A therapeutic approach to preventing self-harm: designers identify more options that foster home-like environments without compromising patient safety.
More evidence shows that both safety and a healing environment can be designed into the built environment of treatment facilities.1 However, designers of these facilities need to be aware that experience and research in medical/surgical settings does not translate well into the behavioral health environment. (2)
Because patient and staff safety cannot be compromised, these concerns weigh heavily into the design, construction, and even the operation of today's facilities. Designers are learning how to respond to these trends, identifying more options to help balance the concern for safety with design elements that foster a more home-like, non-institutional environment.
The extent of the problem
While patient safety in psychiatric units has improved in recent years, there is still a long road ahead. In November 2010, the Joint Commission released a Sentinel Event Alert, noting that nearly 25 percent of hospital suicides were occurring in areas outside of hospitals1 inpatient psychiatric units. (3)
Yet, another study conducted by the American Psychiatric Association (APA) found that 1,500 inpatients commit suicide annually. (4) One-third of successful attempts were made by patients who were on 15-minute checks, while that was not the case for the remaining two-thirds.
This is why current risk assessment tools should not be relied on heavily to determine the likelihood of suicide attempts. Many patients have had multiple hospitalizations and are very skilled at saying the right things and acting so they will be placed on a level of responsibility that will allow them access to a means of committing suicide.
It is strongly suggested that all patient-accessible areas are designed to be as suicide-resistant as possible. Even though common practice is to treat each patient in the least restrictive environment possible, this lack of predictability requires that caution be exercised and a universally suicide-resistant design protocol be developed.
Of the successful suicides, patient rooms and bathrooms are the most common locations.(5) Three in four successful suicides occur by hanging, with doors and wardrobes being the most frequent ligature attachment points.6 However, some 40 percent of successful suicides use attachment points that are lower than waist-high. (7)
Staff safety is also important, Patient-to-staff injuries are not only costly in terms of lost time and worker's compensation, but also in terms of staff morale, attendance, and employee retention. The design and arrangement of units can greatly reduce this risk by providing good sight lines, eliminating areas where staff and patients could be isolated or alone, and making it easy for staff to observe all corridors, day rooms, and areas where patients may be unsupervised.
Since isolated areas cannot be eliminated entirely, designers should consider the use of "personal duress" alarm systems that interface with nurse call, fire alarm, and building security systems. These have been shown to significantly improve staff morale, attendance, and retention while helping to reduce staff stress and anxiety--feelings that can be transmitted to patients and increase disruptive incidents and behavior.
Comfort without compromising safety
There is a growing body of "evidence" that properly designed environments can enhance patient recovery from medical problems. Unfortunately, there are few studies of any quality that examine the impact of design on the treatment and healing of psychiatric patients.
And, findings from the medical arena do not translate properly to psychiatric facilities, because many of the practices these studies endorse are not safe in psychiatric treatment areas.
But there are a number of design details that psychiatric facilities can use to provide a more residential feeling without increasing safety risks for patients or staff. Many of these details are quite common in residential environments, though not in acute-care hospital settings. Among the most common are finishes for floors, walls, ceilings, baseboards, doors, toilet rooms, countertops, vanities, and furniture.
Flooring is another common "residential" element that can greatly influence the comfort and aesthetics of a treatment space.
Carpeting, for example, not only provides a softer and warmer appearance and feel, but also effectively reduces noise. Carpets made with solution-dyed yarns and moisture-resistant backings are stain-resistant and easy to clean in patient rooms or other areas that may be unsupervised for periods of time. Carpet squares, made from the same materials, may work well in corridors and supervised areas.
If a hard surface is needed or desired, consider sheet vinyl, linoleum or rubber flooring. Many new materials offer commercial quality along with a cushioned backing that helps with acoustics, as well as wood grain finishes that have a residential look.
Wall materials and finishes can also be used to create a home-like feel. Painted gypsum board walls are common in both building types and painted finishes are often preferred in behavioral healthcare settings because they are easily repaired and can be updated over time to keep units looking fresh and consistent with changing color trends.
