around their gender identity things. (B_S_M_NM_6)The provision of “flexi wings” (Unit D) and “swing beds” (Unit C) was stipulated as useful in accommodating transgender individuals:we've got rooms in between them. And what I like about those rooms, because I also work with transgender clients … that's really, really good for that. (C_S_M_NM_5)I think it's important if they have those in-between ones for gender (C_S_W_NM_11)Potential controversies about the bedroom allocation of gender-diverse service users was related by one staff member. This pertained to a previous unit set-up:I can remember many years ago… an issue where a transgender client wanted to sleep in what was a female dormitory. They identified as female. The people who most vociferously opposed that were the female clients. (A_S_M_E_5)Failure of the unit layout to satisfactorily provide safe and suitable accommodation of gender-diverse service users was described by some staff. Limiting factors mentioned included the financing of a unisex corridor–“we'd have to have three things set up” , resistance within the cis-gender service user population, and the idea that different transgender service users had different requirements–“one size doesn't fit all.” But the most common sentiment was one of recognition of need:We need to accommodate this. But we don't, we can't possibly accommodate them in the situation we've got. We need to be able to. (A_S_M_NM_8)4. Gender-specific differences and needsGender specific differences in the nutritional, recreational, hygiene, and staffing needs of both men and women service users were reported by staff and service users across the four units.In terms of nutrition, meal portion sizes and the unavailability of snacks and facilities to prepare food in-between meals were criticized as inadequate by staff and service users at several Units. Some staff and service users highlighted portion size as a need expressly relevant to men:A lot of them say the portions aren't as big over here. But these guys, you get a lot of these guys over here, especially the boys, they're big eaters. They're big strapping guys (A_S_W_M_1)Similarly, available physical activity within the units was criticized by staff and service users as insufficient and lacking in relevance to the needs and interests of men, sometimes young men in particular:If some of these guys could just run up and down, up and down, up and down, or have a full basketball court or something, I think that would really, really help. (B_S_W_NM_8)I think physical exercise would benefit especially our young men… I think they need something physical because we're talking young boys here. We're talking about the young men … You know, coloring in pictures ain't it. (D_S_W_M_8)Provision of punching bags and basketball hoops and fixed exercise equipment were suggested by some men service users and staff in some units. Unit A had a basketball hoop, though this was broken at the time of interviews. Men service users on Unit D had indicated their wish for more male-relevant exercise options in a signed petition sent to the management (which was and reportedly disregarded).Occupational activities offered on the units were often viewed as skewed toward women's interests, and seen as too passive, infantile, or culturally inappropriate for men.There's ten of us males, in this ward… Those coloring in and mindfulness stuff, that's what my baby does. (D_S_W_NM_9)Drawing therapy is not appropriate for them. We had a kaumātua [Respected Māori elder] years ago [based on the unit]… and he would do carving and the boys just loved that… And, you know, there's none of him around. (C_S_W_NM_2)In relation to personal hygiene, many women service users on units where unisex bathrooms were prevalent expressed clear differences in hygiene needs, in support of gender-segregated or ensuite bathrooms. These comments were especially present in the interviews from units with very limited number of ensuite bathrooms (units A and B) compared with Unit D where all bedrooms had ensuites.Men and women use bathrooms for different reasons … Men jack off, and get cum everywhere …. so you've got the thing about men, and also woman [have] their periods, and you know there might be some blood left over on the toilet and they didn't realize and it's embarrassing. (A_MH_W_M_9)Gender-specific staffing needs were also highlighted by staff and service users. Observations of need pertained to the therapeutic and care requirements of both men and women. Often service users expressed a wish for same gender staff:When I interacted with staff, it was mainly being like a male nurse who I had a rapport with much more so than with the female nurses. Not because I didn't like them, the female nurses, but with guys talk easier with guys - as simple as that. (C_MH_M_M_3)I think they need to look hiring more women at the front for women, and maybe then, men for men .... My lady doctor, she gets it because she's a woman. (C_MH_W_NM_5)One staff member discussed the importance of having access to psychiatrists of both genders in the interests of provision of trauma-informed care.My personal preference is to have a male and a female psychiatrist on the ward … - but at the moment we've got two males in the ward - because some women, who … have had sexual abuse or trauma, don't like dealing with any of the men (C_S_W_NM_01).Another staff member pointed to the need to work with the individual and their preferences, rather than advocating for same gender staff to service user.Some male staff have a really good rapport with certain female patients. Some female patients can build a good rapport with male… It depends on the patient and the staff member. (A_S_W_NM_3)Gender was found to be a consideration in the staff-service user interactions, in terms of behavior and positioning of staff. This was seen in terms of protecting emotional and physical safety for the service user, but also to buffer staff from allegations of sexually inappropriate behavior or assault. Awareness of the possibility for false accusations of sexual assault by service users about staff was a concern for some male staff members:If you don't have a female to intervene, they could [make] accusations and say ‘this person did this to me'. And you, you know, you cannot say ‘no, no, no'. If they're all males, you know, it just puts our staff and also the patients… in a vulnerable situation. (D_S_W_NM_1)That noted, another staff member suggested that staff of both genders can be vulnerable to allegations of sexual inappropriateness or assault.the females aren't immune to [allegations of] rape as well. We get accused as well, you know … that's why I wish they'd make them segregated a bit better, because it just keeps them both safe. (A_S_W_M_1)Other concerns around staff safety were expressed by some staff including the need for staff to be careful when entering service user's bedrooms:If you're a female, and you've got a male client, and you're talking to that person in their bedroom… how safe are you? (A_S_W_NM_3)Several staff members explained that sometimes, in the interest of protecting staff, they would select a staff member of a particular gender to work with a service user depending on their presentation.One guy, he used to ring the nurses' bell, and then you'd go down there and he'd be masturbating. So when we get those type of guys, we get the male staff to check them. (A_S_W_M_1)5. It goes beyond gender: Non-gender attributes that may influence risk and vulnerability on the unitIndividual attributes, distinct from gender, were also described by some staff and service users as relevant to risk and vulnerability dynamics on the unit. These included those of age, physique, degree and type of mental unwellness, comorbidities including substance use, forensic history, trauma history, and power hierarchies that evolved through unit organization.Age, for instance being younger or older than the majority of one's peers was mentioned several times by staff as a vulnerability, most often for women service users. Adult acute services in New Zealand accommodate people from 18 to 65 years of age. While youth and psychogeriatric facilities cater for ages outside of this bracket, staff noted that people eligible for these speciality services were occasionally admitted to general adult inpatient units, usually for short stays with “special” staff providing one-on-one vigil.Sometimes we get elderly patients and they have to be minded, or young, vulnerable females, they have to give them a minder (A_S_M_NM_9)Older people were sometimes observed to find the unit significantly anxiety provoking. Some of these observations connected perceived vulnerability to very