Designing Spaces for Behavioral and Mental Health Treatment
Ease of Wayfinding and Circulation Cues
Wayfinding helps patients and visitors navigate a facility with minimal assistance and no confusion. Flooring color can identify room types and patterns to guide people toward their destination.
According to the VA design guide for behavioral and mental health facilities, “Design can support elements by using color to identify program areas. For example, a consistent color can identify all staff off-stage areas. Patient units can be identified by distinct and different color palettes. Group Rooms may be identified with consistent color.”31
FGI Guidelines speak to pattern and color contrast research. Patterns and contrast research suggest that flooring with a medium-sized pattern (1 to 6 inches wide, or 2.54 to 15.24 centimeters wide) was associated with more falls than floors with no design or a small pattern (less than 1 inch wide, or 2.54 centimeters wide), or a large pattern (wider than 6 inches). High-contrast patterns with large geometric or swirling designs on floor surfaces have been associated with more patient falls. These patterns can distract and potentially confuse persons with visual acuity issues.
Minimal Contrast Between Types of Flooring
In the United States, 8 percent of the population (26.M), and 1:5 who are over sixty-five are visually impaired. Similar values between different flooring materials help minimize transitions between different types of flooring and may reduce fall risk. Smooth transitions should be provided between different flooring materials. Flush thresholds should be used to reduce tripping hazards. Some flooring types, such as resilient flooring (e.g., rubber, luxury vinyl tile, sheet vinyl) and carpet, should include transition strips that minimize trip hazards.
Slip Resistance
The slip-resistance ratings of flooring surfaces should be appropriate for the area of use—for dry or wet conditions and use on ramps and slopes.
According to FGI 2022 Guidelines for Design & Construction of Hospitals: Wet conditions are common in areas such as kitchens and bathing areas, entries from exterior to interior space, and areas where water is used for patient services. Slip resistance is also an important consideration for ramps and stairways. In dry areas, soft flooring (e.g., carpet, cushioned flooring) can reduce the risk of falls and the impact of associated injuries.
Compatible with Wheeled Devices
Floor surfaces should allow easy movement of all wheeled equipment in the facility. Portable lifting equipment without powered wheels may require more exertion by staff than ceiling-mounted equipment to move an elevated patient around and through a space. The exertion required by staff may increase with the use of carpet; however, different types and brands of carpet may have significantly different levels of resistance to wheeled devices. Installation of a mock-up to test hybrid flooring materials with wheeled equipment and devices used in a facility is recommended. Carpet should not be automatically discounted as inappropriate due to this challenge, as it has significant advantages over hard-surface flooring in terms of noise reduction and acoustics.
Floor Reflectivity and Glare
Finished floors with a high gloss value cause glare that may compromise patient vision by being misinterpreted as a pool of water on the floor or a hole in the floor surface, disrupting the balance. The use of no floor finish flooring eliminates glare. Where a floor finish is required, smooth flooring surfaces should be sealed with a matte finish to reduce surface glare. A minimum LRV of 30 is recommended between floors and walls (wall bases should match the walls) to help define the space.
Sound Attenuation (Reduce Impact Sound)
Reducing impact sound requires specifying the right product for the right space. Acoustic floors should be selected with consideration of sound reduction properties to help preserve sleep and to protect privacy and accuracy of communication in support of HIPAA compliance and medical error reduction.
According to the Veterans Administration’s “Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities”:32
A mental health facility requires special attention to sound control. Acoustic isolation shall be provided from the units to other areas in the hospital and inside each patient and resident room to preserve privacy/confidentiality and to reduce excessive noise. Excessive noise can negatively impact a therapeutic environment for the patient/resident and the staff. It may affect one’s ability to hear or be heard in a normal speaking tone, which detracts from a calm, nonthreatening environment. Excessive noise may heighten some patients’ fear and anxiety levels.
