Designing for Safety in an Adolescent Psychiatric Unit
It has been well documented that self-harm activities are prominent among patients suffering from psychiatric disorders and that inpatient suicides have occurred with increased frequency in many psychiatric units/facilities.1,2,3 The last decade also has seen an alarming increase in the number of violence-related injuries to healthcare providers working in psychiatric facilities.4,5,6 Thus, during the design of Interior Health's new eight-bed adolescent psychiatric unit (APU) at Kelowna General Hospital in Kelowna, British Columbia, Canada, the project design team placed considerable emphasis on developing design recommendations to optimize patient safety and to minimize the effects of violence on staff.
The facility design team for this project included psychiatrists; the unit team leader; frontline staff from an adult psychiatric unit; representatives from plant maintenance, infection control, housekeeping, and laundry; an ergonomic specialist; the facility planner; and the architect and his consultants. This design development team began meeting in March 2004, with most of the design being completed by the end of June 2004 and the new unit officially opening in November 2005.
To gain insight into the desired design, members of the design team traveled to other APUs and inquired into the effective and ineffective aspects of their unit design. Focus group sessions—led by the architect and involving the members of the design team—were conducted at two to three week intervals. During these sessions the architect presented design drawings to the team members and rapidly drew new iterations as concepts were brought forward.
The facility planner, the team leader, and the ergonomic specialist provided recommendations and helped facilitate the process by assisting staff with their contributions to the drawings and asking for their solutions to safety concerns and other design problems. Between these regularly scheduled meetings, the ergonomic specialist was able to “shadow” staff members working in similar units and informally discuss their job, roles, and the types of design problems they encounter in their departments.
The ergonomic specialist also created mock-ups of certain areas so the staff could better visualize the drawings. The ergonomic specialist also conducted an extensive literature review to determine recommended design considerations, as well as an injury analysis of local psychiatric units to determine trends. The architect and planner were provided with the design implications of the information derived from this research.
Throughout this process, staff identified patient and staff safety as being their most important concern. However, it was evident that there was a significant gap in the resources available that outlined facility design considerations to enhance patient and staff safety on psychiatric units. Thus the design team embarked on a journey to develop facility design considerations to enhance patient and staff safety for all future projects in our region without compromising the homelike or therapeutic look we strive for. These design considerations included items such as breakaway curtains in the bedrooms and bathrooms, mechanical blinds in the main living area, plywood behind the drywall, and magnetic paint on one wall for patients to personalize the space without having to use bulletin boards and tacks.
This article highlights a few of these features that are designed to protect patients from self-harm and staff from violent assaults.
Care center security
There had been reports that violent patients had assaulted staff after jumping over the desk and into the care station in many of our facilities. Thus the design team wanted to protect the staff and provide optimal sightlines, while still offering a warm and inviting atmosphere for the adolescents on the unit. The outcome of this input was the provision of a security glass around the care center. This final design, drafted by the architect, was included in the tender drawings.
The finished product was a desk with custom-made security glass (figure 1). It has been very well accepted by patients, their families, and staff. In postoccupancy reviews, most thought that it was an interior design feature and did not realize it was placed there for security reasons.
The front desk at the adolescent psychiatric unit in Kelowna, British Columbia, Canada, features custom-made security glass
Door width and swing direction
Staff reported that patients have barricaded themselves in their rooms to initiate self-harm activities. In one instance, staff had to break an exterior window to assist a man who had attempted suicide and successfully barricaded his door, which only swung one way—into his room. Staff also reported that distraught and violent patients have occasionally barricaded staff in patient rooms.
From an ergonomic perspective, dual door swings are an essential design feature to limit the potential for patient and/or staff entrapment in high-risk areas, including patient rooms, seclusion rooms, interview rooms, and treatment rooms (figure 2). By ensuring that the architects specified door hardware that allowed the doors to swing in both directions (in and out of each patient room and the interview and exam rooms), the facility design made a substantial contribution to staff and patient safety. Although this request resulted in an additional Can$200 per door, if this had been requested postconstruction, it would have cost our organization approximately another Can$1,800 per door.
Dual door swings are an essential design feature to limit the potential for patient and/or staff entrapment in high-risk areas
Ceiling type and ceiling fixtures
Staff reported that patients had hidden drugs and weapons in ceiling areas and have hung themselves from pipes above the ceiling tiles. As a result, the design team recommended that the ceilings in all patient, interview, and exam rooms, and in any space not easily observable, should be constructed of inaccessible solid gypsum board with lockable access panels. Also, acoustic lay-in tile should only be permitted in staff and service areas and observable corridor spaces. It was recommended that the mechanical systems in new buildings be designed so access panels would not be required in patient rooms.
