Running head: LITERATURE REVIEW 1

Literature Review

Maxine Fomunung

Georgia Gwinnett College

LITERATURE REVIEW 2

Literature Review

Few studies have been conducted on how psychiatric ward design impacts patient

behaviors. Facility design can impact its patients’ behaviors by making psychiatric patients more

prone to anger (Bowers et al, Allan, Simpson, Jones,Van Der Merwe, Jeffery, 2009), conducting

redesign that increases space, comfortable environment, and better visiting area (Jenkins, Dye,

Foy, 2014). There are also cases where redesign does not have an impact on psychiatric patient

behavior directly (Urbanoski, Mulsant, Ehtesham, Rush, Novotna, 2013). The direct impact this

topic has on psychiatric patients makes it an important topic for nurses to be aware of allowing

them to stand in the gap and suggest implementation of changes that would improve patient

outcomes. The purpose of this paper is to conduct and alternative review that answers how a

psychiatric facility environmental design can affect patient behavior.

Urbanosky et al. (2013) conducted a qualitative study with the purpose of exploring

whether the inpatient atmosphere has any association with patient outcomes. The sample

included 290 people from Toronto, Canada that were recipients of inpatient care due to mood

and anxiety disorders both before and after a renovation project took place, with the intention of

improving treatment satisfaction as well as the quality of life. The researchers used the Global

Assessment of Functioning instrument to evaluate social, occupational, and psychological

functioning. Self-administered questionnaires completed at admission as well as discharge were

used as another instrument to collect data. The Ward Atmosphere Scale was also used to evaluate

patients' perceptions of ward atmosphere. Patient behaviors before and after the renovation were

assessed using patient's charts. It was hypothesized that after the renovation patients would

experience a more uplifting environment which would lead to better outcomes, path analysis was

used to test this hypothesis. The authors concluded that there was a direct link between global
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functioning and the unit renovation. Findings also suggested however that the redesign did not

directly impact the quality of life scores or treatment satisfaction.

This study had its strengths and its weaknesses. It contributed meaningful evidence that

can be used in the nursing discipline in a sense that it shed light on the idea that this topic needs

more research. The analytic procedures suggested the possibility of bias by noting that the

clinical routines of the staff changed along with the redesign which is why it was not possible

directly link the renovation to improved patient attitudes. The findings in this study were

effectively summarized with good use of excerpts from the data and with strong supporting

arguments because it mentioned that the effects of redesign were nonsignificant in terms of the

quality of life of the patients, and mentioned that quality of life scores before the redesign were

5.6 +/- 12.1 higher at discharge than at admission. The analysis yields an insightful and

meaningful picture of the phenomenon under investigation when it stresses that the relationship

linking treatment setting and outcome is complex. The researchers used strategies such as using

Mplus 6.2 to minimize selection biases related to missing data, which enhances the integrity of

the study. The researchers’ clinical experiences enhance confidence in the findings as most of

them have PhDs. Data collection and recording procedures appear appropriate because self-

administered questionnaires were included which are ideal for a qualitative study. Triangulation

was achieved because data was collected not only through questionnaires but also by assessing

chart reviews. The best possible method of sampling was used to enhance information richness

because both patient and clinician perspectives were used to assess outcomes. A sample size of

290 people may have not been adequate because a bigger population would yield results that

could be applicable to a larger population.

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The purpose of this qualitative study by Bowers et al. (2009) was to investigate the

relationship between violent patient behavior in psychiatric patients to patient characteristics,

physical environment, patient routines, staff factors, the use of contaminant methods, and other

patient behaviors. This study, however, focused on the effects that the physical environment has

on patient behavior. It used a multivariate cross-sectional design. The data in the study was

obtained over a period of six months and included 136 psychiatric wards located in 26 NHS

Trusts in England. The Patient-staff Conflict Checklist was a shift report that was also used to

measure how often the conflict between the patients and the staff was related to aggression.

Another instrument used was the Attitudes to Containment Measures Questionnaire, the Attitude

to Personality Disorder Questionnaire, the Ward Atmosphere Scale, the Team Climate Inventory,

the Multifactor Leadership Questionnaire, and the Maslach Burnout Inventory. Findings include

the idea that when patients are restricted, there is an increase in the chance that they will be

aggressive. The study revealed that the physical environment had an impact on patient behavior

in the sense that the more restrictions on patients, such as seclusion and hospital detention, the

more aggression the patients exhibited. This study also found that there is not enough evidence to

determine whether staffing numbers influences violent patient behavior.

The multivariate cross-sectional design method that was used in the study by Bowers et

al. (2009) is the best possible method of sampling because it allowed the researchers to compare

more the one group at one time, which enhances the richness of the study. The sample was

adequately described as well as the setting. The researchers used strategies such the Overt

Aggression Scale, a widely used and validated instrument, to enhance the trustworthiness and

integrity of the study. There is not confidence in the truth value of the results because the

researchers mention how the staffing numbers were positively correlated with the aggressive
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behavior of the patients, which could be a cofounding variable. The methods for gathering data

such as questionnaires and scales were appropriate for this qualitative study because they

provided results that were how the patients themselves felt. The large scale of this study as well

as the multilevel analysis of this study yields an insightful and provocative picture of the

phenomenon under investigation. The data collected are of sufficient depth and richness because

the researchers mentioned that physical aggression towards objects and other people in the ward

showed that there was a correlation between locking the doors and patient aggression, which

further supports the hypothesis that design affects patient behavior. The researchers attempted to

eliminate bias by identifying possible cofounding variables. Data collection was appropriate

because it was collected over a 6-month period, which can increase the reliability of the results.