real incidents of intimidation, coercion and bullying:For older people if they felt vulnerable, with somebody who might have been strongly coercing them to [give up] their food or their things and stuff, and they have to give it … [using] kind of stand-over tactics, and stuff … I have advocated the need to have a separate area for older service users (D_S_W_NM_9)Access to non-cash assets such as food and cigarettes, as well as unit liberties such as residence on the open unit were sometimes seen as impacting risk and vulnerability. Possession of cigarettes/tobacco was sometimes noted by staff as a risk due to its currency in the acute mental health setting where doors were locked restricting purchase and access to tobacco. Service users talked about coercion by other service users:It can be quite intimidating even with cigarettes … Other people taking your cigarettes off you. And if it's anybody too violent, and they want them, you just...I've handed all mine over before unwillingly. Cigarettes are a big problem in there actually … A lot of people have their leave, so they can just walk over [to the local shop]… so you definitely got access to go over the road, but if you've got a bully in there that wants them then … A guy bought a 50 gram [tobacco] the other day, and by the time everybody had hassled him, it was 50 grams of cigarettes in a day he provided everybody. (A_MH_W_NM_8)Service user forensic history was also a factor staff identified as impacting on vulnerability. A history of criminal offending was viewed by staff as having bearing on future risk of violent behaviors. Staff described service users who had prior involvement with the criminal justice system as “forensics” or as “forensic patients.” This suggests active categorization by staff that distinguishes these service users from their peers. Some staff comments pointed to a different expectation around behaviors, types of unwellness, and moral status of these individuals. Such comments were sometimes derogative in nature. Women and men were included in staff discussions of this risk.Like we've got one lady at the moment, she's ex-Forensics. And yeah, it's all … a risk. Because you've got to be aware of what's present and what's past (B_S_W_NM_2)We were getting a lot of forensic patients here. And we're not supposed to say 'forensic patients'. (A_S_W_M_1)Different understandings of different mental illness diagnoses were also believed to impact on vulnerability, requiring different treatment or separation from others. For example, perception, albeit sometimes erroneous, of heightened risk of violence was regularly noted by staff and service users for some presentations:there's certain people that have been assaulted, myself included, where someone's really, really unwell. Paranoid, schizophrenic, organic' (D_S_W_NM_2).‘Other presentations, such as drug induced psychoses, as well as comorbid substance abuse issues, were also cited by staff as impacting on risk and vulnerability. A frequent notion of substance-related issues being different-in-kind from other forms of mental unwellness was articulated, with a different approach to treatment and assessment of risk sometimes proposed. One staff member described drug-related psychosis as a ‘completely different ball-game' to presentations of ‘true psychotic illness' (A_S_W_NM_2).We've had a few [people with methamphetamine-induced psychosis] come in, and it's quite scary to work with. You think, “Ooh” … They can be violent. They're disorganized, thought-disordered, driven, obviously. But yeah, is this the [right] place [for that]? (B_S_W_NM_005)Physical size and strength were also suggested as impacting risk or vulnerability status, in reference to both staff and service users. Generally, remarks suggested that bigger people, especially male service users, were perceived to be more dangerous, while smaller people, especially women, were perceived to be more vulnerable. One staff member commented, when discussing calming and restraint practices:it's going to come down to strength on strength … if you get a big guy' and ‘there's some big guys you're not going to be able to manage' (A_S_M_M_7).‘This said, there were some exceptions. A staff member noted that, although the bigger male staff might be commonly sent to deal with aggression on the unit, effective crisis management could involve women, and those of smaller physique:having said that, there is now a very small, petite, female [staff member] that comes over, and she's good' (A_S_W_NM_3).‘Further, a staff member noted that service user to staff violence does not follow a strict big-perpetrator-to-small-victim formulation:They don't want to hit the small female, but they've got no qualms hitting the big guy (A_S_M_M_7)In summary, clearly there are factors other than gender that impact on perceptions of risk and vulnerability on the unit, and there are likely to be complex interactions between these and the gendered factors reported by staff and service users in our study. Rather than a singular determinant of risk and vulnerability, gender was revealed to be a factor that could compound and have a multiplicative effect on other predictors of risk and vulnerability, including age, physical size, illness presentation, forensic history, psychosis and drug use.The current heterogeneity of acute mental health facility structure and models of care suggests the question as to whether mental health units should be mixed-gender or gender segregated is moot. Proponents of both approaches tend to argue their position on grounds that include securement of emotional safety, physical safety, and the optimisation of on-unit therapeutic value in a gender vulnerabilities framework.This paper began with the research question: “What are gendered experiences on the acute mental health unit, and what are the implications for facility design and models of care?”. In this framing of the issue our understanding of vulnerabilities in the acute mental health setting were, much like the literature, focused on gendered aspects of vulnerability. However, our findings suggest that while gender is a significant consideration in the delineation of vulnerability, the dynamic of vulnerability is more complex than we initially supposed. Interactions with and between gendered and non-gendered aspects of life on the mental health unit add to the impression of vulnerability.We found that women service users spoke more frequently around trauma experiences, feelings of unsafeness, and hygiene differences, than their male service user counterparts. However, trauma preceding admission was not exclusive to women, and was often but not always characterized by gender-related events. Staff and service user perceptions around safety on the unit sometimes conveyed a male-on-female narrative of harm, but we found that some staff members viewed actual risk as genderless. We found some staff reported concerns around the accommodation of gender-diverse service users; some staff and a transgender service user, found unit organization and model of care inadequate to provide for the needs of these individuals. Staff and service users reported perceived gender differences in domains of recreation, nutrition, hygiene and staffing, although issues around hygiene and bathrooms were specific to units without ensuites, or units where ensuites were not the norm. The recreational and nutritional needs of male service users were seen in particular by staff, as inadequately accommodated. Women service users' concerns were most often aligned with trauma and fears about safety, whereas areas of concern for male service users were more often in relation to the objective fulfillment of activities of daily living.However, non-gendered considerations with regards to vulnerability on the unit were also evident. Categories of vulnerability suggested by study participants include gender, but also age, forensic and trauma history, degree and kind of mental unwellness, substance use issues, physical size and strength, and access to currency including tobacco products and food.Division of unit space that centers on gender difference demands substantiation of gender as a meaningful and effective distinction. Existing literature posits gender has real bearing on the emotional and physical safety of individuals working or resident on mental health units. Moreover, gender is seen as the delimiting factor by which care strategies, resources, and practical accommodations are directed to service user needs. This noted, ability of gender separation to mitigate gender-based violence and harassment on the mental health unit has been viewed with skepticism, due to the potential for this abuse to exist