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Deinstitutionalizing design

January 1, 2011
by Joseph Doherty, A.I.A., LEED AP and Jon E. Sell
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Strategies to design a more residential environment for psychiatric patients
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Leading behavioral health organizations are turning to innovative space planning, architectural and interior design strategies to deinstitutionalize facilities and meet the needs of distinct patient populations. Merging best practices in behavioral health treatment with best practices in design, the industry is moving away from conventional design approaches to create hospital facilities with a more residential environment. 

Rethinking layout and architecture

Many older psychiatric facilities feature double-loaded corridors lined with patient bedrooms, glass-enclosed central nurses' stations, and small enclosed day rooms. While such layouts ensured efficient use of space and staff security, they often resulted in obstructed sight-lines from the nurses' stations.

Combined with long-established approaches to architecture and interior design, it contributed to a very institutional environment, with few of the physical or psychological comforts of home. In addition, this approach did not offer much flexibility in terms of adapting the spaces to changes in patient demographics.

Progressive clinical and administrative leaders and patients' families seek a different type of environment-one with a more residential feel, which supports contemporary best practices in behavioral health treatment for distinct patient populations-and they recognize the value of the investment required to provide this enhanced environment.

Many psychiatric healthcare organizations understand how built environments can impact patients and have begun to incorporate residential elements into their designs. However, for these designs to be effective, an internal cultural change must occur-allowing the staff to be comfortable emerging from the traditionally enclosed nurses' stations and work in a more open environment.

A safe, secure environment

Overall, architectural and interior design must contribute to creating a safe, secure environment for patients, visitors and staff. Decentralized nursing stations or satellite nursing stations are one way to enable staff to be more involved in day-to-day activity on a unit and better able to observe potentially hazardous behavior. “Opening up” nurses' stations, perhaps by removing the glass or by utilizing frame-free glazing panels, can help increase interaction between the staff and their patients (see Figure 1).

Recesses in corridors around support spaces can create a safety hazard by providing patients places to hide. Such hazards are an outgrowth of a facility design that features many small rooms, each with a door, a design that also requires more corridor space. Instead, one can arrange rooms otherwise and lay out spaces to avoid these hazards and cluster support spaces with access through a “staff only” corridor.

Elimination of dead ends, blind corners, and recesses, no matter how insignificant they might appear, is also important to patient and staff safety in patients' bedrooms. For example, in contrast to the design prevalent in acute-care hospitals-featuring an inboard bathroom located just inside the door of the patient bedroom-a better design for a behavioral health facility positions two bathrooms back-to-back between two bedrooms. This design “squares” the shape of each bedroom and ensures that the entire patient room is visible upon entry.

Walls may be used to “fill in” spaces that might otherwise occur (between wardrobes and other casework) to eliminate potential hiding spaces. When fewer option are available (as in the case of renovation) closed-circuit cameras can be installed instead.

Facility safety can be increased through other design features as well, including the use of outward-swinging patient-room doors and by securing movable furniture items. Using damage-resistant materials and finishes can also avoid creating potential hazards. For example, solid surface materials or solid composite panels are more resistant to breakage and abuse, as opposed to laminates, which have layers that can be pulled apart into sharp pieces.

Three zones of risk

A best practices approach to design of a behavioral health unit considers three zones of risk: public, supervised patient treatment/activity, and patient solitude zones (see Figure 2).

Because the public zone is rarely accessible to patients, the need for patient-related security and anti-ligature measures is usually minimal. Finishes and furnishings selected for the public zone can be similar to those of a hospitality lobby. One exception to this guideline is toilet rooms that are accessible to patients before or during the admissions process. Special attention should be given to the design of these toilet rooms to ensure patient safety.

Supervised patient treatment/activity zones comprise all areas in which patients receive treatment and participate in staff-supervised daily activities. While the finishes and furnishings in this zone must be safe and durable, they can be selected with the knowledge that staff supervision and visibility generally help to reduce patients' risk of self-harm.

Patient solitude zones refer to those areas where patients may be alone and unsupervised-typically each patient's bedroom and bathroom. Because of the higher risk of self-harm, room finishes and furnishings need to be carefully selected for durability, damage resistance and safety. Consideration starts with the ceiling, which must be monolithic, seamlessly incorporating security lighting, heating and cooling, and sprinkler fixtures. The furniture must be durable, free of sharp edges and corners, and should be securely fastened to the walls.