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Harpøthetal.
International Journal of Mental Health Systems (2022) 16:53
https://doi.org/10.1186/s13033-022-00562-7
RESEARCH
Do improved structural surroundings reduce
restrictive practices inpsychiatry?
Astrid Harpøth1 , Harry Kennedy2,3,5 , Morten Deleuran Terkildsen1,4 , Bettina Nørremark1,
Anders Helles Carlsen1 and Lisbeth Uhrskov Sørensen1,5*
Abstract
Background and objectives: There is sparse evidence that modern hospital architecture designed to prevent vio-
lence and self-harm can prevent restrictive practices (RP). We examine if the use of RPs was reduced by the structural
change of relocating a 170-year-old psychiatric university hospital (UH) in Central Denmark Region (CDR) to a new
modern purpose-built university hospital.
Methods: The dataset includes all admissions (N = 19.567) and RPs (N = 13.965) in the self-contained CDR one year
before and after the relocation of the UH. We compare RPs at the UH a year prior to and after relocation on Novem-
ber 16th (November 2017, November 2019) with RPs at the other psychiatric hospitals (RH) in CDR. We applied linear
regression analysis to assess the development in the monthly frequency of RPs pre- and post-relocation and examine
underlying trends.
Results: At UH, RPs performed decreased from 4073 to 2585 after relocation, whereas they remained stable (from
3676 to 3631) at RH. Mechanical restraint and involuntary acute medication were aligned at both UH and RH. Using
linear regression analysis, we found an overall significant decrease in the use of all restrictive practices at UH with an
inclination of -9.1 observations (95% CI − 12.0; − 6.3 p < 0.0001) per month throughout the two-year follow-up. How-
ever, the decrease did not deviate significantly from the already downward trend observed one year before relocation.
Similar analyses performed for RH showed a stable use of coercion.
Conclusion: The naturalistic features of the design preclude any definitive conclusion whether relocation to a new
purpose-built psychiatric hospital decreased the RPs. However, we argue that improving the structural environment
at the UH had a sustained effect on the already declining use of RPs, particularly mechanical restraint and involuntary
acute medication.
Keywords: Coercion, Structural safety, Psychiatry, Mechanical restraint, Restrictive practices
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Introduction
Psychiatric inpatient aggression may lead to the
prescription of restrictive practices (RP) such as
seclusion, restraint or involuntary acute medication
[1]. e use of RPs in psychiatry is controversial but
considered necessary to prevent violent behaviour
toward others in hospital wards and prevent self-harm
and suicide. It is widely agreed that RPs should be
minimised as patients report primarily adverse effects
of being subjected to such measures [2]. RPs have been
found to cause physical and psychological harm [3], lead
to violence, and damage the therapeutic alliance, widely
acknowledged as essential to achieving patient recovery
[4, 5]. Conversely, violence prevention in psychiatric
wards is essential to maintain a therapeutically safe
environment and protect other patients and staff [1]. RPs
Open Access
International Journal of
Mental Health Systems
*Correspondence: lisbeth.uhrskov@ps.rm.dk
1 Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry,
Skejby, Denmark
Full list of author information is available at the end of the article
Page 2 of 11
Harpøthetal. International Journal of Mental Health Systems (2022) 16:53
may be prevented and reduced by optimising procedural,
relational-dynamic, and structural factors [6].
e relational-dynamic and procedural factors and
their influence on RP have been extensively researched
[7]. Both improvements in staff training, guideline
implementation, and systematic changes in the dynamic
environment within the wards reduce the use of RPs [8,
9].
Contrastingly, the effect of structural surroundings on
the use of RP in psychiatry has received less attention
[10].
Ulrich et al. have proposed a conceptual model for
how psychiatric ward design may affect aggression and,
thus, ultimately, RP. e fundamental premise is that
psychiatric inpatients experience stressors that foster and
trigger aggression. e physical ward environment can
influence these stressors. us, a well-planned evidence-
grounded ward design may minimize environmental-
related stress by reducing crowding and noise and
providing positive distractions such as gardens accessible
to patients, windows with nature views and increased
exposure to daylight in the wards [11]. In line with this,
other models have suggested that high quality of the
structural surroundings, such as the conditions and
cleanliness of the buildings and the decor, may reduce
conflicts in psychiatric wards [12].
However, even though current literature has affirmed
the physical environment’s importance in supporting
better mental health services outcomes, more rigorous
research is needed to establish the link between
structural surroundings and RP [7, 10, 11, 13].
