Criteria and Approaches in Designing Psychiatric Hospitals

A successful design for a psychiatric hospital requires careful coordination of a multitude of factors; there is no one-size-fits-all solution. The final design will be unique to the individual facility and its stated goals and philosophies. In particular, many elements typically used in general hospitals to address the specific needs of patients and staff are needlessly carried over into behavioral health facilities, even though the functions they are intended to address are not present or needed in psychiatric units.

Range of Psychiatric Facilities

The range of psychiatric facilities includes psychiatric hospitals, psychiatric and neuro-psychiatric nursing units of general hospitals, facilities for the psychiatric medically infirm, geropsychiatric units, alcohol and drug addiction treatment facilities (both inpatient and outpatient), mental health clinics, day hospitals, day treatment centers, and others. In addition to inpatient nursing units, psychiatric hospitals include their associated diagnostic and treatment areas, as well as the necessary dietetic, supply, housekeeping, and administrative spaces common to all hospitals. They do not generally include the complex and high-tech diagnostic and treatment areas of general hospitals.

Psychiatric hospitals may include outpatient psychiatric areas. These areas should be located on a direct path from the lobby, and circulation paths of the outpatients should be separated from the paths of the more acutely ill inpatients. Teaching hospitals will also include spaces for training and education, and often spaces for research studies.

The mental health clinic is the basic outpatient unit, providing an interface between inpatient care and the community. As such, it provides preventative care, primary care, and aftercare. The clinic may also serve as a site for research and for training of mental health professionals on all aspects of outpatient treatment of mental health problems.

A substance abuse clinic provides outpatient care and treatment of alcohol and/or drug-dependent patients no longer needing inpatient care. In a hospital, it should be so located that its patients do not need to travel through other parts of the hospital.

The day hospital has no beds, but is typically located within or adjacent to a hospital. It offers total hospital psychiatric services for acutely ill patients without removing them from the family and community.

The day treatment center provides a supportive learning environment away from a hospital in which patients having chronic difficulties with community adjustment and other psycho-social problems may receive help. Such patients have often had long periods of hospitalization, and need continuing monitoring of their general health and medication needs.

Things to be considered before design Psychiatric setup

Mental health facility design is a critical component of patient care. The design of mental health facilities affects how services are provided and the efficiency with which care is delivered. Equally, if not more important, than its direct functional impact, however, is the psychological impact mental health facility design has on its users. Facility design impacts the beliefs, expectations, and perceptions patients have about themselves, the staff who care for them, the services they receive, and the larger health care system in which those services are provided.

Moreover, facility design can also have a significant impact on the beliefs, attitudes, and behaviors of staff and on how staff identify and interact with patients and the environment.

The facility design also places important emphasis on patient safety. Developing mental health facilities that are safe and healing are not incompatible processes or goals. Healing environments can be designed as safe environments.

Moreover, to the extent that the environment of care in inpatient and other mental health settings is healing and recovery-oriented, it is likely to enhance patient safety; warm, welcoming, and familiar environments often promote a sense of calm in patients and enhance their connection to their surroundings rather than feel detached from or in opposition to it.

Patient engagement is also a critical component of patient safety. When patients feel connected to staff, they are more likely to respond to or seek out these individuals in moments of distress, which can prevent or deescalate personal crisis. For this reason, it is important that environmental design, as well as clinical processes, facilitate staff interaction and connection with patients and discourage isolation or detachment.

1.Behavioral health and its influence on design

The AHA reports that medical and behavioral health comorbidities often complicate care protocols, negatively affect patient outcomes and increase the cost of care.  Several factors are thought to contribute to recent increases in medical and behavioral health comorbidity, including an aging population, the rising incidence of chronic illness and growing issues with substance abuse.  While patients with medical and behavioral health comorbidities are seen in all settings across the care continuum, there is growing realization that current inpatient room designs often fail to meet the unique needs of this population and those who care for them.

2.A holistic approach

Behavioral health conditions have shifted to a holistic treatment approach in which patients take charge of their healing process through individual and team-based care in a supportive and nurturing environment.

Treatment facilities should be designed to be safe and comfortable, emphasizing personal empowerment and individual dignity, thus becoming a catalyst for improving health care practices and enabling patients to take control of their own healing process.

3.Special considerations

Given the range of specialties and ages in behavioral health, it is critical to understand the unique requirements for each to provide a supportive environment. While adult populations may require a higher degree of security, different requirements should be taken into account when designing for other populations.