outside a heteronormative domain . FurtherOur study uncovers a number of key findings, implications of which are that the architectural and built environment and model of care should consider a mixed vulnerabilities lens or framework. We suggest some key aspects of this below.A mixed-vulnerabilities framework and individualized care that considers identity and values the autonomy of service users – flexibility and choice-making.Assuming a mixed-vulnerabilities framework, the assessment of risk of violence and risk of being victimized is best rooted in an individualized, person-centered approach. Person-centered models of care promote strengths-based, flexible, identity-salient, and autonomy-promotive services, which can be mobilized through shared decision-making and self-directed support . A persoOur findings suggest that, while a situation of unmet needs and a paucity of options was described by many staff and service users, facilitation of individual choice-making does not require decisions informed by gender norms. For example, some service users and staff commented on a need for gender-suited activities–especially more physical activities and sports enjoyed by many males. Accommodating this need does not require a focus on gender differences. Providing a basketball hoop creates an opportunity for all who like shooting hoops to do so.Staff and service users acknowledged trauma as a precipitant and amplifier of mental unwellness. Some viewed this as a reason to segregate by gender. Service users have an increased risk of lifetime trauma, and markedly increased risk of having a post-traumatic stress disorder (PTSD) diagnosis compared with the general population . Women sCurrently there is a mental health workforce shortage in New Zealand . The limOur study found that many service users and staff felt unsafe in the mental health unit. While participants sometimes implicated gender as relevant to risk, this view was not ubiquitous. Irrespective of gender's role in unit safety, measures to ensure the physical and emotional safety of people who reside and work on the unit are essential. Measures of surveillance, de-escalation, and practices and design features that assure privacy, are recommended and other recommendations to address safety on the unit have been explored in a related paper from this study . The uniThe built environment can be designed in accordance with salutogenic principals  –comprehIn two of the units studied (A and C), these corridors of bedrooms were gender-segregated. Shared spaces, such as courtyards and lounges, do seem to facilitate social interactions on the units. Service users and staff, however, often said these areas were too small, outdated, and noted a need for more flexibility within the shared spaces for privacy and social interaction. Overseas models of design, and recent research , suggestCategorization of units as gender-segregated or gender-mixed is and continues to be problematic. Provision of gender segregated spaces within an otherwise mixed gender environment was common, with bathrooms, lounges and sleeping areas conferred to specific genders within a blended unit.Incorporation of ensuites, advocated by the Australasian Health Infrastructure Alliance  has mitiIn essence this study indicates that, with the help of creative architecture, gender becomes less relevant to overall unit design.this or that conceptualization of gender accommodations.Our research draws from a qualitative study  that covThe exploration of gender on the unit was a corollary rather than the agenda of the broader study of mental health facility design from which data was sourced. This limited the amount of transcript data pertinent to gendered experience. Further, selection criteria governed by ethics considerations constrained service user participants to those who were deemed competent to provide informed consent. This meant the voices of those more acutely unwell service users were not captured. Acuity of illness, and differences of treatment, may bring a different set of gendered experiences. Those most unwell may be more likely to experience trauma on the unit–due to an increased risk of seclusion and restraint, and vulnerability related to unwellness or medication regimes. It should be noted, we did not ask specifically about staff violence toward service users, though questions were asked around whether service users felt safe.Service user participants were interviewed while they were inpatients. While this avoids recall bias, some of the service users' perceptions may have been influenced by the symptoms they were experiencing, however this does not make any distress experienced less real. We deliberately did not ask about specific mental illnesses, symptoms or diagnoses as we did not want experiences explained away by particular conditions as it the common tendency and dominant medical discourse of much of the literature. We also note that past literature finds that service users are more likely to endorse or react favorably to the organization of the unit in which they are resident , 52. FurFinally, translatability across the 20 adult acute mental health facilities in New Zealand and other similar jurisdictions cannot be assumed. However, the diverse case study design and the consistency of many of our findings and narrative around gender and other aspect of vulnerability across these four cases will likely resonate with other researchers exploring the narratives of those with lived experience, residents and workers in acute mental health settings. Certainly, further research in similar overseas settings is warranted to test this out.Our study challenges the assumption that gender should be the central factor at play when considering unit design and layout strategies in acute mental health facilities. While we found that gender was a prominent aspect of participants' accounts of socialization, trauma, and violence on the unit, it is clear that other factors may be equally important in accommodation considerations. Our study located several co-variables that may have relevance to safety of unit staff and service users. While we find that no single identifier can be seen as sole motivator for unit demarcation, a multifactorial view of dynamics of risk and vulnerability could be used to guide unit organization, in a way where layout and social organization “flexes” with the needs on unit at any time. A person-centered approach–whereby assessment of needs, risks, vulnerabilities, and accommodations is tailored to the profile of an individual, is recommended by the study authors.https://www.otago.ac.nz/council/committees/committees/HumanEthicsCommittees.html.The datasets presented in this article are not readily available because in line with the ethics approval from HDEC ref (17/CEN/94), the full interview transcripts cannot be shared publicly. This is because of their highly sensitive nature and the personal accounts which make them potentially identifiable. For data inquiries please contact the University of Otago Human Ethics Committee through the following webpage: The studies involving human participants were reviewed and approved by the Central Health and Disability Ethics Committee (17/CEN/94). The patients/participants provided their written informed consent to participate in this study.Funding acquisition, ethics and design of study, and data collection was undertaken by GJ. Identification of themes, data analysis, and writing original draft was led by EM with all authors contributing to reviewing and editing. Triangulation of themes in the data analysis was undertaken by all authors. All authors contributed to the article and approved the submitted version.This work was supported by a Marsden Fast Start from the Royal Society of New Zealand under Grant UOO1623.