Older psychiatric buildings from the asylum era may
be inadequate to support treatment as usual and prevent
RP [14]. However, only a few studies have examined
how modern hospital architecture designed to prevent
violence and self-harm and support de-escalation affects
the use of RP as evidence concerning architectural design
features is frequently published in the grey literature [13].
A unique opportunity to examine the effect of
structural surroundings on RP was presented when
the old psychiatric University Hospital (UH) in Aarhus,
dating back to 1852, relocated to a new modern purpose-
built psychiatric hospital in November 2018, thus,
creating a quasi-experimental situation. is study
examines if these improved structural surroundings
decreased restrictive practices in psychiatric inpatient
units.
Method
Setting
Denmark consists of five self-contained regions, one
of which is the Central Denmark Region (CDR), with
approximately 1.3 million inhabitants, 23% of the
Danish population [15]. e psychiatric hospitals in
CDR consist of one university hospital (UH) and four
regional hospitals (RH). All hospitals are considered “one
organisational unit” governed by the same leadership.
Following the Danish Mental Health Act, the overall
national regulations and those specific to psychiatry, the
UH offer specialised treatment for the most complicated
and severely ill patients in CDR [16, 17].
Aarhus University, the Faculty of Health and the
Central Denmark Region have a long-standing formalized
collaboration centred on research and education [18]. For
CDR, the collaboration within psychiatry is primarily
centred and organized from Aarhus University Hospital
Psychiatry (in this paper, UH), as the psychiatric
professors and the majority of associate professors are
affiliated with Aarhus University Hospital Psychiatry.
e UH employed 1476 full-time staff members on the
15th of November 2018; the corresponding number at
the four regional hospitals was 1163 (ranging from 171
to 493). ere is a considerable shortage of psychiatrists
in Denmark, particular at the RHs throughout Denmark;
this is also and in particular the case for CDR [19].
Mental Health Act concerningrestrictive practices
e use of restrictive practices in psychiatry is regulated
by the Mental Health Act (MHA), which states that RP’s
can only be applied to patients admitted to a psychiatric
hospital and must be prescribed by psychiatrists. e
MHA regulates; involuntary admissions and detentions,
involuntary treatments (acute and prolonged medication,
ECT, nourishment), restraint (mechanical or by staff),
surveillance by staff, and involuntary treatment of life-
threatening somatic conditions [20, 21].
In 2014 the Government and the Regions (hospital
owners) decreed that the overall level of restrictive
practices described in the MHA should be reduced,
and the number of individuals prescribed mechanical
restraint should be halved by 2020. To achieve this goal,
all five Regions implemented Safewards [22].
Legislation concerningrestrictive practices
e Danish MHA defines coercion as:” measures for
which there is no informed consent” [21].
Informed consent is provided based on adequate
information from the healthcare professional about
the state of health, treatment options, the risk of
complications and side effects. e consequences of non-
treatment must also be informed. e consent is only
valid if it has been given voluntarily. us, consent is
invalid if it is given under unacceptable pressure, coercion
or concealment of the truth [23]. In mechanical restraint,
a belt is applied around the waist and sometimes straps
for the extremities to fix the patient to a bed. Mechanical
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Harpøthetal. International Journal of Mental Health Systems (2022) 16:53
restraint must be accompanied by 1:1-surveillance.
Involuntary acute medication is administering acute
medication (oral, intramuscular, or intravenous) without
informed consent. e coercion to administer the
medication may be physical or psychological.
Study design
e study is designed as a naturalistic retrospective
quasi-experimental pre—and post-study that includes
admissions for all individual patients (N = 7.566)
admitted to all the psychiatric hospitals (RHs and UH)
in CDR from the 15th of November 2017 to the 16th of
November 2019. We compare the use of RP stratified
by RH and UH one year before and one year after the
relocation of the UH, which took place in mid-November
2018. We set the relocation date to the 16th of November
2018. e RHs did not relocate; furthermore, the internal
organizational structure and training on restrictive
practices remained the same. e RHs thus serve as a
comparison group for the "relocation" patient population
at the UH.
Total dataset
e data included a total of 19.567 admissions from CDR
during the study period. e admitted patients at the
RH were older, and a higher proportion were females
(Table1).
Data andoutcome measures
We drew data from the CDR Business Intelligence (BI)
portal, which contains data from the electronic patient
record and the national register for restrictive practices
in psychiatry. Our dataset constitutes a complete
sample during follow-up of all admitted patients and
corresponding RPs at CDR psychiatric hospitals. e
outcomes of RPs were; total numbers of RPs, mechanical
restraint, and involuntary acute medication.
