THE PHYSICAL ENVIRONMENT


environment on emotional states, behaviour and even patient outcomes. Recently, TNO explored the relation between various design features of psychiatric wards in the Netherlands and the number of seclusions, as well as the lengths of time spent in seclusion. The research questions included: Can design features (the physical environment) of the ward contribute to the risk to be secluded? If so, what are the implications of the findings for the design of psychiatric hospitals?8


Seclusion rooms The study focused on the use of seclusion rooms (with the highest level of safety). One of the most controversial procedures in the Netherlands, seclusion is commonly defined as bringing a patient into a locked room where he or she is alone and able to move around. In the Dutch mental healthcare several types of rooms are used for seclusion. Rooms or designated areas have different designs, furnishing, atmosphere and safety levels. Examples can include: seclusion room, Intensive Care (IC) unit, isolation room, time out room or (stripped and lockable) bedroom. In a seclusion room the highest safety level is applied for the design and interior, with violence-proof finishing and minimal use of furniture. The room is bare in such a way that patients cannot harm themselves or others. In a stripped and lockable bedroom, the


lowest level of safety level is applied. For the patients it makes quite a difference when being taken to an empty room with the highest safety level, or to a designated area with personal attention, a comforting surrounding that can be personalised and adapted to one’s needs. Many initiatives have been taken to create more ‘humane’ alternatives, such as an IC-unit, or spaces that can prevent further escalation, such as the ‘comfort room’. In general, it appears that spaces – such as a comfort room, a garden, a fitness-room, wide corridors and spacious common rooms – where patients can get away and be alone, can help to buffer some of the harmful effects of crowding, increase well- being, and can offer some distraction.


Data and setting To assess the relation between design features of the ward and seclusion rooms we combined two major data sources in the Netherlands. Firstly, data from a multi-centre study on building quality and safety of psychiatric hospitals9


and secondly, a


benchmark study on the use of coercive measures on these wards.10


The first dataset


concerned the design features of 505 locked wards covering 93% of all such wards in the Netherlands. These features were collected on a site visit by a trained researcher. A ward was defined as a physically distinct area with a ‘private’ entry (which can be locked), several (bed) rooms, corridors and common spaces (living room, kitchen, garden, smoking area, etc.), shared by a fixed group of patients and staff. In most cases two or more wards together function as an organisational entity


50 IFHE DIGEST 2013


with the same staff. The type of ward was categorised in two groups – admission wards and non-admission wards, including forensic care.


The second database contained data from


wards on the use of coercive measures as well as patient and staff characteristics, over a 12-month period. Data on coercive measures were collected by using the Argus scale which was completed on a day-to-day basis by nurses. Data on patient characteristics, such as date of birth, gender, ethnicity, marital status, and diagnosis were collected from hospitals’ patient information systems. Staff characteristics covered data such as the total number of nursing staff present on the ward during the day, evening and night (per shift) and the total number of other staff available for patients, for example, psychiatrists, doctors, psychologists or social workers. The study sample consisted of 199 wards


from 16 psychiatric hospitals in the Netherlands. This covered 37% of all locked wards of hospitals with both rural and urban catchment areas. The dataset covered data over a total of 2,446 beds and 23,868 admissions of 14,834 patients.


Design features of the ward Design features included in the study were associated with the quality and the safety of the physical environment and the wellbeing of patients. Around 115 variables per ward were observed, for example the type of rooms, the amount of private and public space (square meters), natural light and views, atmosphere and safety measures. Literature and research-based arguments made it possible to group all of these variables into six theoretical concepts, i.e. ‘families’. Table 1 provides an overview of the six families of design features, including the scales or components that resulted from the nonlinear Principal Component Analysis (CATPCA). This technique was used to reduce the number of design features.


Ward characteristics From the included wards, 46% (n=92) were non-admission wards, 41% were (acute) admission wards and 13% were forensic wards. The mean number of patients per ward was 12. The size of the wards ranged from


87 m2 to 1,321.5 m2


(mean = 460 m2


), with an


average of 13.6 m2 private space per patient and an average of 10 m2 per patient for


common use. Almost all wards had single rooms only. This is mainly due to strong governmental policy in the Netherlands regarding patient privacy. Other design features in favour of privacy and autonomy of patients also scored relatively high. Almost all wards had an outdoor space available for patients. The overall safety level was highest on forensic wards, followed by admission wards and non-admission wards. Most wards had between one and six


seclusion rooms available, located on or nearby the ward. Time-out rooms, isolation rooms, (stripped) bedrooms or designated areas other than seclusion rooms, where patients could be locked up were most frequently present on forensic wards. This can be explained by the stringent safety measures that are more common on forensic wards and, partly because of that, the higher proportion of bedrooms that can be locked. Large differences exist between wards in


the use of coercive measures (incidence and prevalence). In this study most incidents leading to a coercive measure occurred on forensic wards. Overall, the number of seclusions per 1,000 admissions varied between 0 and 2,485 (mean = 183 seclusions per ward). In 94% of all admissions patients were not secluded. Most of the seclusions occurred on forensic wards and the proportion of time spent in seclusion during an admission was also longer on forensic wards than on other wards (see Table 2).


Do design features matter? The findings strongly suggest that the physical environment of the ward has a significant effect on the risk to be secluded.


‘Seclusion is commonly defined as bringing a patient into a locked room where he or she is alone and able to move around.’


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84