Dr. Karlin is affiliated with Psychology Service, Veterans Affairs (VA) Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304 (e-mail: firstname.lastname@example.org). Dr. Zeiss is with the Office of Academic Affiliations, VA Central Office, Washington, D.C. William M. Glazer, M.D., is editor of this column.
Over the past 50 years there has been growing recognition and discussion of the impact of the psychiatric hospital environment on psychiatric patients, stimulated by the early work of Sommer and Ross (1). Empirical research on the effects of environmental factors in inpatient psychiatric settings is still in its infancy; there have been few studies using sophisticated experimental approaches or well-controlled designs. Nevertheless, numerous anecdotal reports and clinical conjecture, as well as a gradually increasing body of empirical data, address the significant therapeutic value of ward environment on psychiatric inpatients. [A bibliography is available in an online supplement to this column at ps.psychiatryonline.org.]
In this column we identify best practices in psychiatric hospital design, synthesizing important findings and themes reported in the extant literature and drawing on our firsthand experience in a consensus exercise to design a new inpatient psychiatry building with four 20-bed units at the Veterans Affairs (VA) Palo Alto Health Care System that will be completed by January 2009. We were active members of the design team and provided extensive clinical input to the design process. The design team followed an interdisciplinary team model and included internal representatives from various departments as well as architects contracted to lead the design process. This review was adopted as a major guiding document by the architectural firm and design team and has subsequently been incorporated into design efforts at other VA facilities. [Design plans for the new hospital are available in an online supplement to this column at ps.psychiatryonline.org.]
The review was conducted by surveying relevant research in MEDLINE, PsycINFO, and the associated literature, including Internet-based sources. Included were articles, reports, and empirical studies identifying salient environmental and therapeutic issues in psychiatric hospital design and patient care, as well as relevant research in related health care settings. The review identified important environmental issues, considerations, and recommendations across multiple domains that have potential for enhancing patient care and staff functioning. Findings are classified into the following five categories, consistent with those described by Harris and colleagues (2) for general hospital settings: ambient features, architectural features, interior design features, social features, and specific issues. The final category addresses issues highlighted in the extant literature that had particular significance in the design process at the VA Palo Alto.
Ambient features include attention to lighting, air quality, and noise. For lighting, soft, indirect, and pervasive or full-spectrum lighting are generally recommended. Spotlight-type recessed lighting should be used sparingly and carefully placed, so as not to focus directly on individuals. Ample natural daylight has been recommended by many authors and is highly valued by patients. Sunlight in patient rooms can promote recovery of psychiatric patients with severe depression. Also, good air quality—with fresh air, good ventilation, and neutral odors—is recommended, as it can facilitate recovery. In addition, highly reverberant spaces should be avoided.
Architectural features are the relatively permanent aspects of the hospital environment, which include the physical plan, layout, size, and shape of the units. Single or nondormitory-style patient rooms enhance privacy and autonomy and, in some cases, may promote participation in treatment activities. Private visiting areas increase privacy and intimacy.
Numerous authors have identified multiple windows with views of nature as a valuable design feature. Views of nature can reduce psychological distress and recovery time and enhance staff functioning and job satisfaction. Large, low windows may improve sensory abilities and reduce delirium and paranoia. Laminated safety glass in group rooms can open up the interior and provide a visual connection to the outside. Outdoor gardens and other elements of nature can serve as "positive distractions." Exposure to nature reduces stress and fatigue and may facilitate recovery. Furthermore, access to nature has been identified by consumers as a priority design factor in general health care environments.
Long, echoic corridors are discouraged by environmental psychologists because of perceptual distortions experienced by some psychiatric patients. Incorporating spatial flexibility into the design process (for example, installing flexible dividers for larger areas) allows for maximal use of available space. The proximity of seclusion rooms to nursing stations should be carefully considered. Close proximity may promote safety but may raise concerns over disruption, whereas greater distance may reduce environmental disruption but decrease staff responsiveness and available staffing resources. In the VA Palo Alto design process, a balance was achieved by locating seclusion rooms near and within sight of nursing stations but outside of main patient corridors and activity areas.
The presence of a staff lounge, garden, or similar congregate space can improve morale and job satisfaction and encourage professional communication. Space for incorporating new technology as it develops should be included in the architectural design. Unit design should encourage family participation and group activities by, for example, having sufficient group meeting space.
Interior design features are the less permanent aspects of the hospital environment. Planning for interior design should take into account the unit's symbolic meaning or the set of messages that the environment sends to its users. For example, having a clearly identifiable reception area and a method of greeting patients and visitors reflects customer service values and patient centeredness. Especially important in this regard is that interior design reinforces treatment goals and positive expectations of patients and staff. Davis and colleagues (3) describe the "physical ethos of the ward" as a "latent message" of expectations for improvement. An empirical investigation examining the effects of remodeling of two psychiatric wards found that remodeling improved patient satisfaction, self-image, and behavior, as well as staff mood and punctuality (4).
Furnishings. One of the most consistent recommendations in the body of literature on psychiatric hospital design is the importance of reducing the institutional feel of the facility and incorporating a homelike environment whenever possible. This type of atmosphere has been associated with enhanced emotional and intellectual well-being and improved patient behavior. Medical staff have also been noted to prefer noninstitutional environments.
