The Emotional Impact of Safety

Balancing technology and psychology in design innovation

By Alison Leonard, AIA, EDAC

We see new safety features every day: metal detectors, plexiglass shields, bullet-resistant glazing, and cameras. While society expects this extra security in order to feel safe, at what point do all of these additions detract from the original design intention of the space?

Yet concept sketches and vision boards for projects never feature security cameras, social distancing parameters, exit lights, or metal detectors. Designers consider the feelings they want the space to evoke and make decisions with intention. How do we incorporate safety precautions that current events dictate buildings need without interrupting the design purpose? At what point do the security features meant to ensure a feeling of safety instead detract from our emotional health, disrupting education in schools and healing in healthcare environments? No matter the type of building, a common theme is evident — reducing stress while fostering and maintaining a sense of community.

The public expects to see security features in municipal and civic buildings and at transportation hubs. But people don’t expect to see them extensively in healthcare, worship, and educational environments. Hospitals and churches are places of hope and healing, and schools are places of learning and community gathering.

Whatever the function of the building, the psychology behind space design is an important consideration. The senses play a critical role in how the human brain interprets where you are and how the space makes you feel. The scale of a room evokes feelings of intimacy or of grandeur. Natural light provides a connection to the outdoors, while a lack of windows can cause claustrophobic conditions or the “casino effect” of losing track of time. Colors and materiality of finishes can drastically change a space from dark and serious to light and whimsical. Each of these factors creates a feeling; in these ever-changing times, feeling safe and secure is vital.

The design of healthcare spaces always presents a challenge. While the goal is to create a patient care environment for clinical success, the patient experience must also be positive and calming. Hospitals, surgery centers, and emergency rooms can be overwhelming to anyone — long hallways, crowded waiting rooms, cold and sterile procedure rooms, and confusing noises. The care team is often stretched thin, working long hours with limited resources, and patients can endure long waits. The COVID-19 pandemic has created isolated environments for patients and clinicians alike, as well as the need for more robust infection control measures. Add a patient in the throes of a mental health crisis to the situation, and the stress levels skyrocket for all involved.

Emergency rooms are not equipped to handle the influx of mental health patients needing help, and that number of patients has increased throughout the pandemic as it continues to take a toll on society’s collective mental health. Standard treatment rooms are not typically designed to provide the level of safety and security for patients in crisis who may harm themselves or who present a danger to the care team. Unfortunately, much of the stigma around mental illness keeps those who need help from seeking care until they are in crisis. Only after being evaluated in an ER will the patient potentially be transferred to a hospital better equipped for psychiatric treatment.

Psychiatric hospitals and behavioral treatment center designs must balance safety and aesthetics. The building has to address the potential for self-harm with vulnerable patients as well as protect healthcare staffers, but also consider the psychology of the built environment.

In recent years, behavioral healthcare design has evolved. Treatment models are no longer synonymous with the asylums portrayed in the film One Flew Over the Cuckoo’s Nest . New facility design employs evidencebased research, and designers have borrowed innovative European concepts to revolutionize psychiatric hospitals in the United States. They foster a normalized environment for care by incorporating key elements such as natural light, views of and access to the landscape, unique and flexible therapy spaces, and durable but homelike materials.

This specialized building type requires a “form follows function” approach to planning and design. It is essential that layouts manage safety concerns for both patient and the care team. But a thoughtful layout, program space adjacencies, and access can help mitigate safety concerns. Flexible use of space is critical when square footage is at a premium and clinical staff prefers a variety of therapy options. Flexibility is also integral because the population and its needs may change.

The approach to the building and the path to the intake area should be simple. The lobby of a mental health unit shouldn’t feel any different than that of any other hospital. A focus on hospitality and dignity, combined with staff empathy, can build trust and camaraderie between the new patient and the care team. It’s important that the intake process not add to anxiety and also vital that the patient and family feel comfortable enough to share information for the staff to complete a thorough risk assessment. Understanding the patient’s stress points is crucial for safety and security and ultimately recovery.