The sample size used was not adequate because the researchers mentioned that the 136

psychiatric wards that were included in this study only accounted for 25% of the projected total

of 551 facilities in England and the study might have benefitted from more participants in the

study to give more concrete findings.

The purpose of this qualitative study conducted by Jenkins et al. (2014) was to assess the

effect of a different ward environment on patient behavior and issues on an NHS Psychiatric

Intensive Care Unit. The research method used was in two three-month periods, and data

collected to assess containment, agitation, and conflict with the psychiatric patients. These

factors were evaluated three months before the changed ward environment and three months

after the changed ward environment. Seclusion, observation, the number of logged aggressive

incidents that occurred, data from the Nursing Observed Illness Intensity Scale, and the ward

environments were assessed using the Environment Assessment Inventory. There were 18

different participants involved in the study, and there were only three females in the old ward
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and all males in the new ward. This study suggested that there was a significant reduction in

episodes of seclusion, aggressive behavior, and agitation in the new ward when as compared to

the old ward. The Environment Assessment Inventory was used to evaluate the new ward. The

researchers in the study concluded that the physical environment of a psychiatric ICU has a

substantial influence on the levels of arousal and hostility in patients, and suggested that there

was a significant (p<0.01; chi square) in total duration and seclusion incidences from the old

ward to the new ward as their evidence. The findings of this study suggest that increased space,

more comfortable environment, better visiting area, and better visibility in the new ward have

positive impact on the agitation levels of the patients.

Information richness in this study by Jenkins et al. (2014) was enhanced when the

researchers mentioned that both wards were mixed gendered and accommodated 10 patients.

This sample size seemed small but since the study focuses on the impact of ward design

specifically they could still provide valid results. The researchers assessed the two patient

groups by analyzing psychiatric disorders, age, and sex, which is an appropriate data gathering

method that ensures comparability. Observation as a means of data collection was appropriate.

Two or more methods were used to achieve triangulation, the Nursing Observed Illness Intensity

scale and the Environment Assessment Inventory, which are also data collection methods that

minimize bias. The NOIIS data gave the study trustworthiness and integrity because it minimized

under-reporting of incidents, which would have skewed the data. The possibility of biases can be

interpreted when the researchers mentioned analyzing the age, sex, and psychiatric disorders of

the patients because these factors can have an impact that may lessen the validity of the findings.

The truth value of this study can be questioned because the researchers suggested that it is not

possible to identify exactly which design feature is primarily responsible for reduced aggression
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in patients. The evidence in this study suggest that nurses too could help implement things such

as better visiting areas in hopes of increasing patient comfortability.

Psychiatric ward design can impact its patients’ behaviors by making psychiatric patients

more prone to anger, conducting redesign that increases space, comfortable environment, and

better visiting area provides for less aggressive patients, and redesign can affect ward

environment which can then improve quality of life but not patient behavior directly (Bowers et

al., 2009; Jenkins et al., 2014; Urbanoski et al., 2013). Contradictory evidence in these studies

includes the idea that redesign only had an impact on the patients when it came to global

functioning (Urbanoski et al., 2013), while the other study two studies suggested that redesign

does have an effect on patient behavior (Bowers et al., 2009; Jenkins et al., 2014). The aspect of

exactly what element of redesign has a direct impact on patient behavior is still unknown.

Two out of the three articles successfully answered the question regarding if psychiatric

facility design has an impact of patient behavior. Based on these articles, it would be good to

recommended to clinicians today the factors that these studies suggested had a positive impact on

patient behavior, such as providing an environment most comfortable to the patient. This topic is

important to nurses because it illuminates tactics that improve psychiatric ward design that

nurses could help implement for their patients and ultimately, improve patient outcomes.
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References

Bowers, L., Allan, T., Simpson, A., Jones, J., Van Der Merwe, M., & Jeffery, D. (2009). Identifying

Key Factors Associated with Aggression on Acute Inpatient Psychiatric Wards. Issues in

MentalHealth Nursing, 30(4), 260-271. doi:10.1080/01612840802710829

Jenkins, O., Dye, S., & Foy, C. (2014). A study of agitation, conflict and containment in

association with change in ward physical environment. Journal of Psychiatric Intensive

Care, 11(01), 27-35. doi:10.1017/s1742646414000065

Urbanoski, K. A., Mulsant, B. H., Novotna, G., Ehtesham, S., & Rush, B. R. (2013). Does the

Redesign of a Psychiatric Inpatient Unit Change the Treatment Process and

Outcomes? Psychiatric Services, 64(8), 804-807. doi:10.1176/appi.ps.004532012