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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The number of books at home is commonly used as a proxy for socioeconomic status in educational studies. While both parents’ and students’ reports of the number of books at home are relatively strong predictors of student achievement, they often disagree with each other. When interpreting findings of analyses that measure socioeconomic status using books at home, it is important to understand how findings may be biased by the imperfect reliability of the data. For example, it was recently suggested that especially low-achieving students tend to underestimate the number of books at home, so that use of such data would lead researchers to overestimate the association between books at home and achievement. Here we take a closer look at how students’ and parents’ reports of the number of books at home relate to literacy among fourth grade students, by analyzing data from more than 250,000 students in 47 countries participating in 2011 PIRLS. Contrary to prior claims, we find more downward bias in estimates of books at home among high-achieving students than among low-achieving students, but unsystematic errors appear to be larger among low-achieving students. This holds within almost every country. It also holds between countries, that is, errors in estimates of books at home are larger in low-achieving countries. This has implications for studies of the association between books at home and achievement: the strength of the association will generally be underestimated, and this problem is exacerbated in low-achieving countries and among low-achieving students. Students with a socioeconomically more advantaged family background tend to achieve better in school . This soMany authors have noted that the number of books at home is a particularly strong predictor of student achievement e.g., . One intBecause of the wide usage of the books at home variable, it is important that researchers examine the reliability of the variable. Prior studies, using datasets that include both students’ and their parents’ reports of the number of books at home have indicated that the reliability is not very good, because the correlation between student-reported and parent-reported data is often quite low and never very high . While rFrom a cognitive perspective, estimation of the number of books at home is a non-trivial numerical task. We expect the accuracy of estimates of books at home to depend on how skilled the person is at numerical estimation tasks in general. Numerical estimation skills are counted among mathematical skills that are tested in international large-scale assessment . Hence, This hypothesis seems not to have been stated before. However, a prior study found higher literacy scores among students who reported the same number of books at home as their parents did than among students whose estimates deviated from their parents’ . While tErrors may be random or systematic, also known as bias. A recent study claimed that estimates are biased downward especially among low-achieving students , based ohigh-achieving students. The reason is that estimates of books at home are made on a scale with a lowest step (0–10 books) and a highest step (more than 200 books). If the true number of books at home is at the lowest step, the only possible error in data is to make an overestimation. Because of the basic association between the true number of books at home and achievement, the true number of books at home is more often at the lowest step for low-achievers than for high-achievers. Thus, the existence of a lowest step of the response scale should cause more overestimation among low-achievers than high-achievers. Similarly, when the true number of books is at the highest step, which will happen more often for high-achievers than low-achievers, the only possible error in data is to make an underestimation. For these reasons, we expect more downward bias among high-achievers than low-achievers.There is in fact reason to expect the opposite to Engzell’s claim, that is, we expect that estimates are biased downward especially among less developed societies, whereas the association between books at home and achievement is stronger in more developed societies . Our working assumption is that the estimation skills of students and parents are correlated, due to their shared genes and shared environment. Thus, when comparing reliabilities across groups, we take the correlation between students’ and parents’ estimates of books at home in a group as a proxy not only for the reliability of student data but also for the reliability of parent data. In other words, a relatively low correlation in a group is assumed to mean that both students and parents in this group make relatively unreliable estimates.As explained above, we use the correlation between students’ and parents’ estimates in each group as a measure of the reliability of their estimates of books at home. Using these measures, we test our hypotheses (1) that data reliability is lower among low-achieving students than among high-achieving students in the same country, and (2) that data reliability is lower in low-achieving countries than in high-achieving countries. We further use mediation analyses to examine whether the latter hypothesis can also explain why the association between achievement and books at home is weaker in less developed countries.parents of high- and low-achieving students differs less than the bias of the students themselves, which seems very reasonable as errors are generally assumed to be generally smaller among parents than students ” There are five response options: None or very few (0–10 books); Enough to fill one shelf (11–25 books); Enough to fill one bookcase (26–100 books); Enough to fill two bookcases (101–200 books); Enough to fill three or more bookcases (more than 200). These options are coded from 1 to 5. A similar question, but excluding children’s books, is included in the questionnaire to parents of participating students: “About how many books are there in your home? ” The five response options are the same intervals as in the question to students, that is, 0–10, 11–25, 26–100, 101–200, and more than 200. These options are coded from 1 to 5. From the questionnaire to parents, we also obtain data on parents’ highest levels of education and occupation.Finally, the development level of a country is operationalized by the Human Development Index (HDI), available from the United Nations Development Programmet-test.The first analysis concerns within-country differences in reliability. We perform a median split of the student sample in each country, based on their literacy score . In each half of the sample, we use the Pearson correlation between students’ and parents’ data on books at home as a measure of the reliability of the data in that group. This yields two reliability measures per country: one measure for below-median achievers and one measure for above-median achievers. We then compare these measures using a paired The second analysis section concerns between-country differences in reliability and other variables involved in the pathway depicted in t-test.A third analysis concerns how the bias in students’ estimates of the number of books at home varies their literacy within countries. In analogy with the first analysis above, we perform a median split of the student sample in each country based on literacy scores. In each group, we use the mean difference between students’ and parents’ estimates as a measure of the bias in students’ data. This yields two bias measures per country, one measure for below-median achievers and one measure for above-median achievers, which we compare using a paired In a final analysis section, we examine how parent-reported books at home fare as a predictor of literacy compared to the other parent-reported socioeconomic variables in PIRLS: parents’ highest education and parents’ highest occupation. We first compare how different socioeconomic variables correlate with literacy scores. We then use multiple linear regression to examine whether the number of books at home predicts student literacy above and beyond parents’ education and occupation.M = 0.38 (SD = 0.12), than for the groups of above-median achievers, M = 0.50 (SD = 0.08), a difference of 0.12, 95% CI , t(46) = 9.02, p < 0.001, paired t-test. Thus, the hypothesis that lower-achieving students make larger unsystematic estimation errors was supported.Across 47 countries, reliability measures were lower for the groups of below-median achievers, A consequence of this hypothesis is that a large difference between the estimates of student and parent indicates that the student is probably a low achiever. To illustrate this phenomenon, Correlations between country-level variables are reported in via a country’s mean literacy level and reliability level indeed produces a considerable indirect effect of the development level on the association between literacy and books at home, whether estimated using data from students or parents. The effects of other paths were not statistically significant, that is, their confidence intervals include zero. Thus, the hypothesis illustrated in For sequential mediation analysis we use Model 6 of the PROCESS macro for SPSS  to calcuB = 0.53, 95% CI , p < 0.001. This is the first arrow in B = 1.42 , p < 0.001, but no significant direct effect of HDI, B = −0.35, , p = 0.12. This means that the effect of HDI on reliability follows the path formed by the first two arrows in B = 0.67 , p < 0.001, but no