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Normalizing the patient environment

February 1, 2006
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Current trends in facility design aim to make inpatient psychiatric care less institutional

As society's awareness and understanding of mental health have evolved, so too have behavioral health treatments and the inpatient environments in which they are delivered. The old model of inpatient behavioral management, in which patients often were viewed as incurable and thus often confined for life, has given way to a new model. Now, structured programs are designed to rehabilitate patients within a reasonable period and return them to productive lives in the community.

This evolution has been supported by state legislation mandating shorter patient stays and greater accountability from behavioral health professionals. In turn, today's inpatient facilities are designed to create a normalizing environment that supports the new behavioral healthcare model.

The normalizing environment is a concept parallel to the healing environment supporting physical healthcare delivery. The normalizing environment is created through a holistic planning and design approach that integrates private and public spaces to support a continuum of socialization within a safe, secure campus. Among the issues driving the planning and design of today's behavioral healthcare inpatient facilities are security, patient room type, dining and recreational facilities, flexibility, and financing.

Transparent Security

The safety and security of patients, staff, and the surrounding community remain critical to the facility's mission, yet today they must be accomplished in a way that is transparent to users. This means creating an environment that feels open and visually connected to its surrounding landscape by using alternatives to traditional fortresslike security walls and fences.

Figure 1. This psychiatric facility for the state of North Carolina is designed to have only a few entrances, increasing security.

Image courtesy of Cannon Design.

Figure 2. Courtyards in a facility for the state of North Carolina allow for secure patient recreational activities and outdoor dining.

Image courtesy of Cannon Design. Security often is now achieved using limited, controlled access to a walled or fenced campus monitored with closed-circuit television (CCTV). There are generally just two or three entrances: one for staff and visitors, one for patient admissions, and perhaps a third for materials management. Similarly, individual buildings have limited, controlled access and CCTV monitoring. Inside, however, the environment is predominantly open, with a few high-security exceptions, such as areas serving forensics, pretrial patients, and adolescent patients.

Reflecting these concepts, three prototype campuses of various sizes were developed for the state of North Carolina (figure 1). The largest, a 432-bed facility under construction in Butner (scheduled to open in the summer of 2007), will have just two entrances to the campus, with three building access points: public/visitor, patient admissions, and materials management. In contrast, the former Raleigh campus was half the size and had 26 entrances.

Private Versus Semiprivate Bedrooms

The ongoing debate between experts favoring private patient bedrooms versus those favoring semiprivate rooms is based on differing philosophies of which facility model better supports rehabilitation—one that offers opportunities for solitude as well as interaction, or one that discourages isolation.

Each treatment philosophy can be supported effectively with sensitive facility design. For example, the North Carolina prototypes will have in each unit 22 private bedrooms of approximately 130 square feet, with private in-room full baths, and 2 semiprivate rooms of 220 square feet, also with in-room full baths. In contrast, a new 156-bed facility under construction for Essex County, New Jersey (in the Newark suburb of Cedar Grove), will have a mix of four 130-square-foot private rooms and ten 185-square-foot semiprivate rooms in a unit, each with an in-room full bath. All the facilities will have secure, fixed furniture and large, vented, yet secure windows.

The Dining Experience

Two major trends in patient dining facilities reflect treatment approaches, as well as facility size and staffing concerns. In the Essex County facility, a dining room will be included within each of the six patient living units to maintain the small community environment and associated relationships, as well as continuity of staff supervision. Patients will eat within their units, leaving after breakfast for their morning treatment and activity programs, returning for lunch, and so on until they return again for dinner. Meals will be prepared in the central kitchen, distributed to each unit via elevator, and served on trays. Patients will be engaged in setting tables and cleaning up.

The large North Carolina facility, however, will function more efficiently in providing all patient meals from three centralized dining facilities. Each is designed around a different theme and type of food service, including a small cafeteria with tray service and a grill/café that will offer meal choices at several serving stations. The dining experience will support individual treatment programs, as patients will be assigned to the dining facility deemed most appropriate to their capabilities at each phase of treatment.