Chalmers Conferences, ARCH12

Towards a design theory for reducing aggression in psychiatric facilities
Roger S. Ulrich, Lennart Bogren, Stefan Lundin

Last modified: 2014-09-11

Abstract


The paper proposes a tentative theory for designing psychiatric environments to foster reduced aggression and violence. A basic premise underlying the design theory is that environmental and psycho-social stressors mediate and trigger aggression. The theory posits that aggression will be reduced if the facility has been designed with an evidence-based bundle of stress-reducing environmental characteristics that are identified and discussed. To make possible a tentative empirical evaluation of the theory, findings are described from a study that compared aggressive incidents in three Swedish psychiatric hospitals of different design. A newer hospital was evaluated as superior to both an old hospital it replaced and another comparison hospital (control) with respect to having nearly all the environmental features identified in the stress-reducing bundle of the design theory. Findings from restraint use data were consistent with the design theory prediction that aggression would be lower in the newer hospital having several stress-reducing environmental features than in either the old or control hospitals. The use of chemical and physical restraints decreased substantially in the new hospital compared to the old hospital it replaced. By contrast, restraint use increased in the control hospital that cared for comparable psychiatric patients according to similar treatment protocols during the same period. The design theory and preliminary findings suggest the possibility that providing better psychiatric buildings with design guided by the best available evidence and theory can play an important role in reducing the serious patient and staff safety problem of aggressive behavior.

Keywords


aggression; violence; psychiatric hospital; psychiatric patients; evidence-based design; stress; healthcare architecture

References


Baum, A. & Davis, G. E. (1980). Reducing the stress of high density living: An architectural intervention. Journal of Personality and Social Psychology, 38, 471-481.

Baum, A. & Valins, S. (1977). Architecture and Social Behavior: Psychological Studies of Social Density. Hillsdale, NJ: Erlbaum.

Baum, A. & Valins, S. (1979). Architectural mediation of residential density and control: Crowding and the regulation of social contact. Chapter in L. Berkowitz (Ed.), Advances in Experimental Social Psychology, Vol. 12. New York: Academic Press, 131-175.

Beauchemin, K. M. and Hays, P. (1996). Sunny hospital rooms expedite recovery from severe and refractory depressions. Journal of Affective Disorders, 40(1–2), 49–51.

Benedetti, F., Colombo, C., Barbini, B., Campori, E. & Smeraldi, E. (2001). Morning sunlight reduces length of hospitalization in bipolar depression. Journal of Affective Disorders, 62(3), 221-223.

Blomkvist, V., Eriksen, C. A., Theorell, T. Ulrich, R. S. & Rasmanis, G. (2005). Acoustics and psychosocial environment in intensive coronary care. Occupational and Environmental Medicine, 62, 132-139.

Bowers, l., Stewart, D., Papadopoulos, C., Dack, C., Ross, J., Khanom, H. & Jeffery, D. (2011). Impatient Violence and Aggression: A Literature Review. Report from the Conflict and Containment Reduction Research Programme, Institute of Psychiatry, Kings College London.

Carpman, J. R. & Grant, M. A. (1993). Design That Cares, 2nd Ed. American Hospital Association.

Chou, K. R., Lu, R. B. & Mao, W. C. (2002). Factors relevant to patient assaultive behavior and assault in acute inpatient psychiatric units in Taiwan. Archives of Psychiatric Nursing, 16(4), 187-195.

Cox, V. C., Paulus, P. B. & McCain, G. (1984). Prison crowding research: The relevance for prison housing standards and a general approach regarding crowding phenomena. American Psychologist, 39(10), 1148-1160.

Crowner, M. C., Douyon, R., Convit, A. & Volavka, J. (1991). Videotape recording of assaults on a state hospital inpatient ward. Journal of Neuropsychiatry, 3(2), 59-64.

Daffern, M. & Howells, K. (2002). Psychiatric inpatient aggression - A review of structural and functional assessment approaches. Aggression and Violent Behavior, 7(5), 477-497.

Day, K., Carreon, D. & Stump, C. (2000). The therapeutic design of environments for people with dementia: A review of the empirical research. Gerontologist, 40(4), 397-416.