significant direct effect of mean literacy, B = 0.40 , p = 0.17, or of HDI, B = 0.08, , p = 0.65. This means that the effect of HDI on the strength of the association follows the path formed by the three arrows in The mediation analysis reported in M = −0.16 (SD = 0.21), than in the groups of below-median achievers, M = −0.06 (SD = 0.23), a difference of −0.10, 95% CI , t(46) = 5.66, p < 0.001, paired t-test. Thus, the hypothesis that downward bias in books at home data is stronger among high-achieving students than low-achieving students was supported.Across the 47 countries, there was stronger downward bias in students’ estimates of books at home in the groups of above-median achievers From the results in r = 0.59, 95% CI , p < 0.001. This finding suggests that if books at home could be measured more reliably, it is likely that it would more generally be the strongest socioeconomic predictor of literacy.Which of the three socioeconomic variables had the strongest correlation with literacy varied across countries. In some countries it was books at home (12 countries), but most often it was parents’ education (34 countries). However, recall that the correlation with books at home is attenuated by low reliability, which also varies across countries. This is illustrated by a scatter plot in books, βeducation, and βoccupation. These coefficients were generally positive and statistically significant at the p < 0.05 level; exceptions were one country in which βbooks was not significantly positive, and eight countries in which βoccupation was not significantly positive. The average country had βbooks = 0.16, 95% CI , βeducation = 0.21, 95% CI , and βoccupation = 0.11, 95% CI . We conclude that the number of books at home in general has a considerable effect on literacy above and beyond parents’ education and occupation, even when attenuated by low reliability.To drive home the point that the number of books at home predicts literacy above and beyond other socioeconomic variables, we also report multiple regression analyses with parents’ books at home data, parents’ highest level of education, and parents’ highest occupation as simultaneous predictors of student literacy. As shown in The number of books at home is a commonly used proxy of students’ socioeconomic status in educational studies. One reason is that this variable is present in all international large-scale studies, which makes it easy to compare results across data sources . On the via genetic transfer, and that interest in reading is beneficial for academic achievement  is that, lacking data on the true number of books at home, we cannot tease apart errors in students’ estimates from errors in parents’ estimates. To get around this problem, we focused on group level comparisons. We assumed that the estimation skills of parents and students are correlated, especially at group level . To measure the overall reliability of estimates in a group, we used the correlation between students’ and parents’ estimates. If our assumption is correct, this measure of overall reliability will, across groups, simultaneously capture variation in the reliability of students’ and parents’ estimates. Consistent with our assumption, we found that the reliability measure in a country is a very strong predictor of the strength of the association between literacy and books at home, whether estimated by parents or students.In this paper we do not present any equations; our hypotheses were motivated by verbal arguments. The same hypotheses could alternatively be derived in a more formal way, that is, we could formulate a formal model of estimation errors that depend on achievement, fit this model to existing data, and show that simulated data from the fitted model support the same hypotheses.The number of books at home is a valuable variable for researchers seeking to understand how family background influences children’s literacy—but this variable has specific reliability issues that researchers need to be aware of to avoid incorrect interpretations of data. It is not possible to quantify how researchers should adjust findings obtained using data on the number of books at home. Qualitatively, though, researchers should expect that observed associations between books at home and achievement (or any other variable) are weaker than the true associations, especially in lower-achieving group of students.https://timssandpirls.bc.edu. The Human Development Index is available from the United Nations Development Programme (http://hdr.undp.org/) for 45 countries in our study; we use HDI values obtained from other sources for Taiwan (https://www.dgbas.gov.tw) and Northern Ireland .Publicly available datasets were analyzed in this study. This data can be found here: Data from the 2011 wave of PIRLS are available at: Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.KE conceived of the study, performed the analysis, and wrote the paper. JL, OH, and AR contributed to the survey of the literature and to the discussion, and provided critical feedback on the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the Swedish Research Council under Grant 2014–2008.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Background: Dancing is an engaging physical activity for people living with Parkinson’s disease (PD). We conducted a process evaluation for a PD trial on online dancing. Methods: “ParkinDANCE Online” was co-produced by people with PD, healthcare professionals, dance instructors, and a PD organisation. The evaluation mapped the following inputs: (i) stakeholder steering group to oversee program design, processes, and outcomes; (ii) co-design of online classes, based on a research evidence synthesis, expert advice, and stakeholder recommendations; (iii) trial fidelity. The key activities were (i) the co-design of classes and instruction manuals, (ii) the education of dance teachers, (iii) fidelity checking, (iv) online surveys, (v) and post-trial focus groups and interviews with participants. The outputs pertained to: (i) recruitment, (ii) retention, (iii) adverse events, (iv) fidelity, (v) protocol variations, and (vi) participant feedback. Results: Twelve people with PD, four dance instructors and two physiotherapists, participated in a 6-week online dance program. There was no attrition, nor were there any adverse events. Program fidelity was strong with few protocol variations. Classes were delivered as planned, with 100% attendance. Dancers valued skills mastery. Dance teachers found digital delivery to be engaging and practical. The safety of online testing was facilitated by careful screening and a home safety checklist. Conclusions: It is feasible to deliver online dancing to people with early PD. Implementing research-informed therapeutic interventions into clinical practice is a cornerstone of evidence-based clinical practice ,2,3. ForDance therapy is one form of structured physical activity thought to be beneficial for some people living with Parkinson’s disease ,20. It iDance classes for people living with PD have been implemented in community settings, either as group tuition or one–one sessions ,30,31,32“ParkinDANCE” is an evidence-based dance therapy program for people with Parkinson’s disease. It has been co-produced and implemented by Fight Parkinson’s , implementation scientists, and stakeholders from the Parkinson’s community, including people living with Parkinson’s disease . Key eleDriven by the restrictions associated with the COVID-19 pandemic and the requirement for many people to stay at home, we co-created “ParkinDANCE Online” and conducted a clinical trial . BecauseWe registered on the ANZ Clinical Trials Registry (ACTRN12620001042932) and the La Trobe University Human Ethics Committee granted ethics approval (HEC18520). We have also provided open access A process evaluation addressed each of the aims, based on the model by Moore et al.  and the See Stakeholders in this evaluation were people with idiopathic PD (dancers), dance instructors, physiotherapists (who were assessors and process auditors), occupational therapists, nurses, and representatives from Fight Parkinson’s, Victoria, Australia. A research analyst developed and administered a Research Electronic Data Capture (REDCap) database  and accoPeople living with PD were included if they met the following inclusion criteria: modified Hoehn and Yahr stages 0–2.5 ; aged 18The dance instructors were experienced in conducting dancing classes for people with basal ganglia conditions. They had been trained by MEM and VM in the pathophysiology of movement disorders and management of PD. As with the health professionals in the project, they had completed good clinical practice (GCP) training, first