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A therapeutic approach to preventing self-harm

November 15, 2011
by James M. Hunt
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Designers identify more options that foster home-like environments without compromising patient safety

The focus on suicide prevention and patient safety in behavioral health treatment environments has led designers to include more elements that could be seen as “institutional,” or even “prison like.” Yet, designers know that more patient-centered designs can have a positive effect on a patient's self-perception, sense of well being, and healing. 

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 hospitals' 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.