It was also deemed essential that ceiling fixtures, including smoke detectors, lights, and sprinklers, be carefully selected. Again staff reported that patients had broken off ceiling fixtures to use them as weapons, had caused extensive flooding by breaking off sprinkler heads, or had attempted to hang themselves from these fixtures. Thus the design team provided detailed specifications of what these features should look like and how they needed to be installed to limit access or tampering. The prominent criteria given to the consultants were that the fixtures had to be recessed and tamperproof and secured with tamperproof screws (figure 3). The planner also ensured that all HVAC grilles had either small perforations or mesh placed behind the grille to decrease the patients’ ability to fasten an item to the grille and hang themselves.
Ceiling fixtures had to be recessed and tamperproof and secured with tamperproof screws
Staff duress system
Another strongly recommended design consideration that Interior Health now incorporates into all new mental health areas is an effective staff duress system, which can be activated by a staff member in a potentially harmful situation. Careful selection of the system was required because in the past these systems often created false alarms, aggravating our staff to the point that they often turned the entire system off. The loud audible alarm further aggravated distraught patients. However, a silent alarm that went to a central nursing station would sometimes not be responded to if staff were not in the nursing station at the time.7
The wireless system incorporated into the APU silently identifies the exact location of the duress call and can notify nurses of the location through a pager. Each staff member also wears a pendent on a double-breakaway lanyard around his or her neck so he or she can easily report a duress call from anywhere on the unit. This system can also function as a nurse call system when required.
Staff suggested that any equipment that could be thrown or could produce glass shards when broken should have the option of being concealed and locked if needed wherever feasible throughout the unit. Thus all computer work areas, television stands, and telephones accessed by patients were protected in lockable cabinets. Figure 5 demonstrates an example of the millwork provided to house the patients’ computer workstations and the television/stereo stand.
Staff reported frequent episodes in which distraught patients punched holes in the walls and windows by either punching or throwing objects into the surface. The design team recommended that all windows and glass be shatterproof tempered glass. They also recommended that all mirrors be composed of ¼-inch polycarbonate or steel frame secured to the wall, and that mechanical blinds be placed on the windows in the main living area.
Additional safety features
Furniture in the bedrooms and bathrooms was carefully selected to incorporate breakaway rods and door openers that could not be used as a hanging apparatus and drawers that could not be easily removed. The walls were reinforced with plywood and drywall, and one wall in each room was painted with magnetic paint so the adolescents could personalize the space with pictures and posters without having to use bulletin boards and tacks.
This project has provided our organization with the opportunity to develop facility design considerations to optimize patient and staff safety in psychiatric facilities. By integrating the expertise and experience of frontline staff with information gained from injury and incident analyses and a literature review, the design team was able to provide specific safety recommendations that were successfully incorporated into the design of the eight-bed adolescent psychiatric unit. We are now in the process of formally evaluating the effectiveness of these considerations.
More thorough information on facility design considerations for psychiatric units is available through the recently published articles by Interior Health.8,9 Expanded versions of these are available upon request. Another excellent article that was sourced and aided Interior Health with developing these recommendations is “Guidelines for the Built Environment for Behavioral Health Facilities.”10HD
- Hawton K, Fagg J, Simkin S ,et al. Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. British Journal of Psychiatry 1997; 171:556-560.
- Patient Safety and Psychiatry – Recommendations to the board of trustees of the American Psychiatric Association. APA Task Force on Patient Safety 2003.
- White J. Suicide-Related Research in Canada: A Descriptive Overview. A background paper prepared for the Workshop on Suicide–Related Research 2003.
- National Collaborating Center for Nursing and Supportive Care. Violence: the short-term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. London UK:National Institute for Clinical Excellence (NICE); Feb. 2005:292.
- NSW Department of Health. Violence Risk Identification and Assessment. 2003.
- Occupational Health and Safety Agency for Healthcare in British Columbia. Violent and Aggressive Behaviour in Acute Care: A Literature Review. 2003.
- Gamble L. A Macro-Ergonomic Approach into Staff Duress, Nurse Call, and Staff to Staff Communication Systems Acquisition and Utilization in Healthcare. Proceedings of the Association of Canadian Ergonomics Conference Oct. 2006.
- Gamble L, Bryant Maclean L. Facility design considerations to reduce the violent encounters in emergency and psychiatric departments. Proceedings of the 2006 International Ergonomics Association Conference.
- Gamble L, Fowler D. Essential patient and staff safety design considerations for mental health facilities. Proceedings of the Association of Canadian Ergonomics Conference Oct. 2006.
- Sine D, Hunt J. Guidelines for the Built Environment of Behavioral Health Facilities. National Association of Psychiatry Health Systems. 2003. www.naphs.org.