Crowding and Aggression on Inpatient Psychiatric Wards

Between February 1 and December 15, 1996, all verbal and physical aggressive acts of patients admitted to two closed observation wards of the Broeders Alexianen Psychiatric Hospital in Tienen, Belgium, were recorded. Aggressive behavior was scored with a revised version of the Staff Observation Aggression Scale (SOAS) (8,9). The SOAS consists of five columns in which features of the incident are described, including the provocation of the aggression, the means used during the aggressive incident, the target of the aggression, its consequences, and the measures taken to stop the aggression.

On the two wards studied, the main goal is crisis intervention and diagnostic evaluation. The mean lengths of stay on the two wards in 1996 were 33 days (median=13 days) and 17 days (median=nine days). Due to the short length of stay and the resultant high patient turnover, ward occupation rates varied greatly, which made them suitable settings for studying the effects of crowding on inpatient aggression. Furthermore, at the start of the study, one of the wards was scheduled to be rebuilt. In the middle of the study, on July 9, 1996, a courtyard was opened for patients of ward 1. The inner court was connected with two entrances to the ward, which increased patients' opportunity to walk around freely. The frequency of aggression on the rebuilt ward 1 was compared with that on ward 2, before and after the spatial enlargement of ward 1.

The purpose of this study was to examine whether ward crowding was associated with an increase in aggressive incidents per patient and whether enlargement of the ward space resulted in a decline in aggressive incidents.

During the study period, 212 male and 142 female patients were admitted to the wards. The average age was 41 years, with a range from 15 to 55 years. The most common diagnoses were drug-related problems (38 percent), mood disorders (20 percent), psychotic disorders (18 percent), and personality disorders (18 percent).

A total of 226 aggressive incidents were recorded. The weekly number of aggressive episodes varied from 0 to 15, the average being 4.9 incidents a week. About half of the incidents (115 incidents, or 51 percent) involved physical aggression. Eighteen of the 226 aggressive episodes (8 percent) led to mild or moderate injury to victims.

In this study, ward crowding was found to be modestly correlated with the number of aggressive incidents per patient per week. Although the effect sizes are small and causality remains unclear due to use of the correlational approach, this finding corresponds with the clinical impression that high ward turmoil can overstimulate and frustrate patients and thus may contribute to aggression. In one of our earlier studies (1), 14.4 percent of inpatient aggression was induced by the behavior of fellow patients.

However, extending the space in one of the two wards did not result in a significant reduction in aggressive incidents. It may not be the physical space in terms of square meters that matters but rather the psychological or social space (10). On a crowded ward, more patient-patient interactions take place, and it is harder for patients to find rest or privacy. The average noise level on a packed ward is also higher.

Future research could investigate whether an increase in undesired patient-patient contacts is indeed associated with aggressive behavior. Also, a lack of opportunity for patients to retreat and be alone if they desire may be associated with aggression. It should also be noted that the staff-patient ratio is lower on a crowded ward, and the resulting relative inaccessibility of the nursing staff may frustrate and anger patients (1).

Preventing crowding is likely to enhance the ward atmosphere and may improve safety. We feel that unless contraindicated, as may be the case with suicidal or self-mutilating patients, every inpatient should be provided with a bedroom of his or her own.

Mr. Nijman is a senior researcher at the Psychiatric Hospital Welterhof in Heerlen, the Netherlands, and in the department of psychology at the University of Maastricht in Maastricht, the Netherlands. Mr. Rector is director of patient care at the Psychiatric Hospital Broeders Alexianen in Tienen, Belgium. Send correspondence to Mr. Nijman at Psychiatrisch Centrum Welterhof, P.O. Box 4436, 6401 CX, Heerlen, the Netherlands (e-mail, [email protected]).