A growing older population points to increasing numbers of seniors with dementia and mental illness. Older adults often are brought to the ED for care, compounding overcrowding. Because of their ages, these patients have longer lengths of stay, tying up valuable ED space. Additionally, most EDs are not equipped to address the specific needs of the elderly. Geriatric patients, because of their medical and physical limitations, require corridors with handrails to promote ambulation. Lighting and flooring materials should be designed to address limitations of sight and to reduce falls. The transition between materials and contrast levels of flooring color also should be considered.

Facilities for children and adolescents should be designed to address the unique aspects of this age range. Their physical needs and cognitive abilities change over time, giving them different perspectives on their environment. What appeals to a young child may not be engaging for an adolescent, yet the environment needs to respond to all.

Research has shown that positive distractions can enable a child to be more receptive to treatment and to be treated with fewer medications. As much as possible, the environment should strive to provide a sense of normalcy. The patient room becomes a place where a child can have more control over the environment and can personalize his or her space. Play spaces are important tools to reduce tension and anxiety. They can allow for learning and exploration by enabling children to engage with their environment.

Caring for the mental health of military personnel and veterans can be wide-ranging. The issues they face include PTSD, as well as traumatic brain disorders, drug addiction, pain management, sleep disorders and suicide. Though PTSD and traumatic brain injuries represent major mental health care needs, psychological issues more generally go beyond these specific problems.

Many veterans perceive constant threats to themselves and their families, thereby responding differently to environmental conditions. For example, open atrium spaces may be considered threatening to a veteran with combat experience. The Department of Veterans Affairs has embraced a Plane tree model of care that focuses on creating more welcoming and family-friendly environments.

4.Therapeutic Environment

The character of the immediate surroundings can have a profound affect on the psyche of a psychiatric patient. The New York Psychiatric Institute reports a dramatic drop in the number of patients who need to be restrained since occupying their new facility with its bright open spaces. Every effort should be made to create a therapeutic environment by:

•       Using familiar and non-institutional materials with cheerful and varied colors and textures, keeping in mind that some colors and patterns are inappropriate and can disorient older impaired patients, or agitate patients and staff. See also VA Interior Design Manual.

•       Admitting ample natural light wherever possible.

•       Providing a window for every patient bed, and views of the outdoors from other spaces wherever possible. Views of nature can be restorative.

•       Providing inpatients with direct and easy access to controlled outdoor areas

•       Providing adequate separation and sound insulation to prevent confidential but loud conversation from traveling beyond consulting offices and group therapy rooms.

•       Giving each patient as much acoustic privacy as possible—from noises of other patients, toilet noises, mechanical noises, etc.

•       Giving each patient as much visual privacy, and control over it, as is consistent with the need for supervision.

5.Daylight, art, color

The positive impact of daylight has been shown in one study to reduce the length of stay for bipolar patients (www.ncbi.nlm.nih.gov/pubmed/8882914). In this study, 174 patients with clinical depression were assigned to either sunlit or dimly lit rooms. Patients in the sunny rooms stayed an average of 16.9 days compared with 19.5 days for those in the dimly lit rooms.

In a report published by the Coalition for Health Environments Research called “Color in Healthcare Environments” (www.healthdesign.org/chd/research/color-healthcare-environments), the effect of color on health care environments was found to be limited. Despite numerous studies on color, there is no evidence to support a one-to-one relationship between a given color and a given emotional response. Although studies show a mood-color association, there is no evidence of colors being emotional triggers. Individual responses to color vary and are influenced by their culture and physiological and psychological makeup. The trend in behavioral health design is toward the use of brighter, more optimistic color palettes and away from those that are more neutral.

There have been studies that indicate that the use of realistic art can be beneficial in behavioral health settings to reduce patient anxiety and agitation. Results showed that medication dispensed for anxiety and agitation was significantly lower on days when a realistic image of a landscape was displayed. In addition to better outcomes for patients, the cost of medication was compared for the different conditions, establishing a potential financial case for the annual cost savings of $4,000 to $27,000.

Utilizing nature as a healing distraction benefits all ages of patients. By allowing the lines between interior and exterior to blur, the benefits of the outdoors can be brought inside. Similarly, accessible outdoor spaces that carefully address safety concerns can be calming, positive and therapeutic distractions.

