Effects of improved hospital architecture on coercive measures

Coercive measures, such as seclusion and physical or mechanical restraint – with or without medication – are widely used as a last resort in psychiatric practice to prevent serious harm to self or others. However, the effectiveness of these measures is empirically questionable (1). Further, patients perceive them as traumatic and they potentially exacerbate mental illness (2–4). Thus, extensive efforts have been made to reduce their application (5), for example by training staff in social problem solving (6), by placing patients with some specific diagnoses in specialized acute wards (7), or by organizing psychiatric emergency response teams (8). Besides interventions focusing on organizational procedures and personnel, we observed that substantial structural improvements of psychiatric facilities may help to prevent coercive measures. In early 2011, a large German university psychiatric clinic was moved into a new building with substantially increased ward space (from about 200 sqm for 16-18 patients to 400 sqm for 17 patients), changed room settings (from mainly 2-4 bed rooms to only 2- and 1-bed rooms), improved sanitary arrangement (from 2 toilets/showers per ward to one for each room), more natural lighting (from small windows to almost picture windows), modern home electronics and large balconies. Additional factors which may influence the application of coercive measures (8,9), such as the staff-to-patients ratio, guidelines for coercive measures, and the distribution of psychiatric diagnoses in the clinic, remained relatively constant. However, staff was slightly reduced after the move and a de-escalation training for the staff had been implemented since 2008. We compared coercive measures from January 2005 to December 2010 (before relocation) with measures from April 2011 to June 2014 (after relocation) applying two-sample t-tests. A few outlying data points were omitted from the analysis using the 1.5 interquartile range which, however, only marginally affected the results. Data points were averaged per quarter (three months) and represented coercive measures per average occupied beds (varying between 97 and 175). The quarter in which the relocation took place was not considered. The number and duration of mechanical restraints as well as coercive medication significantly dropped by 50-85% in the three and a half years following the relocation: the mean number of restrained patients per bed decreased from 0.069 to 0.035 (t(35) + 5.534; p<0.001; 50%), the mean number of days with restraints from 0.227 to 0.083 (t(35) + 5.153; p<0.001; 63%), the mean duration of restraints (in hours) from 2.156 to 1.039 (t(35) + 2.973; p+0.005; 52%), and the mean number of coercive medications from 0.043 to 0.006 (t(35)+6.073; p<0.001; 85%). Thus, the decreased use of mechanical restraints was not compensated by an increased use of coercive medication. These data suggest that improvements in the structural environment potentially reduce coercive interventions. As the relocation in our observation represents a natural experiment, it certainly lacks the control of potentially confounding factors. However, we speculate that the architectural changes may influence coercive measures via mediators such as increased patients' wellbeing, improved staff-patient relationship, and more opportunities for patients to withdraw from stressful situations.