Seclusion, or containment of a patient in an enclosed area, is a common practice in psychiatric acute wards. Traditionally such areas have been used for the dual purpose of meeting the safety and containment needs of behaviorally disturbed patients, and obtaining a decrease in sensory and emotional input (based on the belief that external stimuli would cause patients to suffer excessive mental anxiety). The design and furnishings of the seclusion area are influenced by this need to reduce external stimuli and maintain safety. They are typically sparsely furnished minimizing risk of any physical harm. For example windows don’t have curtains, walls don’t have paintings or decorations, and there are no external sources of stimuli like TV. These norms have been in place for over a century and it is time to test them within a controlled framework, which this study attempts to do.
To compare development in symptoms, behaviors, treatment and patient satisfaction of a traditional interior and an interior furnished like an ordinary home in a seclusion area
The study was carried out in the acute department of Ostmarka hospital in Norway which has a catchment area of 140,000 inhabitants, with an equal distribution of rural and urban patients. The acute ward was chosen from one of the two hospitals where patients are admitted. The seclusion area in this ward consists of two separate wings with sitting room, bathroom, WC and two single patient rooms. Before the study the two wings were identical with sparse furniture, grey colored walls without pictures, no window curtains, single lamps, laminated paint, and single bed and chair or metal tubes. For the study, one of the wings was redecorated and refurnished to look like a Norwegian home (keeping in mind the security constraints). The walls received wainscoting, colorful wallpaper and paintings; the ceilings were lowered and had multiple lighting spots, the windows tasteful curtains; wardrobes, chairs, flowers and personal items were added in the patient rooms; and Italian ceramic tile covered the entire bathroom. The other wing was kept as before in a traditional (T) manner.
56 consecutive patients admitted to the acute ward (who met inclusion criteria) were allocated to two different seclusion areas, one with a traditional interior and one decorated as an ordinary home. Patients who did not qualify were sent to a different ward. Symptoms of psychopathology, therapeutic steps taken, violent episodes, length of patient stay and patient satisfaction were recorded. All instruments used were standard, and validated tools, routinely used with psychiatric patients. Patient satisfaction was also collected on discharge on a visual analogue scale. Informed consent was not obtained from the patients because the mental condition of the patients made this problematic. The study was approved by the Ethics committee.
Despite a detailed recording of patient functioning, behaviors, symptoms and therapeutic steps taken by the staff, the study did not find any negative effects of changing from the traditional interior to a more home-like environment. No significant differences were found in patient satisfaction , although the data indicated that women had more positive reactions to the new interior compared to men. The number of incidents of violence registered in the refurbished side was higher (4) compared to the traditional side (1)- but this was not statistically significant. Number of incidents of vandalism occurring in the units was higher in the traditional side compared to the new side which had no such incidents.
Author identified limitations included the effect that the staff may have had in influencing the results – total number of incidents of threatening behavior was found to be lower in the study period compared to previous years. Authors argue that knowledge of a study can frequently make the staff act differently. Authors therefore state that they cannot rule out the suggestion that the two interiors had different effects and that these differences were masked by the staff factors.
Additionally, the study does not explain why the number of incidents of violence may have been more in the refurnished unit, or if specific design features may be responsible for this effect. A large number of design features have been introduced in the refurbished unit- the study does not provide any insight into which of these design features were more (or less) effective than others.