•       Use of new lighting systems, high performance glazing, increased use of natural light, natural materials, and colors

•       Use of (soothing, not exciting) artwork

•       Attention to details, proportions, color, and scale

•       Bright and open public and congregate spaces

•       Comfortable and intimately scaled nursing units and offices

•       Compatibility of exterior design with surroundings

6.Safety and security

The approach to safety has shifted from traditional locked-down units and enclosed nurse stations where patients spend the majority of their time alone in their rooms. The focus is now on providing comfortable environments, with reduction of barriers and with a more residential character. However, the safety of patients and staff is the most critical aspect of design.

Generally, zones of risk, in which patients may cause harm to themselves or others, identify an approach to addressing security needs based upon areas of greatest concern. Zones of high risk are those in which patients are alone and unsupervised, such as the patient room, toilet room or shower, or a seclusion room. Medium-risk zones include those in which patients may have some supervision, are in small groups and are rarely alone, such as in group rooms, day rooms, laundry or the dining room.

Low-risk zones are those in which patients are observed and accompanied, such as in corridors, or where patients are not allowed, such as staff spaces, clean and soiled rooms and housekeeping rooms.

Suicides are the greatest concern and studies recommend that staff have visual access to patients at all times to reduce such incidents. For the design of patient spaces, the objects in the room and design features, such as door knobs, shower curtains, window treatments, ceiling and fixtures, need to be specified to prevent self-harm.

The potential suicide of patients is a special concern of psychiatric facilities. The facility must not unwittingly create opportunities for suicide. Design to address this and other safety and security issues includes:

•       Plumbing, electrical, and mechanical devices designed to be tamper-proof

•       Use of breakaway shower-rods and bars, no clothes hooks

•       Elimination of all jumping opportunities

•       Control of entrances and exits by staff

•       Provision for patient bedroom doors to be opened by staff in case of emergency

•       Laminated glass for windows in inpatient units

•       Fiber-reinforced gypsum board for walls

•       Special features in seclusion rooms to eliminate all opportunities for self-injury, including outward opening door with no inside hardware

•       Careful consideration of appropriate locations for grab bars and handrails. Where they must be used in unsupervised spaces, and patient profile justifies extra care, special designs are available that preclude their use for self-injury.

•       Eliminate the use of door knobs and handles

•       Solid material specified ceilings

For areas with the highest level of concern, specifications for lighting fixtures, ceiling systems, mirrors and hardware must be considered carefully. For furnishings, solid, securely mounted or built-in furniture may be appropriate where the furniture is meant to be stationary. In other cases, where furniture should be moved to allow for flexibility in the space, consideration of the weight of the piece is important. Most guidelines recommend determining whether furniture or other components in a room cannot be turned into a weapon or be used to hide contraband.

Of the studies identified, there is some knowledge that can be useful to design teams. One category, the physical environment and its relationship to social behavior, provides some guidance on patient rooms. Single patient rooms have been found to eliminate roommate issues. Patient privacy is greatly enhanced and there are fewer disruptions and incidents that typically can occur in shared rooms. Private rooms also promote a quieter environment, leading to better sleep for most and lowered levels of agitation for some patients. However, findings differ for children’s environments and some disagreement exists about the safety of private vs. shared rooms. For counseling spaces, on the other hand, social aspects are found to be particularly important because comfort, relationships and communication are essential to improving outcomes.

While much of the available information identifies how to mitigate harm to the patient or staff, studies have emerged that focus on the modification of behaviors through careful and thoughtful approaches to the design.

In an article in the New York Times, evidence-based design researcher Roger S. Ulrich identified violence in psychiatric facilities as a significant area of concern that can be impacted through the design of the facility (www.nytimes.com/2013/01/13/opinion/sunday/building-a-space-for-calm.html). He believes that the goal of facility design should be to reduce stress and, thereby, reduce aggression. Typical inpatient units are not designed for calm, nor do they serve to support a patient’s ability to cope.

A Swedish study cited by Ulrich identified architectural features to reduce stress and aggression that were incorporated into a hospital’s design. A significant reduction in the use of patient restraints was found and the number of patient sedations was considerably lower. Ulrich believes this is an indicator that the environment can positively influence behavior.

7.Sustainability

Psychiatric facilities are public buildings that may have a significant impact on the environment and economy of the surrounding community. As facilities built for "caring", it is appropriate that this caring approach extend to the larger world as well, and that they be built and operated "sustainably".

8.Building Attributes

The design of a successful psychiatric facility should:

•       Promote staff efficiency by minimizing distance of necessary travel between frequently used spaces

•       Allow easy visual supervision of patients by limited staff. Nurse stations on inpatient units should be designed to provide maximum visibility of patient areas.