Ceilings in residences are often gypsum board, frequently with some type of applied texture. These and other types of "hard" ceilings are preferred in behavioral health units because they prevent access to ceiling areas, built-in ceiling elements, or possible ligature attachment points. Gypsum board ceilings are ideal for any areas or rooms in which patients may be alone or free from direct supervision. These include:
* Bath or toilet rooms
* Lounges or day rooms
* Patient rooms
Of course, acoustical or "lay in" ceiling systems are another familiar site in many commercial and healthcare facilities. They are preferred for maintenance purposes, however, as opposed to safety, because they allow easy access to building mechanical, electrical, plumbing, and communications system components.
In areas where line of sight is good and the level of observation is relatively high, "lay in" ceiling products may be used as a convenience if the need for access is great and the number of specialized access panels needed for maintenance or repairs become excessive or unsightly. Such areas could be corridors with direct observation from the nurse station, activity rooms and group rooms.
Patient room furniture
Patient room furniture can have a reasonably residential look with only a few modifications. Beds are preferred to be platform type, without any openings or drawers below the mattress area. The mattress should meet hospital standards and be placed on a bed frame that uses a fixed, solid panel in place of a box spring.
It is strongly suggested that beds be securely anchored in place to prevent movement. That way, patients are unable to use beds to barricade doors, prop them vertically against walls to provide for ligature attachment, or stack them to use for climbing.
These beds are available in wood, which generally has a more residential look, provided that it has an appropriate finish. Finishes must resist liquids, including urine and strong cleaning agents. Beds that are assembled from multiple pieces of material (wood, plastic, etc.) must have tight, sealed joints that prevent disassembly or breakage that would allow individual parts to be used as weapons.
Other patient room furniture may also be made of wood, but must be robustly designed and constructed to prevent breakage and disassembly. Furniture may include open, non-adjustable shelves that are stoutly constructed (no accessible joints), fastened firmly in place, and free of any movable (or removable) drawers and doors.
Seating in patient rooms may consist of built-in areas with removable cushions or very lightweight movable plastic chairs. While these are less common in residences, both are preferable to bolting a stool or bench to the floor to prevent the seating from being thrown or used as a weapon. The level of concern decreases for areas where staff can better observe patients, such as activity rooms, day rooms and lounges.
In these more public locations, more conventional cabinetry may be used, but must be equipped with cabinet handles or pulls that prevent anything from being looped or tied to them. Contemporary style recessed pulls or more traditional style cup pulls may be suggested here.
Television sets in these areas can be typical flat-screen sets if they are provided with a tamper resistant enclosure. While such enclosures are not found in residences, they are fairly unobtrusive and effectively secure the electrical outlets, cords, wires, and cable TV jacks from patient access. Newer flat-screen TV sets are much easier to secure in this fashion than older, bulkier models.
Furniture in these areas also can retain a residential appearance if specially designed wood tables and seating are used. Upholstery must have hospital-level fire ratings and should be puncture-and stain-resistant. Chairs that incorporate reversible, interchangeable, and replaceable cushions are readily available and are both attractive and practical for this application.
In summary, then, in the selection of furniture for patient rooms and common areas, safety must prevail over the desire for "normal" residential appearance and function.
Keep an eye out for "trouble spots"
By eliminating as many environmental hazards as possible, well-designed, well-built behavioral health units enable staff to focus on patient treatment, rather than protection, and enable patients to focus on recovery. That's why effective facilities combine items that are routinely used in residential settings, though many other features and accessories must be different in design or functionality in order to minimize possible hazard.
Here are three good examples of places you might not think to look for potential problems, as well as some potential solutions:
1. Wall baseboards and moldings
Vinyl or rubber cove base is often used in commercial and institutional buildings, but not often in residential construction. Though common in medical settings and hospitals, these baseboard materials can pose problems due to the fact that they can be pulled loose from walls to create small hiding places for contraband. If pulled loose in longer strips, they may also be used as weapons or even ligatures.
Baseboard materials can sometimes be eliminated entirely where concrete block walls exist, but this requires a high level of workmanship by the flooring installers to ensure that a tight, continuous joint is achieved between floor and wall edges.