Dobrohotoff, J. T. & Llewellyn-Jones, R. H. (2011). Psychogeriatric inpatient unit design: A literature review. International Psychogeriatrics, 23, 174-189.

Donnerstein, E. & Wilson, D. W. (1976). Effects of noise and perceived control on ongoing and subsequent aggressive behavior. Journal of Personality and Social Psychology, 34, 774-781.

Evans, G. W. (2003). The built environment and mental health. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 80(4), 536-555.

Green, R. G. & O’Neal, E. C. (1969). Activation of cue-elicited aggression by general arousal. Journal of Personality and Social Psychology, 11, 289-292.

Hagerman, I., Rasmanis, G., Blomkvist, V., Ulrich, R., Eriksen, C. A. & Theorell, T. (2005). Influence of intensive coronary care acoustics on the quality of care and physiological state of patients. International Journal of Cardiology, 98(2), 267-270.

Heerwagen, J. H. (1990). The psychological aspects of windows and window design. In K. H. Anthony, J. Choi, and B. Orland (Eds.), Proceedings of 21st Annual Conference of the Environmental Design Research Association. EDRA: Oklahoma City, 269-280.

Ittelson, W. H., Proshansky, H. M. & Rivlin, L. G. (1972). Bedroom size and social interaction of the psychiatric ward. In J. Wohlwill & D. Carson (Eds.), Environment and the Social Sciences. Washington, DC: American Psychological Association, 95-104.

Karlin, B. E. & Zeiss, R. A. (2006). Environmental and therapeutic issues in psychiatric hospital design: Toward best practice. Psychiatric Services, 57(10), 1376-1378.

Kumar, S. & Ng, B. (2001). Crowding and violence on psychiatric wards: Explanatory models. Canadian Journal of Psychiatry, 46, 433-437.

Kumar, S., Ng, B. & Robinson, E. (1999). The crowded ward. Psychiatric Services, 50, 1499.

Kweon, B-S., Ulrich, R. S., Walker, V. & Tassinary, L. G. (2008). Anger and stress: The role of art in an office setting. Environment and Behavior, 40(3), 355-381.

Marcus, C. C. & Barnes, M. (1995). Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations. Martinez, CA: Center for Health Design.

Marcus, C. C. & Barnes, M. (Eds.) (1999). Healing Gardens: Therapeutic Benefits and Design Recommendations. New York: Wiley.

Nanda, U., Eisen, S. L. & Baladandayuthapani, V. (2008). Undertaking an art survey to compare patient versus student art preferences. Environment and Behavior, 40(2), 269-301.

Nanda, U., Eisen, S., Zadeh, R. & Owen, D. (2011). Effect of visual art on patient anxiety and agitation in a mental health facility and implications for the business case. Journal of Psychiatric and Mental Health Nursing, 18(5), 386-393.

Ng, B., Kumar, S., Ranclaud, M. & Robinson, E. (2001). Ward crowding and incidents of violence on an acute psychiatric inpatient unit. Psychiatric Services, 52(4), 521-525.

Nijman, H. L. I. (2002). A model of aggression in psychiatric hospitals. Acta Psychiatrica Scandinavica, 106 (Suppl. 412), 142-143.

Nijman, H. L. I., à Campo, J. M. L., Ravelli, D. P. & Merckelbach, H., L., G. (1999). A tentative model of aggression on inpatient psychiatric wards. Psychiatric Services, 50(6), 832-834.

Nijman, H. L. I., Palmstierna, T., Almvik, R. & Stolker, J. (2005). Fifteen years of research with the Staff Observation Aggression Scale: A review. Acta Psychiatrica Scandinavica, 111, 12-21.

Nijman, H. L. I. & Rector, G. (1999). Crowding and aggression on inpatient psychiatric wards. Psychiatric Services, 50, 830-831.

Palmstierna, T. Huitfeldt, B. & Wistedt, B. (1991). The relationship of crowding and aggressive behavior on a psychiatric intensive care unit. Hospital and Community Psychiatry, 42, 1237-1240

Palmstierna, T. & Wistedt, B. (1995). Changes in the pattern of aggressive behavior among inpatients with changed ward organization. Acta Psychiatrica Scandinavica, 91, 32-35.