•       Include all needed spaces, but no redundant ones. This requires careful pre-design programming.

•       For inpatient units, provide a central meeting area or living room for staff and patients and provide smaller rooms where patients can visit with their families

•       Make efficient use of space by locating support spaces so that they may be shared by adjacent functional areas, and by making prudent use of multi-purpose spaces

•       Giving each inpatient the ability to control his immediate environment as much as possible, i.e. lighting, radio, TV, etc.

•       Providing computer stations for patient use when patient profile and treatment program allow.

•       Designing features to assist patient orientation, such as direct and obvious travel paths, key locations for clocks and calendars, avoidance of glare, and avoidance of unusual configurations and excessive corridor lengths.

•       Designing a "way-finding" process into every project. A patient's sense of competence is encouraged by making spaces easy to find, identify, and use without asking for help. Color, texture, and pattern, as well as artwork and signage, can all give cues. (For a guide to clear signage, see VA Signage Design Guide.).

•       Providing exercise equipment for patient use where appropriate for the program of care.

•       Providing access to kitchen facilities, preferably on the unit, where snacks or meals can be prepared by patients, when patient profile allows.

9. Operational Consideration

Bring the services to the patients and maximize therapeutic opportunities

Consistent with the goal of recovery and the desire to treat patients in the least restrictive setting possible, there is a general trend for patients in inpatient mental health settings to have shorter lengths of stays. To maximize treatment services, patient engagement, and interdisciplinary care processes in an inpatient setting, there should be adequate treatment, therapy, and staff space on the inpatient unit, thereby minimizing movement and separation of the patient and service provider.

Create Non-Institutional Treatment Environment

Creating a more familiar, therapeutic environment helps reinforce the recovery focus of the program and reduce institutional stigma often associated with mental health treatment facilities. To this end, interior and exterior features of mental health facilities are increasingly home-like in appearance and feel. Inpatient and residential facilities, where feasible, are single story or village-like, with multiple exterior courtyards bringing in more natural light and views of nature. The interior design embodies safe, residential components, with improved aesthetics, ventilation, and noise control. Traditional inpatient environments with enclosed areas and physical barriers between staff and patients, such as enclosed nursing stations, are typically not needed or favored in most inpatient facilities today and are being replaced with open concept nursing stations of reduced size that blend into a more open environment and promote normal social interaction and engagement.

Private Patient Rooms and Bathrooms

Many inpatient mental health facilities in the private sector are moving toward having exclusively, or primarily, single occupancy rooms. An inpatient facility with all private patient rooms allows more patient assignment flexibility, enhances patient privacy, and reduces disruptions and incidents related to a shared patient bedroom. Single occupancy patient rooms have the benefit of being more private and having less noise, which may be agitating to some patients and can disturb sleep.

On Stage and Off Stage Design

The “on-stage, off-stage” concept separates, where possible, patient pathways (“on-stage”) throughout the facility from materials management, food service and clean materials delivery within the facility, as well as staff support areas (“offstage”). This minimizes noise, disruption and distractions in areas actively used by patients.

Use of Technology

Technology in mental health facilities provides benefits in enhancing security, communications, and patient care. Security enhancements include: door control, inventory control, and facility monitoring. Communication enhancements include: access to continuously updated patient treatment documentation by all appropriate members of a patient’s interdisciplinary care team.

The patient care includes “telemental health.” “Telemental health” refers to remote visual/audio communication between the patient and care team professionals. Individual consultations may utilize personal computers with a camera. This technology is important to ensuring continuity of care for those patients living in remote or rural areas. All inpatient, residential, and outpatient facilities should have audio- and video-conferencing capability for both individual and group use. Appropriate band-width capability should be available at the facility to allow for maximal use of telemental health care. Furthermore, computer access is an important component of recovery and rehabilitation and should be incorporated into the design of inpatient, residential, and appropriate out patient .

10.Design View

Flexibility

The design of a mental health facility needs to respond to changing workloads, care objectives, and technologies, such as wireless technologies for staff.

• Spaces should be universally designed to accommodate a range of related functions.

• Standardization of unit layouts should be developed to reduce care team orientation to different units and to streamline maintenance of each unit.

 • Group spaces in particular need to be designed and grouped to accommodate a range of functions and to accommodate change if possible.

Efficiency

• Support spaces, such as storage and utility rooms, should be designed to be shared where possible to reduce the overall need for space.

