Designing for Calm
By ROGER S. ULRICH
Published: January 11, 2013
IT should come as no surprise that violence in mental health facilities causes psychological and often physical harm to health care workers and patients. What’s shocking is how prevalent it is.
Globally, a third of all patients admitted for psychiatric care are involved in violent incidents, according to a 2011 analysis by researchers at King’s College in London. In Sweden, where I teach, it’s estimated that more than half of psychiatric care staff members are exposed to physical violence each year, an experience mirrored in many other countries.
Efforts to reduce violence in psychiatric hospitals have focused on identifying potentially aggressive patients through clinical histories and improving staff training and care procedures. But these approaches, while worthy, are clearly not enough. While definitive numbers are hard to come by, the incidence of violence in care facilities appears to be going up.
Research suggests, however, that there’s an effective solution that has largely been overlooked: designing hospital spaces that can reduce human aggression — to calm emotionally troubled patients through architecture.
Currently, questions about design at psychiatric care facilities are viewed through the prism of security. How many guard and isolation rooms are needed? Where should we put locked doors and alarms? But architecture can — and should — play a much larger role in patient safety and care.
One prominent goal of facility design, for example, should be to reduce stress, which often leads to aggression.
For patients, the stress of mental illness itself can be intensified by the trauma of being confined for weeks in a locked ward. A care facility that’s also noisy, lacks privacy and hinders communication between staff and patients is sure to increase that trauma. Likewise, architectural designs that minimize noise and crowding, enhance patients’ coping and sense of control, and offer calming distractions can reduce trauma.
Thanks to decades of study on the design of apartments, prisons, cardiac intensive care units and offices, environmental psychologists now have a clear understanding of the architectural features that can achieve the latter — and few of these elements, if incorporated into a hospital design from the outset, significantly raise the cost of construction.
Providing day rooms and other shared spaces with movable seating, for example, gives patients the ability to control their personal space and interactions with others. Sound-absorbing surfaces reduce noise (and stress), as do designs that offer more natural light.
Some features, like single-patient bedrooms with private toilets, do increase the building cost — but that is arguably offset by the reduced trauma for patients and hospital workers.
Violence, after all, isn’t just a danger to well-being, its effects — from medical care to lawsuits — are frequently expensive, too.
Colleagues from Chalmers University of Technology and Sahlgrenska University Hospital and I recently performed a study using a psychiatric hospital, Ostra Hospital in Gothenburg, that opened in 2006. Of the 10 architectural features researchers have identified that are likely to diminish stress and aggression, Ostra has nine.
Data on aggressive incidents were compiled for the hospital and compared with those from two other psychiatric facilities. One was an older facility replaced by Ostra, which had only one of the stress-reducing features. A third institution located in the same region also had just one of these architectural elements. Despite the wide differences in design, though, the three hospitals were similar with respect to the number of beds, types of patients, treatment protocols and staffing levels.
The drop in the use of patient restraints — a proxy for incidents of aggression — was striking. The number of patient sedations at Ostra was 21 percent lower than at the hospital it replaced, and the use of physical restraints fell by more than twice that (44 percent). At the third facility — which operated during the years of both the old and new hospitals in Gothenburg and therefore served as an experimental control — the use of both forms of restraint continued to rise, suggesting that the difference was probably not because of a general improvement in care procedures over the period examined.
Comparison studies like this one have limitations, certainly. It’s hard to know for sure that there weren’t major differences in patient care and training between the old facility in Gothenburg and the new. But evidence from myriad studies and design research strongly supports the notion that architectural design can reduce violence.
The principles, moreover, have implications for the wider health care system. Aggressive behavior and violence in health care are by no means limited to psychiatric wards; they are also common in emergency rooms and other hospital departments. If you have the misfortune of needing to visit the E.R., expect to feel even more stress if you find yourself in a crowded waiting room with fixed rows of seats and a blaring television whose channel cannot be changed.
Environments like these increase the chance that one patient or family member may accost another person in the waiting room, or speak or gesture angrily to a nurse or doctor.
To reduce the odds of such aggression, it’s time we put our growing understanding about stress-reducing design into architectural practice. At a time when health care payment policies are changing to reward better quality, reducing emotional trauma in care facilities should not only improve the lives of patients and health care workers, but perhaps even lower the cost of care as well.