Pati, D., Harvey, T. E. & Barach, P. (2008). Relationship between exterior views and nurse stress: An exploratory examination. Heath Environments Research and Design (HERD), 1(2), 27-38.

Raanaas, R. K., Patil, G. G. & Hartig, T. (2011). Health benefits of a view of nature through the window: A quasi-experimental study of patients in a residential rehabilitation center. Clinical Rehabilitation, 26(1), 21-32.

Ruback, R. B., Carr, T. S. & Hopper, C. H. (1986). Perceived control in prison: Its relation to reported crowding stress, stress, and symptoms. Journal of Applied Social Psychology, 16(5), 375-386.

Sherman, S. A., Varni, J. W., Ulrich, R. S. & Malcarne, V. L. (2005). Post-occupancy evaluation of healing gardens in a pediatric cancer center. Landscape and Urban Planning, 73, 167-183.

Sloane, P. D., Mitchell, C. M., Preisser, J. S., Phillips, C., Commander, C. & Burker, E. (1998). Environmental correlates of resident agitation in Alzheimer's disease special care units. Journal of American Geriatrics Society, 46, 862-869.

Sommer, R. (1969). Personal Space. Englewood Cliffs, NJ: Prentice Hall.

Stokols, D. (1972). Distinction between density and crowding - Some implications for future research. Psychological Review, 79(3), 275-278.

Topf, M. & Dillon, E. (1988). Noise-induced stress as a predictor of burnout in critical care nurses. Heart Lung, 17(5), 567-574.

Ulrich, R. S. (1984). View through a window may influence recovery from surgery. Science, 224, 42-421.

Ulrich, R. S. (1991). Effects of health facility interior design on wellness: Theory and recent scientific research. Journal of Health Care Design, 3, 97-109.

Ulrich, R. S. (1999). Effects of gardens on health outcomes: Theory and research. In C.C. Marcus & M. Barnes (Eds.), Healing Gardens. New York: John Wiley, 27-86.

Ulrich, R. S. (2009). Effects of viewing art on health outcomes. Chapter in S. B. Frampton (Ed.). Putting Patients First, 2nd Edition: Best Practices in Patient-Centered Care. San Francisco: Jossey-Bass, 129-149.

Ulrich, R. (2012). Evidensbas for vårdens arkitektur 1.0: Forskning som stöd for utformning av den fysiska vårdmiljön. Göteborg: Centrum för vårdens arkitektur, Chalmers Tekniska Hogskola.

Ulrich, R. S., Simons, R. F., Losito, B. D., Fiorito, E., Miles, M. A. & Zelson, M. (1991). Stress recovery during exposure to natural and urban environments. Journal of Environmental Psychology, 11, 201-230.

Ulrich, R. S., Zhu, X. & Lu, Z. (2008a). Effects of the Physical Environment of Mental Health Facilities on Patient Aggression: Implications for Facility Design. Unpublished report for the Douglas Mental Health University Institute, Douglas Institute Renewal Project, Montreal.

Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J., Seo, H-B., Choi, Y-S., Quan, X. & Joseph, A. (2008b). A review of the research literature on evidence-based healthcare design. Heath Environments Research and Design, 1(3), 101-165.

Ulrich, R. S., Berry, L. L., Quan, X. & Parrish, J. (2010). A conceptual framework for the domain of evidence-based design. Health Environments Research and Design, 4(1), 95-114.

Vaaler, A. E., Morken, G., & Linaker, O. M. (2005). Effects of different interior decorations in the seclusion area of a psychiatric acute ward. Nordic Journal of Psychiatry, 59(1), 19-24.

Virtanen, M., Vahtera, J., Batty, G. D., Tuisku, K., Pentti, J., Oksanen, T., Salo, P., Ahola, K. & Kivimäki, M. (2011). Overcrowding in psychiatric wards and physical assaults on staff: Data-linked longitudinal study. British Journal of Psychiatry, 198, 149-155.

Whitehouse, S., Varni, J. W., Seid, M., Cooper-Marcus, C., Ensberg, M. J., Jacobs, J. R. et al. (2001). Evaluating a children's hospital garden environment: Utilization and consumer satisfaction. Journal of Environmental Psychology, 21(3), 301-314.

 


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