aid training, and education in safe and effective delivery of digital dance sessions.The physiotherapists, occupational therapist, and nurse were registered with the Australian Health Practitioner Regulating Authority. Fight Parkinson’s was the key industry partner and is a not-for-profit organisation that provides education, advice, advocacy, and health programs for people with PD and their families.The PD dancers were recruited by Fight Parkinson’s using convenience sampling . Fight PTwelve people with comparatively early-stage PD, four dance instructors and two movement disorders physiotherapists, were included in the 4-week trial. There were nine females and three males with a mean age of 58.1 (SD: 8.1) years and an age range of 34 to 63 years included in the dancer group. The mean duration of PD was 4.3 (SD: 3.7) years, with the mean Hoehn-Yahr PD rating scores of 1.8 (SD: 0.7). Seven participants were retired, five worked part- or full-time and three participants reported falls within the last 6-months. Their demographic details are summarised in There were four dance instructors  with a mean age of 43.6 years and 18.6 years of dance teaching and performing (range 10–32 years). They were experienced in delivering dance to people living with PD and were accomplished in dance genres such as jazz, ballet, tap, hip hop, Bollywood, salsa, Brazilian dance, Latin, ballroom, and Argentine tango. Their demographic details are summarised in The two physiotherapy (PT) assessors were both experts in movement disorders and registered with AHPRA. Both had bachelor’s and master’s degrees, were aged 30 and 62 years, respectively, and had 40 and seven years of clinical and research experience, respectively. Their demographic details are summarised in Electronic copies of consent forms, audio-recordings, and de-identified transcriptions were stored on a secure university research drive with access restricted to the main lead researcher and project manager. Demographic and assessment data were stored in a secure Recap folder accessible to the lead researcher, project manager, and REDCap survey developer.ParkinDANCE Online procedures were described previously . The onl(i)Mapping contextual factorsContextual factors that shaped how ParkinDANCE Online were delivered related to (i) the COVID-19 pandemic, which necessitated all participants to work from or stay at home and to access the classes via the internet (ii) our recent systematic review findings on dance for PD , which iIn Melbourne, Australia, the first COVID-19 hard lockdown commenced on 21 March 2020, and the most recent lockdown finished on 22 October 2021. During this time, people were isolated to their home environment, sometimes alone and sometimes only with direct family members. Social isolation was widely reported ,54, and (ii)Methods for “Process Analysis of What was Delivered”(a) Planning for deliveryPrior to delivery of this new mode of dance therapy, a steering committee of stakeholders from La Trobe University and Fight Parkinson’s was formed . Key considerations included safety, staff training, dance program content, delivery of classes, and how to ensure that people with PD were engaged in co-production. The steering committee obtained ethics approval and appointed project staff. The interventions and procedures were co-designed by the team in conjunction with each individual dancer.®. Two experienced movement disorders physiotherapists (PTs) then conducted full assessments online via Zoom®. Under the supervision of the chief investigators, the project manager conducted PT assessor orientation and dance instructor education, research project training, and choreography feedback. This ensured that safety protocols, class content, dance routines and assessments were delivered as planned. The chief investigator also checked dance class plans, choreography, and music to ensure alignment with the ParkinDANCE model and to ensure compliance with ethics and copyright regulations.Prior to the dance classes, the project manager, who was a registered physiotherapist, conducted safety screening at home via ZoomThe team co-designed a range of manuals for dancers , dance i(b) Management of protocol variationsWe recorded any unintended variations from the planned delivery on the fidelity checklist . Variati(iii)Methods for Recording “What Was Delivered”(a) Participant orientationThe preliminary screening data for each participant was checked by the project manager for eligibility. This included participant training, provision of manuals and resources, and completion of dress rehearsals. These data were recorded in the fidelity checklist .(b) Pre- and post-intervention blinded assessmentEach PT assessor was assigned the same six dancer participants for pre- and post-intervention assessments using outcome measures for balance, gait, quality of life, and disability. The PT assessor guidelines were used in conjunction with orientation and a dress rehearsal with the project manager. Each assessor had an orientation meeting with their assigned participants and then scheduled a full online assessment one week before and two weeks after the dance intervention. Results were uploaded into REDCap for further analysis.(c) Dance class choreography and music plansA dance instructor manual was developed by the research team prior to implementation of ParkinDANCE Online. The manual was used for pre-intervention dress rehearsals between the lead researcher, dance teachers, and project manager. The manual contained class plans (including suggested music and choreography) to be used by the dance instructors to inform the choreography for their classes. Each dance teacher documented the details of each of the classes that they delivered, as well as their impressions of participant performance and engagement. The diaries were stored in REDCap.(d) Post-session surveys (dancers and dance instructors)Attendance was recorded by the dance instructors. Where a class was missed, due to technology difficulties, it was rescheduled and completed. A post-class online survey was sent to each participant and dance instructor within 24 h of class completion using REDCap questions, which included music and dance enjoyment, adequacy of rest breaks, class structure, and class enjoyment. The dance instructors also completed post-class surveys (eight surveys for each of three dancers) about delivered content, technology problems, safety, and health.(e) Post-intervention interviews and focus groupsTwelve dancers with PD were individually interviewed by the project manager. The zoom interviews were audio-recorded, transcribed verbatim, thematically analysed within an interpretive phenomenological framework, and comprehensively reported . Four da(iv)Analysis: ParkinDANCE Online was implemented as plannedThe analysis of whether ParkinDANCE Online was implemented as planned, and the extent to which the expected outputs occurred was determined from process mapping as recommended by Antonacci et al. . Steps i(a) Process identificationThe first process pertained to the recruitment protocol, and the second related to the co-designed screening documents. We audited the process by which Fight Parkinson’s performed recruitment and screening using pre-prepared documents that included a letter of invitation, participant information and consent forms, eligibility criteria, doctor screening tool, personal information, medical information, and self-assessment of technology and safety at home. The next process was the development and use of project manuals. Co-designed project manuals included a participant manual, video conferencing guidelines, physiotherapy (PT) assessor guidelines, PT assessor manual, and a dance instructor manual. The participant manual and video conferencing guidelines were distributed to all participants before the intervention commenced. The PT assessor guidelines and manual were used in conjunction with orientation and a dress rehearsal with the project manager. The dance instructor manual was used in conjunction with pre-intervention dress rehearsals with the lead researcher and project manager.