• Minimize unnecessary travel distances for nursing staff to use support space and to reach patient rooms in an inpatient setting. Place most frequently used support areas closest to the central nursing area.

Patient Needs

Patient and resident dignity, respect for individuality, and privacy should be maintained without compromising the operational realities of close observation, safety, and security. Patient and resident vulnerability to stress from noise, lack of privacy, poor or inadequate lighting, ventilation and other causes, and the subsequent harmful effect on well being, are well-known and documented .A key architectural objective should be to reduce emphasis on the institutional aspects of care and to surround the patient with furniture, furnishings, and fixtures that are appropriate from a safety standpoint but are more residential in appearance. Proper planning and design should appeal to the spirit and sensibilities of both patients and care providers. A spirit of community should be encouraged. Mental health facilities should be environments of healing that allow the building itself to be part of the therapeutic setting and process. The technical requirements to operate the building should be unobtrusive and integrated in a manner to support this concept.

Risk Reduction

The following facility detailing, planning, and design concepts should be integrated into the project to reduce the following risks in mental health facilities:

Elopements:

1. Allowing one way in and out of congregate areas, as allowed by code.

2. Courtyards instead of fenced outdoor areas.

3. Electronic door controls for emergency egress as allowed by code.

4. Simple circulation with no blind spots.

5. Casual observation (visibility from staff offices and work areas that are not directly responsible for observing patients)

Patient Behavioral Incidents

1. Visibility

2. Specify products for the facility that can not be used as a weapon or used in a suicide attempt.

3. Design appropriate abuse resistance in areas where patients are left alone for periods of time.

4. Integrate technology to assist in observing and maintaining security inareas not readily visible to staff.

5. Equipment, carts, and other supplies should be adequately stored in locked rooms. Alcoves should not be used for storing or parking of equipment, carts and assistive devices in corridors and other unsecured areas.

Reducing Patient/Staff Injuries:

1. Appropriate accommodations for disabled and bariatric patients.

2. Eliminate balconies, openings, etc. that would allow a patient to jump from an elevated platform.

3. Patient rooms and other areas where patient is alone have enough abuse resistance to allow time for an appropriate response team to arrive before a patient harms themselves or is able to exit the space.

Reducing Patient and Staff Stress:

1. Natural light in staff/patient areas.

2. Noise control.

3. Open layout, with no unnecessary barriers between staff and patient.

4. Space for both patients and staff is designed so neither feels trapped or vulnerable; overcrowding is avoided.

5. Attractive views of the exterior.

6. Use of natural materials, a soothing color palette and residential character in the interior design of the facility.

7. Familiar and healing environments.

8. Patient and staff areas that allow for relaxation and controlling one’s social environment (e.g., quiet rooms, staff lounges, secure outdoor space).

Common Mistakes in Designing Psychiatric Hospitals

Some organizations state they have a very low tolerance for risk and want the safest possible environment for their patients. Other organizations, desiring a more home-like ambience, require upgraded finishes that appeal to a different aesthetic. These two approaches can lead to very different design solutions. Most hospitals fall somewhere between the two extremes. Other basic differences between organizations that can affect their design goals are their funding source (public or private) and organizational structure (not-for-profit or for-profit). Other variables that influence key components of the final design are patients’ average length of stay, diagnoses, acuity, age, and co-existing medical conditions and whether they are voluntary admissions or committed by the court.

Suicide prevention and other patient and staff safety issues in psychiatric treatment units present a unique set of issues for the designer,we have continued to visit newly constructed facilities that have serious design mistakes that must be corrected before patients can be admitted.

Unique in our experience was a request from one of these visits from the hospital’s insurance company. We found it interesting that the insurance company recognized there were problems with this facility although the design architects were confident their design was safe.

Other facilities have spent substantial amounts of money remodeling existing units with changes that not only did not resolve patient and staff safety issues, but in some cases actually made the units less safe.

Conclusion

The specific design criteria and approaches described in this chapter emphasize establishing healing and patient-centered environments of care, while promoting the functional and operational missions of the facility.

Patient and staff safety and security, including physical safety and security requirements, infection control, and fall prevention, are also integral components of mental health facility design. However, these approaches should not and need not detract from the healing environment. Specific strategies and design approaches are provided for promoting safety and security in the environment of care without compromising the healing and welcoming quality of the environment.

Author:Sivakumar Murugesan. Consultant :-Healthcare Project & Quality Accreditation