To evaluate changes that may affect the use of RP dur-
ing follow-up, we included data on: patient age and gen-
der, hospital of admission (UH versus RH), length of stay,
readmission proportion, date of admission, and foren-
sic status (forensic patient versus not). For each admis-
sion, we selected the highest-ranking diagnosis in the
Table 1 All admissions at the University and Regional Psychiatric Hospitals in Central Denmark Region before and after the relocation
of the University Hospital on November 16th 2018. Demographic, diagnostic and clinical characteristics of admissions
1 November 15th 2017 to November 15th 2018
2 16th November 2018 to November 16th 2019
University hospital p-value Regional hospitals p-value
Pre-relocation
period1Post-
relocation
period2
Pre-relocation
period1Post-
relocation
period2
Demographics, all admissions
Age, years, mean (SD) 38 (17.4) 37 (16.4) 0.0238 40 (17.9) 40 (16.8) 0.074
Sex, female, n (%) 1902 (52) 2038 (55) 0.016 3842 (54) 3739 (58) < 0.0001
ICD- 10 primary diagnosis, all admissions n (%) n (%) n (%) n (%)
F0 Organic mental disorders, n (%) 98 (3) 53 (2) 181 (3) 175 (3)
F1 Psychoactive substance use disorder, n (%) 225 (6) 156 (4) 475 (8) 555 (8)
F2 Psychotic disorders, n (%) 1149 (32) 1228 (35) 1643 (28) 1799 (28)
F3 Mood disorders, n (%) 938 (26) 834 (24) 1147 (20) 1393 (22)
F4 Anxiety disorders, n (%) 436 (12) 374 (11) 984 (17) 968 (15)
F5 Eating disorders, n (%) 136 (4) 113 (3) 53 (1) 40 (1)
F6 Personality disorders, n (%) 364 (10) 450 (13) 586 (10) 689 (11)
F7 Mental retardation, n (%) 42 (1) 46 (1) 116 (2) 75 (1)
F8 Disorders of psychological development,
n (%) 81 (2) 73 (2) 207 (4) 285 (4)
F9 Behavioral disorders in childhood, n (%) 60 (1) 67 (2) 126 (2) 145 (2)
Other diagnoses, n (%) 124 (3) 125 (4) 398 (7) 360 (6)
Total number of admissions, N (%) 3653 (100) 3519 5916 6479
Clinical characteristics, all admissions, N
Readmission within 30 days, n (%) 943 (26) 1031 (30) 0.001 1829 (31) 2346 (36) < 0.0001
Any diagnosis of substance use disorder, n (%) 668 (18) 582 (17) 0.051 1039 (18) 1110 (17) 0.527
Forensic psychiatric admissions, n (%) 540 (15) 658 (19) < 0.0001 754 (13) 832 (13) 0.873
Page 4 of 11
Harpøthetal. International Journal of Mental Health Systems (2022) 16:53
International Classification of Diseases, tenth revision
(ICD-10) as the primary diagnosis, excepting F1 diagno-
ses [24]. F1 diagnoses were only registered as a primary
diagnosis if this was the only diagnosis. Furthermore, we
constructed a variable, substance use disorder (SUD), if
any F1 diagnosis was registered during the study period.
For all RPs regulated according to the Mental Health
Act, we included; type, date, and duration. e Act was
revised twice during follow-up, and one type of RP was
removed with the revision May 2019 [25] due to lack of
use (< 10 incidents per year in CDR). Seclusion and time-
outs are not permitted according to the MHA.
Relocation; thenew hospital
e relocation of the UH took place in mid-November
2018. e old UH was inaugurated in 1852 outside the
centre of Aarhus [26]. e new UH is purpose-built on
Aarhus’s somatic university hospital campus. e new
UH was designed to improve; 1) security for patients,
staff and the public, 2) efficiency of in and outpatient
treatment, 3) somatic treatment for psychiatric patients
by closer proximity to the somatic hospital and 4) social
well-being [27].
A large part of the old UH buildings maintained the
outwards appearance of an asylum. Contrastingly, the
new UH resembles the adjacent somatic hospital. e
new UH has 257 beds, a reduction of 7 beds compared
to the old UH. e number of beds at the RH was 253
throughout the study period. Security for staff, patients,
and community and patient privacy are prioritised.