Familiarity. Patient rooms should have a familiar tone. Research reveals that people prefer familiar rooms over decorative or stylish rooms. Upholstered furniture should be included whenever feasible. Although furniture can be used as a weapon and should not be easy to lift or throw, it should not be too heavy to allow for easy movement. Flexible design for interchanging pieces and resistance to damage are also important. Artwork (soothing, not exciting) is recommended. Images of nature can reduce anxiety. Some authors have suggested installing carpeting to enhance comfort and appearance, although this must be balanced against the likelihood of soiling. Above all, the decision to install carpeting should be made in consultation with nursing and housekeeping staff.
Color. Several authors have suggested incorporating color in the interior design. Studies of wall color choice have yielded inconsistent results. However, there are some fairly consistent general recommendations. First, monochromatic, bland color schemes and fashionable or trendy palettes or pastels should be avoided. Brighter colors may be preferred for patients with depression and some older adults, but they could be overstimulating for highly agitated patients. Second, warm blue tones often have a soothing or sedating effect, presumably because of their shorter wavelengths, and they may be particularly suitable for the calmest areas. Using closely related colors of the same value and intensity also has been reported to have a calming effect. Third, blue-green colors can have a negative effect on mood for patients with depression and less energy. And finally, seclusion room walls should be a "calm, but definitive color, not white or gray" (5).
Other interior design considerations. Unit design must accommodate the competing goals of stimulating patients who are withdrawn and depressed without overstimulating patients who are manic and agitated, while simultaneously fostering a sense of optimism about hospitalization.
Different functional areas may be differentiated through color, lighting, carpeting, wall graphics, and furnishings.
Inclusion of natural plants has been recommended by several authors and has been found to be preferred by staff. Devlin (6) found that the addition of plants was the feature rated most positively overall in his investigation of the redesign of multiple psychiatric units.
To promote safety, shatterproof windows, breakaway curtain rods, tamper-proof electrical outlets, stainless-steel mirrors, and lockable water taps are recommended. Avoiding the construction of blind corners is also recommended. Furthermore, natural wood veneer has been used to soften the look of doors, hallway rails, and nursing stations. Finally, several authors recommend against having highly polished floors or other reflecting surfaces because of glare.
Patients should have the ability to control their level of social contact. Designing spaces where patients can retreat, including spaces where they can form social relationships, is recommended. Areas prone to overcrowding should be avoided. Privacy may increase environmental satisfaction and place attachment. Day rooms should be open and flexible and encourage interaction with staff, while also allowing for personal autonomy. There is some evidence that small-group circular arrangement of furniture may promote socialization.
Open versus closed nursing stations. Open nursing stations have been recommended by several sources. Edwards and Hults (7) found significant positive psychological, behavioral, and social effects after the removal of glass partitions from psychiatric unit nursing stations at a VA hospital. Patient requests of nurses at nursing stations were dramatically reduced, as were negative beliefs of patients. Improvements in ward milieu and patient-staff communication were also noted. Closed nursing stations, which were more typical before the development of psychoactive drugs, often convey an image of staff inaccessibility and are not welcoming to patients and visitors.
Available reports of experiences with open nursing stations do not support concerns of patient abuse of increased access to nurses, although additional empirical research on this issue is needed. Contiguous, secure space, closed to patients, is recommended to maintain confidentiality of patient records.
Special considerations with older patients. There are unique issues and recommendations for designing facilities for older psychiatric patients, which were incorporated into the design of a geropsychiatric unit at the VA Palo Alto. Because of the decline in selective attention in late life and reduced stimulation among many older patients, it is especially important that moderate environmental stimulation be provided to older adults in careful balance. Glare and noise are particularly aggravating environmental factors, especially for those with sensory or cognitive impairment. Moreover, high levels of illumination are needed for older patients, particularly those with dementia. Low levels of light not only decrease visibility but can also promote agitation. In a study examining the effects of intra-institutional relocation on older long-term care residents, residents identified brighter lights as positive changes (8).
Pictures of familiar images and eras and a familiar dining experience can stimulate memory and enhance meaning and adjustment among older patients. Opportunities for exercise or other physical activity may also enhance personal well-being and provide energy outlets to reduce negative behaviors associated with dementia.
Furthermore, shorter corridors are easier for older patients to navigate and limit reverberation. Sufficient visual cues can promote orientation and reduce wandering. Suicide-proof (enclosed bottom) handrails and grab bars throughout the facility are particularly needed with older patients to promote balance and mobility. In addition, chairs (and commodes) should have sufficient height and arm length as well as adequate back support in order to facilitate balance when rising. It is also important that bathrooms be large enough to accommodate wheelchairs and care attendants. Finally, increasing the visibility of toilets may reduce incontinence among older patients with cognitive impairment.
Research findings and clinical conjecture reported over the past 50 years have indicated that the psychiatric hospital environment can play a significant, if often underrecognized, role in patient and staff functioning. High-quality care and positive clinical outcomes in inpatient psychiatric treatment necessitate a broad conceptualization of forces that lead to therapeutic changes that include attention to environmental design. Clinically informed, patient-centered design features can positively affect social, cognitive, motivational, emotional, and physical processes among patients and staff (9,10).
Our review of the research literature and experience with the design process strongly suggest an approach to design that is inclusive, dynamic, and interdisciplinary. Consultation and ongoing dialogue with internal staff, patients, and external professionals, throughout the design process (including postoccupancy, if possible) is recommended. In addition to providing a broader perspective and greater identification of salient design and patient care issues, such an approach yields important process outcomes. When given the opportunity to provide genuine input in the planning process and to feel like their opinions matter, staff members are more likely to accept realistic compromises and adapt to the final design of the facility (3,11,12).