(b) FidelityFidelity checking ,59 was a(v)Stakeholder ViewsImplementation success was also determined from qualitative analyses of in-depth interviews from key stakeholders. The experiences and perspectives of the dancer participants, PT assessors and dance instructors were explored to gain insight into co-design processes, facilitators, and barriers in design and delivery, as well as suggestions for future design. Individual interviews were conducted with each of the dancer participants and the two PT assessors, and a focus group was conducted with the four dance instructors. (i) The contextual factorsThe contextual factors that shaped how ParkinDANCE Online was delivered were predominantly related to the lockdown conditions in Victoria, Australia, associated with the COVID-19 pandemic. This meant that all therapies were required to be delivered digitally. People could not meet face-to-face and were only permitted to leave the home for up to one hour per day. Although our recent global systematic review on dance for PD  showed t(ii) What interventions and procedures were delivered?The interventions and procedures that were delivered are summarised in (iii) Whether ParkinDANCE Online was implemented as planned and the extent to which the expected outputs actually occurredThe fidelity checklist  verified(iv) Stakeholder views about implementation, barriers and recommendations(a) Dancer participant in-depth interviewsOverall, the dancers with PD reported being able to master new movements and skills. They advised that being guided by experienced dance instructors helped them to enjoy the classes and learn new skills. They also reported that the type of music and beat helped them to dance. They advised that support and information from the research team helped them to prepare for the online delivery. The results of this analysis are published in Morris et al., 2021 .(b) Dance instructors focus groupFour dance instructors attended the audio-recorded focus group, which lasted for 55 min. All dance instructors had a positive experience and felt well-prepared and supported. The following five themes were identified and supported by quotations linked to the transcript: (1) online therapeutic dancing is accessible and enjoyable; (2) safety procedures are essential for online delivery; (3) screening and provision of participant summaries are essential; (4) with training, dance instructors can adapt class content to movement disorders and individual symptoms; and (5) digital delivery requires training and technology support.b1. Online therapeutic dancing is accessibleAll of the dance instructors indicated that online delivery facilitated classes that people could access when otherwise unable, whether due to COVID-19 restrictions, medical limitations, geographical location, or transport availability.“it was fantastic to make it accessible for people who are regional … clients I had were able to access the technology and use that and navigate their way around it, and I didn’t feel like I needed to compromise the session being an online format”P3, lines 29–35“I’m really happy that the online option was available, and I think that it is great that they can do it from home, and they don’t need to necessarily leave their house”P1, lines 55–58“they don’t necessarily have the means or a person to be able to bring them to class or face-to-face classes, for example, or they just may be a little bit too far for them to be able to travel”P4, lines 90–93b2. Safety procedures are essential for online deliveryAll of the dance instructors appreciated the education about the importance of safety procedures and valued the safety screening.“I really appreciated that you did the screening, and also to discuss with them what’s a safe space to work in. I think that was really valuable to have that prior to the sessions”P2, line 117“emphasised on the importance of the room setup … with regards to safety … they need to be free of space, no rugs”P3, lines 602–604“first and foremost, we’ve got to be able to make sure they’re doing safe things”P4, line 314b3. Screening and provision of participant summaries are essentialThe pre-intervention screening procedures and participant demographic data were considered by dance teachers to be helpful for planning, individualising, and progressing the dancing classes.“I was really impressed with the screening. The three people that I had were all at different levels … made the modifications and progressions, depending on the client … screening was really valuable”P2, lines 125, 129“I felt like I had enough information from my participants. All three of them were completely different … that conversation prior to our first session on the phone actually helped me get a bit more information … helped me understand where they’re at and what they’ve done, and possibly what they would be capable of doing in class”P1, lines 142–148“the screening was very valuable, to know a little bit of the background. I found that was very important … really helped me understand their ability and their level”P3, lines 164, 171“the screening was very valuable … so that it was very clear for me as to how to move forward and work with each individual”P4, lines 175, 181b4. With training, dance instructors can adapt classes to individual symptomsThe dance instructors all valued the preparation, education, and support manuals provided by the research team. They were able to tailor classes to the individual and respond to symptom fluctuations.“I felt a lot of the pre-planning, recording our sessions and writing—I felt that really helped for me planning, that when we came live, I think that was a really good … I had a lot of guidance and support in the actual preparation of how to deliver a safe class. That was really good. And I felt there was a lot of planning involved and support from the research team”P3, line 434–441“the actual communication that you gave us was really clear, the follow-up was clear”P2, line 412“I really felt supported all the way. The communications were great and just guiding us through the preparations was really great for us to have a clearer idea of what the study would be focusing around and for our own preparation”P4, line 450–452“going back and referring to that manual was quite important”P3, line 509“I would put another kind of element in the class so that I could see how they would cope with that amount of movement … adapt that session to that particular person”P1, line 590b5. Digital delivery requires training and technology supportDance instructors reported that online delivery requires a stable internet connection and a device that can be moved and show the entire body. Video conference manuals provided a reference point, and many dancers had access to technology support.“the clients I had were able to access the technology and use that and navigate their way around it, and I didn’t feel like I needed to compromise the session being an online format”P2, lines 33–34“they adapted to Zoom. Some knew a lot more about technology than others, but everyone sort of adapted”P3, line 47“all of my students were great on Zoom, and even if they maybe had some troubles every now and then, we kind of had a bit of a discussion about it and almost kind of made it a social element to the session as well”P1, lines 59–61“making sure that you’re tracking and using the (dance instructor and videoconference) manual method to do that. So, I think in planning and to know what you’ve done and to clearly document things in those ways, I found it quite useful”P2, lines 503–505(c) Physiotherapy assessor in-depth interviewsThe two movement disorders physiotherapists who conducted the pre- and post-intervention assessments were individually interviewed in detail. From the de-identified transcribed audio-recordings, two analysts reached a consensus on the following four themes and identified the supporting quotations linked to the transcripts: (1) online dancing can be made safe with participant screening and environment checks; (2) assessor expertise, preparation, guidance, and support are essential; (3) online delivery enables increased access to therapeutic dancing; and (4) online assessment is challenging and requires measurement and technology adaptation.c.1 Online dancing can be made safe with screening and environment checksThe assessors, who were movement disorders physiotherapists, reported that the screening of medical symptoms and home environment could make the online dancing safe.“I very much felt it was delivered safely, and I think the particular cohort of participants we had were very appropriate for online delivery”P1, line 66–67“I certainly felt that I got a good idea of their falls risk, level of balance from that (online assessment). I think if there’d been anyone that I’d been really concerned about, it would’ve picked up in the assessment, and I would’ve passed that back to you”P1, lines 128–130“their screening was really, really useful to know that they’d been in a kind of initial safety screen and risk assessment”P1, line 178“they were (well screened). They were all very keen, they were all able to follow instructions, and to engage in the tasks, and were quite appropriate … I don’t recall having any safety concerns”P2, line 365c.2 Assessor expertise, preparation, guidance, and support are essentialThe physiotherapists acknowledged that their expertise in movement disorders was an advantage, and they agreed that the preparation and orientation provided by the research team was valuable.