Author:Sivakumar
Murugesan. Consultant :-Healthcare Project & Quality Accreditation
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 start up Psychiatric unit design
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
a.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.
b.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.
c.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.
d.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.
e.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
a.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.
b.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.
c.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.
d.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)
e.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.
f.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.
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