Homes often use wood for baseboards, door trim, and window trim, often with a clear or semi-transparent finish that allows the wood grain to be visible. These wood trim pieces can be quite thin and not attached securely. For better security, use a fairly thick (a minimum of % inch) material that is very securely attached with tamper-resistant fasteners and construction adhesive. It is further suggested that a pick-resistant sealant be installed at the top and all vertical edges to reduce the risk of patients hiding things behind the board.
Door finishes are often similar in both residences and hospitals. Semi-transparent wood finishes are common in both settings. Some hospitals use painted metal or wood doors (as do some residences) but the look of natural woods are considered by some to add "warmth" and give a more comfortable quality to the space. While synthetic wood-grain doors are also available, surfaces like these that are touched by patients are sometimes easy to identify as "fake" and therefore are not as pleasing.
2. Door hardware, knobs, hinges, seals
Door hardware is so well understood and common that it does not always attract our attention as a safety issue. Yet, door hardware is vitally important to safety and, because it's "touched" by patients, essential to the "feel" of the environment.
While the door handles and levers typically-used in residential and commercial settings are not acceptable (because they can provide ligature attachment points), there are a range of safe, lever-handle locksets available that retain a very conventional look, feel, and function.
When it comes to door hinges, touch is not a factor, but safety is again critical. Continuous hinges, sometimes referred to as piano hinges, are the preferred option in behavioral health units because their continuous, top-to-bottom design allows for normal door operation yet prevents looping or attachment of ligatures.
If smoke seals are required on patient room or corridor doors, special seals are available that look very similar to regular weather stripping, yet break into 8-inch long sections when removed to prevent them from being used as ligatures.
3. Windows and window shades
Windows and window shades are another area where reasonable compromises between residential look and institutional safety may be possible. Window glass itself must be breakage-resistant, yet can retain the look of regular glass. For remodeling jobs, existing glass may be retrofitted with a security window film or an additional layer of appropriate, breakage-resistant material over the inside facing glass surface.
Curtains and shades are a little more difficult. Window curtains are now being discouraged, even when they are equipped with flush-mounted tracks and break-away attachments. It is now recommended that horizontal or vertical blinds be installed and covered with a panel of approved safety glazing to keep patients from accessing the blinds themselves.
The resulting shade can retain a very typical residential appearance, though the operating mechanism must be modified to reduce potential patient hazards. Another option is utilizing roller shades to filter or block light. Depending on the design of the shade and the needs of the patient population, these fixtures can be installed behind a clear, protective panel, or exposed to the room.
(1.) Ulrich Roger S. (1984). View through a window may influence recovery from surgery. Science, 224 (4647), 420-421.
(2.) Sine and Hunt. "Common Mistakes in Designing Psychiatric Hospitals" Al A Academy of Architecture for Health Journal September 2009
(3.) Sentinel Event Alert, The Joint Commission. ...
(4.) American Psychiatric Association, A.P., Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, American Journal of Psychiatry, 2003.160: p. 1-60
(5.) Joint Commission, Sentinel Event Statistics as of March 31, 2009. www.jointcommission.org/NR/rdonlyres/241CD6F3-6EFO-4E9C-90AD-7FEAE5EDCEA5/0/SE_Stats_3_09.pdf. Accessed June 28, 2009
(6.) Joint Commission. Accreditation Program: Behavioral Health Care. National Patient Safety Goals. www.jointcommission.org/NR/rdonlyres/DA83B449-FFB0-40B7-9516-080C2504F02D/0/BHC_NPSG.pdf Accessed June 28, 2009.
(7.) Joint Commission. Inpatient Suicides: Recommendations for Prevention. Sentinel Event Alert. November 6, 1998. www.jointcommission.org/SentinelEvents/SentinalEventAlert/sea_7.htm
James M. Hunt, AIA, NCARB, is president of Behavioral Health Facility Consulting in Topeka, Kan. Hunt is the co-author of the Design Guide for the Built Environment of Behavioral Health Facilities, which is published by the National Association of Psychiatric Health Systems and available at www.naphs.org.
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|Title Annotation:||DESIGN FOCUS|
|Author:||Hunt, James M.|
|Date:||Nov 1, 2011|
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