“It was like a (pre-assessment) familiarisation … meant you actually met them and got a little bit of a feel, saw them moving a little bit before you were doing the assessment then a few days later … it gave me a really good insight. So that was definitely very valuable to do”P1, lines 83–86“you certainly need physiotherapists that are familiar with working with people with Parkinson’s … also taking into account that kind of holistic approach with cognition and picking up if someone is impulsive”P1, lines 142, 146“that  was brilliant. Really useful to have”P1, line 196“I was using every ounce of skill I had to try and help to make the person feel supported and move it through (the assessment)”P2, line 215“I felt I had easy good communication with yourself, or with (the research team)”P2, line 503c.3 Online delivery enables increased access to therapeutic dancingThe physiotherapists had previously participated in the in-person delivery of therapeutic dancing for PD. They reported that the online option was a necessary alternate for people who could not reach community classes.“the idea to trial a feasibility of the online was good. And I think it needed to be done. And I think it’s opened up the doors to delivering programs online, whether that’s dance or other kinds”P1, line 58–60“one of the benefits is it allows people to participate rurally. But I don’t know if many of the participants were drivers. And so that if they’d had to be somewhere, they would have had to have got there either by someone driving them, or by public transport, which again is probably not very accessible”P2, lines 68–72“being in people’s homes was accessibility … they weren’t tired when they got there, they were fresh. For a lot of people, having made the whole effort of getting ready and going out, and getting to somewhere, and parking, and getting in, they’re already a bit tired, for these people who do get tired more quickly”P2, lines 639–640c4. Online assessment requires measurement and technology adaptationsThe physiotherapists were experienced in the assessment of people with PD. They reported barriers to online assessment that included not being able to manually assess strength, balance, and rigidity and adjusting to the visual challenges of digital devices.“I’m used to doing it in person, I know which tests are riskier … you have to tailor that approach online. But certainly, being familiar with which parts of the assessment are the riskier part … you just have to think about it a little bit more (online)”P1, lines 153, 157, 166“I adapted the assessment to try and minimise how much the participant was moving the laptop. I did all the assessments where they were in where I needed them in full standing”P1, lines 205–206“you can’t recreate it (push/pull test) over Zoom, because you can’t actually pull—you wouldn’t—you can’t get someone to unbalance themselves … with the rigidity testing, again, you need to feel the movement”P1, line 223, 225“everyone worked out a way to have a runway that was visible, so that they had to walk away from the screen and then back towards it again. I found it much harder to pick up gait abnormalities than I would have normally”P2, lines 110–112“keep in mind when they’re administrating it (UPDRS assessment) because, I think the motor part takes longer online than it does in real life … you haven’t seen the person walk in, you haven’t seen their arms do anything. You have to make the person do it all”P2, lines 251, 254–256“it (pre-assessment meeting) helped just to sort of calm down any anxiety over the technical side of using Zoom and just get them, I guess, used to the format”P1, lines 101, 105–107“I don’t think you could do it with a desktop because you can’t get that movement … I think if we tried using mobile phones, there would be a little bit of an issue of safety with them trying to hold the phone and position the phone, because it’s just not as stable as a laptop”P1, lines 315, 318“if the lighting was good and the webcam was good, there were no issues. But if their webcam wasn’t great, it didn’t feel as accurate as assessing in person”P1, line 555“another challenge I think was the mental concentration. I think we all know that doing a Zoom interview is quite challenging cognitively”P2, line 205Online dance therapy offers great potential for movement patterns and associated choreographies to be adapted to individual needs. Whereas physiotherapy has traditionally optimised motor control, movement in the context of dancing affords opportunities for creative expression, and enjoyment, in addition to increasing the amount and range of structured physical activities. This process evaluation showed that the ParkinDANCE Online classes quickly reached the target group of people living with idiopathic PD who were living at home and seeking to become involved in structured physical activity. Despite the COVID-19 lockdown that was in place throughout the entire period of this trial , the onlThe key stakeholders were satisfied with the project design and delivery. Of note, the people living with Parkinson’s reported satisfaction with the online medium and enjoyment of the ParkinDANCE program. They found the online classes to be engaging, enjoyable, and therapeutic. The dance teachers advised that receiving education about PD was very helpful, as well as how to modify choreography and music to adjust for movement disorders and non-motor symptoms. The physiotherapy assessors reported that it was essential to have access to comprehensive reporting templates and training in how to administer online formats of the UPDRS and other tools. Fight Parkinson’s, the key industry partner, cited the importance of regular, well-organised project meetings and the detailed tracking of project deliverables. They reported that all materials, information, and resources were suitable for the target audience.Stakeholder views showed that implementation success was largely related to the co-design and co-production of the project. This is in agreement with the recent research on the value of co-design in rehabilitation ,64,65,66The other recommendations evolving from the trial were: (i) participant manuals are helpful for supporting implementation and should be professionally produced and made available online; (ii) reliable, safe, and valid methods for administering the UPDRS and other measurement tools online need to be confirmed; (iii) health care professionals and dance instructors need education and training in how best to deliver online dance classes for people with progressive neurological conditions such as PD; (iv) people living with PD need access to reliable technologies, such as a stable internet connection and a digital device such as laptop, as well as digital literacy and capability.Although this process evaluation did not aim to investigate the factors associated with the demand and supply of participant recruitment, this can be influenced by factors such as the methods of referral and the availability of professionals to recruit, screen, enrol, and teach the participants. In other contexts, such as singing , it has There were several limitations of this trial. Although it is one of the first controlled trials of dancing online for PD, it was a phase I trial. A need exists for a randomised controlled trial to reduce sources of bias. We were not able to control PD medications during the trial, and variations in medication could have increased the amount of variability in results. An important limitation is that the age range inclusion criteria was limited to adults aged 18–65, and older adults were excluded. Further research is needed to adapt the program for older adults with PD. In addition, we excluded people with comorbidities; future trials need to test whether ParkinDANCE Online is safe and effective for people with PD who also have other chronic conditions, given that most older people have two or more chronic conditions. Future digital innovations and virtual reality are likely to afford an array of advanced technologies to give participants greater access and opportunities to engage in art health therapies from geographically wide-spread communities.The success of online dancing for PD was related to a strong theoretical framework supporting dance therapy design, close adherence to pre-determined interventions and procedures, and incorporating stakeholders in the design and implementation of this innovative and accessible method of online dancing.