Aggression in A&E is a growing problem, costing the NHS millions, but experts believe, design has a key role to play in reducing its impact. Here Kieren Morgan, Design Review Panellist for the Design Commission for Wales shares over 20 years’ experience in healthcare projects, explaining how good design influences behaviour and where it’s been used successfully.
“Recent reports show that violence and aggression towards NHS staff is costing at least £69million a year in absenteeism, reduced productivity and increased security and the NHS in England is turning to designers for help. However, while this collaboration may be new, the theory behind its benefits is not.
“Leading researchers in what is known as evidence-based design include Dr Roger Ulrich, whose studies date back to the early 1990s. Ulrich linked poor design to certain negative effects on patients such as increased feelings of anxiety, slow recovery rates, greater need for pain relieving drugs and, in certain situations, longer stays in hospital. Between 1999 and 2002, Dr Rosalia Lelchuk Staricoff and her team at the Chelsea and Westminster Hospital carried out ‘A Study of the Effects of Visual and Performing Arts in Health Care’, attempting to scientifically evaluate its impact on the psychological, physiological and biological outcomes of treatment.
“Results showed that the integration of visual and performing arts significantly altered clinical outcomes, reduced the amount of drug consumption, shortened the length of stay in hospital, improved patient management and enhanced the quality of service which contributed towards increased job satisfaction. In Trauma and Orthopaedic wards, patients exposed to visual art and
live music during their post-operative period required less analgesia per day than patients who were not, and their admission period was cut by a full day.
“Elsewhere research has found that in mental healthcare, the use of harsh colours or abstract art increases anxiety levels which can result in negative or violent behaviour. The balance of the type of visual art used is therefore crucial – but it’s not just art that impacts on behaviour. Patients suffering from burns have been found to feel more comfortable when the colours of the treatment rooms are neutral or cool in tone, such as light blue. This is also linked to reduced need for analgesia.
“Views and sounds of nature have also been linked to calming patients, again reducing drug dependency and speeding recovery times. This means shorter stays in hospital and the knock- on effect is that it puts less strain on the health service. This is a technique known as positive distraction, with pleasant art, relaxing music or sounds, good daylight and views into landscaped areas helping deflect patients’ thoughts away from anxiety and aggression.
“In the USA, and increasingly the UK, patients receiving aggressive treatment such as radiotherapy can programme their own treatment environment. Smart technology can allow them to control the mood of the lighting, choose soothing background sounds or music, as well as selecting scenery, such as a seascape or cornfields via an interactive wall or ceiling. Effectively, they can create their own unique atmosphere.
“Treatment can often leave patients feeling vulnerable as they feel they have little control over what is happening to them. Allowing patients a certain degree of influence over their environment gives them back some control and dignity in what can be a traumatic and anxious treatment regime. It can also improve their receptiveness to drugs and treatment, reducing their stay in hospital.
“Waiting for hours to be seen in a crowded A&E when you are unwell, perhaps in shock and profoundly anxious can be a recipe for trouble. In such a high stress confusing environment a well-designed A&E department will enable staff to process patients more efficiently and effectively. Clear sight lines assist staff to identity potential problems and flash points whilst providing staff with ‘safe havens’ increases their sense of safety, making them feel more in control and able to cope better with workplace stress. This, in turn, helps reduce absenteeism, saving the NHS money, and helping to attract and retain qualified staff – a recurring problem for the NHS.
“Patients also benefit from a happy workforce, at ease and properly focussed on their jobs. This added benefit results in a positive effect on the quality of care provided, which all contributes to improved patient recovery times. From a patient perspective the A&E department is often crowded, poorly lit, enclosed and noisy. All these factors are known to increase anxiety levels, confusion, heart rate, stress and the potential for aggressive behaviour. A well designed department can mitigate many of these factors by introducing the calming
effect of natural light, views to landscape, soothing music or sounds, along with separate areas for children and young adolescents.
“One of the major challenges for designers and healthcare managers in Wales is translating this evidence into meaningful design tools that can be applied to future projects. North America is ahead of the game and has been applying evidence based design for many years. In the UK our approach is more often to treat healthcare buildings as simple construction projects rather than recognising that they are places which need to be carefully designed for the care and treatment of people who are ill or injured, using the best evidence available to understand their needs, anxiety and condition.
“Although there is much to do to embed what we know into everyday practice so that good design supports good service delivery, there are some positive signs emerging. The Welsh Assembly Government’s ‘Design for Life: Building for Wales’ programme has pushed forward the agenda for single patient rooms, leading to a better quality environment for patients. Both the recently completed Ysbyty Aneurin Bevan Hospital in Ebbw Vale and its sister hospital in Caerphilly due to be completed later this year are great examples of incorporating good views, landscaped areas and courtyard spaces to create positive distraction for patients. These hospitals indicate an increasing awareness from those who commission our healthcare projects that design can support staff in their jobs and help patients get better quicker.
“However, the problem remains in the awareness gap between design professionals and those who commission our hospitals. Too often the pressures of short term capital costs, rather than long term benefits and savings, take precedence. This is a false economy, given the ensuing long terms costs that result from failure to embed the lessons and evidence of the research. A building that is cognitive and shows an understanding of the importance of design in affecting behaviour will save money over a 20-30 year period by reducing the cost of expensive pain relieving drugs, analgesics, staff recruitment and absenteeism.
“Ultimately, long waiting times will always risk people getting agitated, and while we know good design has a huge impact, it’s also a matter for departmental management and for awareness among the wider public. We need to better direct people to the level of care they need to reduce numbers turning up to A&E no matter what their condition. The Welsh Assembly Government’s “‘Choose Well’ campaign provides colour coded advice for the most appropriate course of action, from dialling 999 to administering self-help – but it needs greater promotion. If people go to the right place, pressure on A&E is reduced along with agitation and aggression, and staff may more easily prioritise those who really do need A&E services.
“While design cannot cure people, it has more than a small part to play. By adopting a cognitive approach to the way we design and commission healthcare buildings, we can create a more efficient and calmer environment for staff to thrive in, saving the NHS money in the process, and, best of all, contributing to more effective care for patients.”