Impact Resistance and Durability
Patients in behavioral and mental health settings may become violent. Such incidents potentially cause more impact on flooring in these spaces than in traditional healthcare settings. This calls for the highest level of impact-resistant and durable flooring.
Durability Considerations for Spaces in Continual Use
Flooring that does not need to be stripped, waxed, and recoated is most beneficial for a BMH center. The noise associated with maintenance protocol could negatively impact the serene ambiance at the heart of healing. Even more disruptions occur if the flooring needs replacing. A no-finish floor and durable flooring sustain the rigor of the setting, reduce the associated person-hours to maintain, and mitigate noise.
CONCLUSION
A debt of gratitude is owed to architects, designers, and care centers for normalizing the patient experience in behavioral and mental healthcare settings.
The VA Design Guide Mental Health Facilities Design Guide identifies key criteria in the selection of interior finishes, and those also apply to flooring selection, such as aesthetic value, therapeutic attributes, maintainability, durability, infection control sustainability, and safety and security.
The Advisory Board notes that inequities in behavioral healthcare impact the financial outcomes of healthcare organizations. Despite high and growing demand, access to reliable behavioral health services is challenging. Provider shortages, stigma, and limited reimbursement create significant barriers to timely, cost-effective behavioral healthcare.
They go on to share that improving behavioral health has the potential to significantly improve clinical outcomes and healthcare costs. Behavioral health conditions are prevalent. Approximately 70 percent of patients with a behavioral health condition have a medical comorbidity. Additionally, “deaths of despair” (from alcohol, drugs, or suicide) have more than doubled since 1999. Despite the prevalence of behavioral health conditions, they often go untreated. Less than half of patients receive treatment.
By many accounts, behavioral and mental healthcare and acuity levels continue to increase. Mental health experts interviewed by Forbes33 listed some areas of increase: social media-induced anxiety, work burnout, eating disorders, and neurodivergent conditions affecting mental health. For NAMI, the National Alliance on Mental Illness, three future goals34 stand out: 1) To help people get help sooner, 2) to help them get the best care possible, and 3) to detach mental healthcare needs from law enforcement. All signs point to an overarching need for more spaces for those with mental and behavioral health challenges and those who care for them. This is why the floor matters: as a foundation for therapeutic care that allows patients to heal and transition back to whole, healthy lives in a society that supports their healing.
ENDNOTES
1“Behavioral Health: Cheat Sheet.” Advisory Board. 6 May 2020. Web. 27 September 2023.
2“Treatment Settings.” National Alliance on Mental Health. Web. 27 September 2023.
3Card, A., Taylor, E., Piatkowski, M. “Design for Behavioral and Mental Health: More Than Just Safety.” The Center for Health Design. 2018. Web. 27 Sept. 2023.
4“Behavioral & Mental Health.” The Center for Health Design. Web. 27 September 2023.
5Card, A., Taylor, E., Piatkowski, M. “Design for Behavioral and Mental Health: More Than Just Safety.” The Center for Health Design. 2018. Web. 27 Sept. 2023.
6“About Us.” The Center for Health Design. Web. 27 September 2023.
7,8“Safety Risk Assessment Tool.“ The Center for Health Design. 2014, 2017. Web. 27 September 2023.
9,10McMurray, K.N. “Behavioral Health Design Guide.” January 2022. Web. 27 September 2023.
11Abushusheh, Addie, Taylor, Ellen. “Memory Care: The Intersection of Aging and Mental Health.” The Center for Health Design. January 2020. Web. 27 September 2023.
12Browning, William; Ryan, Catherine; Clancy, Joseph. “14 Patterns of Biophilic Design.” Terrapin Bright Green. 2014. Web. 27 September 2023.
13Grinde B, Patil GG. “Biophilia: does visual contact with nature impact on health and well-being?” International Journal of Environmental Research and Public Health. 6 September 2009. Web. 27 September 2023.
14Browning, William, Ryan, Catherine, Clancy, Joseph. “14 Patterns of Biophilic Design.” Terrapin Bright Green. 2014. Web. 27 September 2023.
