The behavioral health setting presents some unique challenges for the door and hardware industry. Naturally, the safety and security of the patients within the setting, as well as the safety and security of medical staff, administrative staff, environmental services, visitors and family members, are the primary concerns. In recent years, the trend has also been towards helping to create a more "restorative" environment, one in which the patient can not only be protected from physical harm but can be treated in an environment that proactively contributes to the patient's improvement.
Behavioral health has transitioned into creating a restorative environment to promote health.
In trying to create a more therapeutic environment within the behavioral health setting, there is a request that we in the door and hardware industry have been hearing more frequently, one which succinctly describes the evolution of door design: "Please take the prison out of our facility." Behavioral health has traditionally been viewed as a caretaker type of industry. The prime directive has long been – not without justification – to keep patients from harming themselves; to provide enough medication to help suppress any urges to harm themselves or others; and to keep them within the facility.
Behavioral health has transitioned into creating a restorative environment to promote health, rather than a prison from which patients can't escape. The question is how does the behavioral health industry restore people to a level that allows better social interaction and a higher quality of life? And how does the door and hardware industry contribute to that mission?
Before answering that question, it is necessary to define exactly what constitutes a behavioral health setting. It can be an outpatient or inpatient setting, depending on the severity of the condition. It can be a clinic that treats both physical and mental disorders, or a facility totally dedicated to behavioral health concerns. It can be a primary hospital that offers a self-contained Alzheimer's unit. It can be a Department of Veterans’ Affairs hospital that treats returning soldiers from the effects of post traumatic stress disorder (PTSD). It can be a facility for children, adults, and/or the elderly. Ultimately, the behavioral health setting can take on a variety of forms, can serve a number of different clients, and can pose widely divergent door and hardware requirements.
Regardless of the type of behavioral health facility, two main objectives surface: safety and security will remain the top considerations; and facilities will employ a methodical, step-by-step approach to ensure that all areas of the behavioral health facility are well-protected.
Typically, the perimeter of the facility would be considered first, and then work inwards. In doing so, we would ask these questions:
- What type of security do we need for exterior entrances and egress points and who needs access? Who should be denied access?
- What building codes - local, state and federal - must we comply with (e.g., American with Disabilities Act)?
- How would emergency situations or operational goals affect the openings?
- Are there energy-efficiency considerations?
Moving from the exterior of the facility to the interior, we must make decisions on a number of elements:
- What types of egress and access must the stairwells offer?
- What level of protection/security do patient rooms require and who needs access (i.e., medical staff, dietary staff, environmental services, etc.)
The next step is to determine what type of patient population the facility is serving. Does it service children and/or adults? Does it serve the elderly? Does it serve dementia patients? Is it a facility with no access unless accompanied by hospital personnel? In answering these questions, we're looking for hardware that is appropriate for each population, from a physical strength perspective as well as mental capacity and/or patients’ ability to harm themselves.
However, as mentioned earlier, the new thrust is also to offer a more restorative environment. Years ago, it was all about simply keeping people secure. Often, that meant mag locks – a great concept because there are no moving parts, and they are hard to reach since they are typically positioned on top of the door. In addition, because they are self-contained, there were no elements that a patient could turn into a weapon, which contributed to a safer environment. Mag locks are still appropriately used for entrances that require interlocking doors.
In an effort to create a less institutional, yet safe, atmosphere, there is a wave of innovative products that also contribute to the safety aspect. One of the most promising developments has been the introduction of trim with ligature-resistant characteristics; that is, products with rounded profiles and no sharp edges which could allow a person to attach anything to the lock or lever in order to inflict bodily injury on themselves.
Just as important, manufacturers are trying to design locks that don't look like locks. The industry as a whole is trying to add an artistic and architectural flair to locking devices. In order to do so, it is first necessary for us to change our way of thinking about doors. In the behavioral health field, doors are starting to be viewed as openings rather than closings. More specifically, the door is not something to "lock in" the patient but rather an opening to a restorative and healing environment.
With that in mind, we can take some research from the evidence-based design world and apply them to the behavioral health market. We know, based on empirical data that if patients have a view of nature and natural settings, healing times are compressed. We also know that if patients can be engaged in various forms of artwork, their treatments are more successful. The question is, how do we take those concepts and apply them to door hardware – that is, how do we take a door and make it into a piece of art?
Combining art with safety and security may lead to the concept of the door within the door – or what is known as the "wicket" or barricade-resistant door. A patient door typically opens in, so if a patient goes into his or her room, closes the door and barricades it, there is typically no way to get the patient out; the wicket door solves that problem. Hospital personnel can simply take a key, open the wicket door, and gain access to extricate the patient from the room. Recent innovations also include a double swing hinge with emergency release stop, to allow the inswinging door to become outswinging, with the use of a simple tool to release the stop.
Another current trend is the change in the use of electric strikes. While they are efficient and are often used in behavioral health settings, traditional electric strikes tend to cut into the frame which means that an access point has been created. If a no-cut-in strike can be used instead – one that will go into the existing strike opening – that can be a real advantage, as it presents no visual cue to patients that there is something they can potentially utilize to harm themselves.
How else can the door and hardware industry respond to the needs of the behavioral health environment? Most every healthcare facility is under some type of noise reduction initiative. Consequently, wood doors are becoming a strong preference in behavioral health. Wood and thermally fused doors are not only highly robust and secure, they are very sound-absorbing, as well as creating a warmer, more hospitable environment. Because of these qualities, many facilities are moving away from the familiar steel doors for interior applications.
Ultimately, everything on a door is under scrutiny in a behavioral health setting, not only for improved security and safety but for better aesthetics: the doors, the door frame, the angles on the frame, the lock, even the hinges (slanted, concealed, etc.). The ultimate goal is to create an opening that is not only safe for everyone involved but one that will actually promote healing.