Focusing on well-being of staff, patients + visitors with a salutogenic approach

In the United States, one in five adults and one in six youth experience a mental health illness each year, according to the National Alliance of Mental Illness. Increased societal stress rests heaviest on those already experiencing mental or behavioral health challenges. A confluence of societal factors exacerbated isolation and anxiety in the past few years, including technology supplanting person-to-person interaction, the COVID-19 pandemic and a lack of accessible and affordable support services — all against a backdrop of political conflicts, climate change and gun violence.

A healing, therapeutic environment reduces length of patient stay, allows a greater number of patients to be served by any given facility and helps address capacity issues many behavioral health facilities and providers face. Behavioral health facility designers can help in several tangible ways, by using tools and techniques of salutogenic design that increase the health and well-being of staff, patients and visitors.

This paradigm-shifting approach moves past the traditional approach of addressing factors that contribute to disease, and focuses on those evidence-based building techniques and technologies that promote health. A salutogenic approach can benefit all facilities, whether modernizing outdated buildings or designing new facilities.

Welcoming to health
From first impressions to treatment areas, communicating value through design can help contribute to a world where patients feel safe and respected as they pursue needed healthcare. The impacts of design are felt far beyond the facility, as welcoming architecture and shared spaces can help break down negative perceptions and stereotypes held by surrounding communities. No longer are behavioral health facilities the imposing, institutional “asylum on the hill.” They are beautiful, inviting spaces that visually communicate an investment in the health and well-being of the patients they serve.

Connecting to daylight and outdoors
Daylighting and outdoor access are important to healing, but more challenging in behavioral health environments for two key reasons. First, many patients take medications that make them photosensitive, thus requiring limited exposure to sunlight. Second, traditional glare control devices, such as blinds and shades, pose a ligature risk to patients in the facility. A combination of outdoor experiences allows patients to select the most comfortable environment: full sun outdoors, shaded outdoors, enclosed open-air patios or enclosed interior sunrooms. Integrally glazed motorized blinds provide glare control, while reducing ligature risk and meeting the graspability requirements of the Americans with Disabilities Act.

Central State Hospital seeks to promote circadian re-synchronization in its dayrooms through exposure to natural daylight (skylight and perimeter glazing) and artificial lighting systems (tunable lighting at smaller breakout spaces).
Copyright: © EYP, A Page Company

Circadian resynchronization through design
Human beings maintain a 24-hour circadian cycle through photoentrainment, or calibration to periods of light and dark, regulated by receptors in the eye known as intrinsically photosensitive retinal ganglion cells. Circadian disruption is correlated with psychiatric disorders including major depressive disorder, bipolar disorder, anxiety and schizophrenia. Targeted re-synchronization improves symptoms of these disorders. Exposure to both natural light through daylighting and access to the outdoors helps regulate the day-night sleep-wake cycle. Where natural lighting is insufficient, supplementation with artificial circadian lighting systems can provide targeted lighting in the correct color wavelengths to support proper sleep cycles for patients. Due to significant time spent indoors, circadian lighting in key patient spaces, such as dayrooms, can be implemented to help regulate patient sleep-wake cycles.

Addressing pathogenic concerns
In other building typologies, contagion-prevention techniques, such as permanent entryway systems in vestibules, can help prevent contaminants from entering a building. However, walk-off systems can pose a ligature risk, and vestibules are generally considered hazardous in inpatient environments due to the nature of the confined space. As a result, air control and treatment techniques internal to the building are required and include cross-contamination prevention (source separation and exhaust), MERV-13 or better filtration (as recommended by the ASHRAE epidemic task force), increased outdoor air ventilation, demand-controlled ventilation and UV treatment in cooling coils. For infection control during an outbreak or pandemic, the ability to isolate systems in specific living or treatment areas can help contain pathogens; incorporation of technologies to permit virtual meetings and simulcast events can also help the facility deliver treatment when infections are high.

 Sound transmission reduction
Loud and frequent noises in inpatient environments are disruptive to the healing environment. The Facility Guidelines Institute includes targets for spaces such as bedrooms and treatment rooms, but the current behavioral health model of care involves patients visiting many spaces daily to mirror life outside a facility. As a result, it is vital to anticipate sound levels, sound-related adjacencies and speech privacy requirements throughout the facility. While other building typologies can reduce sound transmission through proper door hardware, cam hinges pose a ligature risk, and gaskets pose both an ingestion and weaponization risk. Other strategies, such as active sound masking, may be required to provide the level of privacy recommended by FGI.

Restorative spaces and sensory overstimulation
Creating restorative spaces involves managing sensory inputs to promote positive stimuli and avoid overstimulation. While color recommendations can be highly subjective and vary by cultural context, research generally indicates utilizing lower saturation, lower contrast colors associated with calm, such as blue, and avoiding colors associated with bodily fluids or anger, such as red. Bringing nature into the space physically or through images or patterns, also known as biophilic design, has been shown to improve cognitive performance, reduce stress hormones and promote muscle relaxation. Imagery in behavioral health environments should avoid abstraction, unrealistic scales and any sense that it can be confused for a real element in the space. Olfactory comfort can be provided by reducing organic odors through easily cleanable materials and carbon air filtration. Acoustic comfort within a space is challenging due to minimal use of carpets and fabrics for cleanability and risks associated with acoustic panel ceilings; surfaces out of patient reach can be acoustically treated, such as with spray coatings, to soften the acoustic environment within a space.

Healthful materials
Proper material selection can assist with reducing known physical health symptoms and creating an environment that is precautionary for exposure to additional hazardous materials. VOCs can cause a wide range of physical symptoms from headache to nausea, dizziness, fatigue, loss of coordination and damage to the liver, kidney and central nervous systems; low-VOC materials are widely available and help reduce these impacts. Materials and components free of persistent, bioaccumulative and toxic chemicals, such as mercury, lead, cadmium and copper should be selected to avoid the impacts of long-term inpatient exposure. Material ingredient reporting standards can further assist in finding materials that have been evaluated and found to meet thresholds on the most hazardous chemicals, which can be more significant in behavioral health facilities where ingestion risk is a concern. Products without Red List, Substance of Very High Concern and Benchmark B1 hazards can help meet this criterion.

Looking to the future
Anywhere human beings live, work and interact is a space that can benefit from an open conversation about strategies to enhance mental health and well-being. Thus, salutogenic design can benefit a wide range of building typologies. The strategies here, specific to inpatient behavioral health environments, promote a welcoming, calming environment that can help reduce patient length of stay and increase throughput, while simultaneously communicating the worth, value and dignity of those coping with mental and behavioral health challenges.