15Piche, Mary-Ellen, Luna, Gina. “Designing an Evidence-Based Healing Environment.” American College of Healthcare Executives. Web. 27 September 2023.
16Johnson J., Hall L.H., Berzins K., Baker J., Melling K., Thompson C. “Mental healthcare staff well-being and burnout: A narrative review of trends, causes, implications, and recommendations for future interventions. International Journal of Mental Health Nursing. 2018. Web. 27 September 2023.
17Shanafelt T.D., Balch C.M., Bechamps G.J., Russell T., Dyrbye L., Satele D., Collicott P., Novotny P.J., Sloan J., Freischlag J.A. “Burnout and career satisfaction among American surgeons.” Annals of Surgery. 2009 Web. 27 September 2023.
18Nanda, U., Malone, E., and Joseph, A. ). Achieving EBD Goals through Flooring Selection & Design.” 2012. The Center for Health Design. Web. 27 September 2023.
19Florence CS, Bergen G, Atherly A, Burns ER, Stevens JA, Drake C. “Medical Costs of Fatal and Nonfatal Falls in Older Adults.” Journal of the American Geriatrics Society. March 2018. Web. 27 September 2023.
20“Promoting Patient Safety.” Patient Safety Network. Web. 27 September 2023.
21Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J., Seo, H. B., Choi, Y. S., ... & Joseph, A. 2008. “A review of the research literature on evidence-based healthcare design.” HERD: Health Environments Research & Design Journal. 2008. Web. 27 September 2023.
22Bae, S., & Fabry, D. (2014). “Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review.” Nursing Outlook. March-April 2014. Web. 27 September 2023. < https://pubmed.ncbi.nlm.nih.gov/24345613/>
23Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. “Nurses’ work schedule characteristics, nurse staffing, and patient mortality.” Nursing Research. January-February 2011. Web. 27 September 2023.
24,25“Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.” U.S. Department of Veterans Affairs. January 2021. Web. 27 September 2023.
26“Healthy Flooring.” Healthcare Without Harm.” Web. 27 Sept. 2023.
27“Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.” U.S. Department of Veterans Affairs. January 2021. Web. 27 September 2023.
28Harris, D. D., & Detke, L. A. (2013). The role of flooring as a design element affecting patient and healthcare worker safety. HERD: Health Environments Research & Design Journal, 6(3), 95-119.
29Moussatche, H., & Languel, J. (2002). Life cycle costing of interior materials for Florida’s schools. Journal of Interior Design, 28(2), 37-49.
30,31,32“Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.” U.S. Department of Veterans Affairs. January 2021. Web. 27 September 2023. <
33Butkovic, Marija. “6 Experts Weight In On The Present And The Future Of Mental Health.” Forbes. 11 July 2022. Web. 27 September 2023.
34“A Bridge Between Our Rich History and Future Opportunities.” National Alliance on Mental Illness. Web. 27 September 2023. https://nami.org/NAMInet/Board-of-Directors/Governance-Documents/NAMIStrategicPlan2020
Sandra Soraci EDAC, LEED AP, NCIDQ, is the Director of Healthcare and Senior Living Segment Strategy, for Tarkett NA. Sandra’s diverse and deep career-specific focus on healthcare and commercialization efforts fully informs the customer decision-making journey. Flooring is no longer a design feature, it is an investment in health and safety, and we all have a stake in improving outcomes for our customers. Healthy environments support the healing process, and that begins at the ground level, with the floor. Through an evidence-based design lens, Tarkett Flooring continually seeks to create flooring solutions that contribute to greater connection, safety, and overall well-being. Healthcare is ever-changing; my passion is to educate, elevate, and transform sales enablement to fully support what our healthcare customers tell us they need the floor to do.
Kathy Price-Robinson is a nationally known writer focusing on building and architecture. Her award-winning remodeling series ran 13 years in the Los Angeles Times. She has written for dozens of publications in the design and building industry and developed more than 100 continuing education.