There are countless factors to be considered in product selection to create warm, inviting, and comfortable healthcare spaces for patients and staff. Those concerns can range from ease of use to infection control to maintainability. But when designing for behavioral health settings, further consideration needs to be paid to durability and safety measures that aren’t required in most other healthcare settings.

Patients at behavioral health facilities can have a variety of issues and be prone to violence and suicide. They’re at risk of harming themselves or others, including other patients and staff members.

Therefore, it’s essential to make determinations about every aspect of building design and maintenance based on the potential risk. For example, coat hooks, grab bars, toilets, showerheads, or wardrobes need to be anti-ligature to prevent patients from trying to hang themselves. Furniture needs to be secured in place so it can’t be thrown or moved to block doorways, and must be free of sharp points, screws, and hidden pieces of wood that can be turned into weapons. Even maintenance items such as plastic trash liners can become a suffocation hazard for suicide-risk patients.

In addition to safety, durability features are another concern. Beyond regular wear and tear, behavioral health patients might actively try to destroy furniture or finishes by slamming doors, kicking walls, throwing furniture, and puncturing fabrics.

To further understand the design considerations for this specialized population, it’s important to collaborate with staff members who specialize in behavioral health, since they know their patients best and will see things from a different point of view.

“I expect to be immersed in the decision-making process when altered or new products are added to the patient care milieu,” says Vareen O'Keefe-Domaleski, Vice-President Patient Care Services and Chief Nursing Officer at Bradley Hospital (East Providence, R.I.). “I can feel sharp points, find ‘hidden’ holes, and see ligature points that others may not notice.” 

Once a better understanding of the safety needs and features is established, it’s time to look at specific products for behavioral health facilities. Here are some options and the design considerations to be made for each.

Furniture and fabrics

Finding furniture that’s less institutional-looking without compromising safety can be challenging. Working with facility managers and clinical staff early in the selection process to test furniture is critical, in order to compare actual performance to the manufacturer’s product literature.

Furniture assembly is paramount in the decision-making process. Furniture must be durable and easy to clean, and be free of parts that patients can easily remove. Sharp edges or ligature points must be avoided, and all furniture should be free of nails. Only tamper-resistant screws can be used, and all bottoms of upholstered furniture must be sealed.

Since behavioral health patients tend to be more abusive to furniture than other patients, look for fabrics that surpass 500,000 double rubs in a Wyzenbeek Abrasion Resistant test, which looks at a fabric's ability to withstand surface wear from rubbing a piece of  #10 cotton duck fabric.

Other important considerations are fabrics that are ink-resistant or “graffiti free” and have moisture barriers that can stop liquid and stains on the surface. 

Depending upon patient acuity levels, chairs with sled bases are preferred to those with four legs, since legs can be removed and used as weapons. Loose furniture must be heavy enough to help prevent patients from throwing it. Attached cushions without crevices are best to keep patients from hiding contraband in or under them.

Springs, too, can be harmful if removed by a patient, so chairs that don’t contain springs as part of their construction, such as molded furniture, are ideal. Soft upholstered foam furniture must not have any plywood pieces hidden inside.

Furniture should also be free of exterior tags to prevent patients from hurting someone if a piece is tossed, and metal vents should be removed, since they can be used to inflict bodily harm.

Edging details for counters and tables should be reviewed to ensure that materials cannot be easily removed. One-piece molded edging is preferred over plastic laminate self-edging, which can be very sharp if removed. Solid surface material with bullnosed edges is a great option for horizontal surfaces, including nurses’ stations and built-in desks. 

In the patient rooms, built-in wardrobes or bookcases should have sloped tops to deter ligature. Some facilities may prefer open units with fixed shelves over drawers and doors, or consider limiting wardrobes to a height of 36 inches to avoid them being used as ladders. Platform beds with antimicrobial wear layers and mattresses containing ballistic materials to prevent rips are available. If desirable, beds can be secured to floors to prevent them from being moved and edges can be sealed with tamper-resistant sealant so liquids or contraband can’t be put underneath.

Electronics such as TVs, tablets, and computers should be properly protected with tamper-proof clear resin. Special cases are available, but their institutional look makes custom built-ins more appealing.

Ceilings and flooring

Sound control and noise mitigation are critical components of comfort and privacy in a health environment, and ceiling and flooring products play a big role in addressing these issues.

Acoustical ceilings are designed to address sound absorption and sound attenuation (blocking), but in a behavioral health setting, specific safety considerations need to be taken into account, such as acuity of patients, level of supervision, and the height of the ceilings. For instance, patients have been known to chew and swallow fiberglass ceiling tiles, fashion weapons out of metal ceiling grids, and hide contraband in ceiling plenums.

Conventional ceiling tiles can work if it’s a highly supervised area with low-acuity patients. When greater security is needed, security/tamper-proof acoustical metal ceilings are an option.

Specifying cushioned-back, resilient flooring can also help to dampen sound reverberation. For example, Brattleboro Retreat (Brattleboro, Vt.) installed both security acoustical ceilings and cushioned-back resilient flooring to help quiet existing spaces. “Patients have responded to the calming effect of the muffled sounds and soothing colors,” says Eileen Glover, Brattleboro Retreat’s clinical manager of the lesbian, gay, bisexual, transgender adult in-patient unit.\

In addition to acoustical properties, flooring surfaces need to stand up to contact with food, water, or bodily fluids, and should be slip resistant and easy to clean. Seamless, antimicrobial resilient flooring with a cushioned back is an option for patient areas. This flooring comes in a variety of styles, colors, and patterns, and many manufacturers recommend using a two-part structural urethane adhesive for in
stallation, which takes longer to cure but helps prevent dents in the soft floor. It also provides an impact-resistant bond with high peel strength, which reduces the chance of patients ripping up the flooring.

To make a space feel cozier while maintaining a safe environment, designers can also consider a combination of flooring designs, such as colored resilient flooring within a wood-grain style to create the look of an area rug.

Striking a balance

Finding the right combination of durable finishes and furniture without sacrificing comfort and appeal is an ongoing challenge. Fortunately, more products that address this issue are being introduced to the market. Meanwhile, through collaboration with clients and healthcare providers, designers can continue to educate themselves on how to make behavioral health spaces safer and more hospitable.

Lilliana Alvarado is a senior member of the healthcare interior design group at Lavallee Brensinger Architects (Manchester, N.H.). She can be reached at lilliana.alvarado@lbpa.com.