A design risk assessment will also steer the building design. Understanding staff operations and the clinical team’s approach to patient therapy can lead to a design that creates a collaborative healing environment. On some scale, decisions will be made about which program spaces are high-, medium-, and low-risk. High-risk areas include patient rooms, toilet rooms, and other spaces where a patient shouldn’t be left alone; medium-risk spaces have staff supervision, a group type setting, or limited access for some patients. Low-risk spaces are typically public areas, administrative areas, for staff only, and support spaces on the unit that are locked. Design decisions will be made about which spaces and risk levels will require ligatureresistant fixtures and hardened finishes. Other infection control and social distancing considerations may need to be factored in for each type of space, depending on the trajectory of COVID-19 and future pandemics.

For inpatient hospitals, the specific populations (adolescent, adult, geriatric) and acuity levels dictate the ideal number of patient rooms per unit, unit shape, and length of corridors. Design trends include open care team stations to encourage transparency between staff and patients and to facilitate communication and trust. Some staff still prefer a closed care team station for protection from potential patient violence.

Research has shown that a hybrid model between the two options may be the best solution. A direct line of sight from decentralized care team stations into patient rooms is the best practice for patient safety as well as discouraging negative behaviors and affording patients some choices and control of their personal space. Singleoccupancy rooms are typically preferred. Sometimes they can be personalized with a color preference, offer privacy for quiet meditation, and respect dignity — especially when sensitivity is needed regarding gender.

It is also important to provide areas outside the patient’s room for interaction. Large, flexible spaces for group activities are necessary, but it is also important to provide quiet areas like window seats or built-in benches along a corridor. Unique spaces for therapy like music, art, gardening, and dance allow expression. A gym provides space for much-needed exercise and activity, especially for pediatric and adolescent populations. An enclosed courtyard with views to the exterior gives patients access to fresh air as they walk on secure paths. When needed, a sensory room creates a safe space for a patient who needs to de-escalate. This innovative room, a safe alternative to moving a patient into seclusion, includes music, lighting, tactile elements, and images to meet any patient’s needs.

While material selections may vary between pediatric and adult populations, one thing that doesn’t change is the importance of patient safety. Colors and textures are essential to human-centered design, but understanding the risks associated with standard design elements in behavioral health environments is imperative. Increased infection control measures from COVID-19 can also limit the type of materials available for use.

The addition of building materials with warm wood finishes, natural textures, and colors supports a normalized environment for healing. Durable, easy-to-clean surfaces are essential, but some impact-resistant materials make it difficult to control sound levels and may require supplemental acoustical products. Continuous sheet flooring with an integral or mechanically-fastened base is best. This helps avoid wall base that can be peeled off and used as a weapon. Ceilings should be at least 9 feet high above finished floor and contiguous in high-risk areas. Products like acoustical ceiling tile in a grid should be avoided as they allow patients to hide contraband. Lighting fixtures should have lenses, be recessed where possible, and have a tunable control if possible. LED lighting that can be adjusted to the circadian rhythm is beneficial and requires less maintenance than typical lamps.

Eliminating everyday items that can be used to loop, wedge, or create a point of ligature is challenging but necessary to create a safe environment for patients at risk. In the last decade, the market has grown exponentially with safe, innovative products that are aesthetically pleasing and ligature-resistant. In past years, fixtures were stainless steel, prison-like, and sterile. Built-in furniture and millwork that include a sloped top enclosure are dependable options, in addition to the few furniture companies making off-the-shelf solutions. Products that must be selected for patient and staff security include door hardware, glazing and exterior windows, lighting and plumbing fixtures, mechanical diffusers, toilet accessories, furniture, sealants and fasteners, and interior finishes.

When we think about the role that safety and security play in the psychology of spaces, mental healthcare is different from most building types. While airports and municipal buildings make their security features noticeable enough to deter trouble, behavioral health facilities typically do their best to blend it away. To reduce stigma around mental health design, designers strive to normalize the built environment for care.

Thoughtfully designed spaces can empower patients, foster feelings of independence and dignity, and discourage some negative behaviors. Many providers are quick to build a fortress and prison-like environment, thinking that the highest level of safety and security possible is best when, in reality, a balance between the safety level and creating a healing environment promotes accountability and wellness. The extremes limit recovery and can cause patients to be defensive instead of open to new ideas and coping techniques.

To choose which types of spaces to be in (like sociopetal spaces designed to bring people together) or sociofugal spaces (designed to emphasize privacy) to dim their lighting, adjust their temperature controls, or simply open the window can foster the sense of control that a patient may need to jump-start a journey to wellness. Allowing patients the freedom of choice is a welcomed privilege.