Both the new and old UH features mostly single rooms,
whereas the new UH patient rooms all have large ensuite
bathrooms. e wards at the new UH have airlocks,
wider halls, and anti-suicidal features avoiding ligature
points and hiding cables. At the old UH, fencing provided
perimeter control for shared gardens, and access to fresh
air was limited. e new UH has structurally integrated
courtyards, providing patients unlimited access to round-
the-clock outdoor areas. At the new UH, four 16-bed
wards were merged into two 26-bed wards. e m2 per
patient in general psychiatry increased from 55 m2at
the old UH to 67 m2 at the new hospital, patient rooms
increased from 15.5 m2 to 18.6 m2, and the area for
activity rooms increased from 48,5 to 60.6 m2.
During the study period, the number of admissions
declined at the UH and increased at the RHs. e decline
in admissions was, among others, probably caused by
the decrease in beds at UH; furthermore, the catchment
area for UH decreased at the new UH while a similar
increase took place at RHs. Finally, patients could refer
themselves to the psychiatric emergency room at the old
UH, whereas referral from a physician is required at the
new UH (Table1).
Statistical analysis
We used descriptive statistics to quantify the
characteristics of the study population, use of RP, and
admissions. We used the chi-square test to examine the
following categorical: sex, type of coercive measure,
diagnosis, forensic psychiatric patients, and diagnosis
of substance use disorders (ICD-10, F1). We used the
Mann–Whitney U test on the numerical variables: age,
duration of manual restraint, duration of mechanical
restraint, and length of admission at the time of the
coercive measure.
We applied linear regression analysis to assess change
or trend in the monthly frequency of RP. e use of linear
regression enabled us to examine if any changes in the
underlying trend in the use of RPs could be attributed
to the relocation of the UH. Linear regression models
were fitted to examine the effect of relocation, stratified
on location, allowing for different slopes pre and post-
relocation and with and without continuity at the point
of relocation. ese models were compared using
likelihood-ratio tests to a model that enforced the same
linear slope throughout the study period.
Data management and analyses were conducted using
Stata 16 software [28].
Ethics anddata security
e study was registered at the Central Denmark Region
Research Database (file number: 1-16-02-9-20) and
approved by the Danish Patient Safety Authority (file
number:31-1521-146).
Results
Changes inadmission patterns duringthestudy period
e number of admissions fell (from 3.653 to 3.519) at
the UH during the study period, whereas it increased at
RH (5.916 to 6.479). During the study period, the main
change in admission pattern was a significant increase at
both UH and RH in the proportion of readmissions and
females admitted. e proportion of admissions where
the patient had any substance use disorder diagnosis did
not increase at either UH or RH. e overall diagnostic
distribution remained fairly stable during the study
period at both RH and UH (Table1).
Restrictive practices
A total of 13.965 RPs were prescribed for 2.114 indi-
vidual patients in CDR during the observation period.
At UH, the number of RPs performed decreased from
4.073 before relocation to 2.585 after relocation, whereas
it remained stable (from 3.676 to 3.631) at RH (Table2).
roughout the study period, the overall use of RPs was
lower at the RH compared to the UH when measured as
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Harpøthetal. International Journal of Mental Health Systems (2022) 16:53
RPs per admission: with 0.9 RP per admission at UH ver-
sus 0.6 at the RHs.
e proportion of involuntary admissions
(involuntary admission/all admissions) remained stable
after the relocation (UH: 12% before and after; RH: 11%
before and 12% after).
e proportion of restrictive practices performed
during the first 24h of admission at UH increased from
33% (1332/4073) pre-location to 42% (1096/2585) post
relocation (chi2 p < 0.0001), at RH it increased from 44%
(1630/3676) to 52% (1885/3631) (chi2, p < 0.0001).
At UH, the median length of mechanical restraint
increased from 5.8h (IQI 2.0—15.1) to 6.8h (IQI 2.5—
18.8) post-relocation (two-sample Wilcoxon rank-sum
test, p = 0.011). Correspondingly at RH, the median
length of mechanical restraint increased from 7.8 h
(IQI 2.4—16.1) before to 9.2 h (IQI 3.5—18.3) two-
sample Wilcoxon rank-sum test (p = 0.0425).
Using linear regression analysis, we found an overall
significant decrease in the use of all restrictive practices
at UH with an inclination of -9.1 observations (95% CI
-12.0;-6.3 p < 0.0001) per month throughout the two-
year follow-up. However, the decrease post-relocation
did not deviate significantly from the already downward
trend observed one year before relocation. Similar anal-
yses performed for RH showed a stable use of coercion
(Fig.1). us, we did not find evidence to support the
hypothesis of significantly different slopes pre- and
post-relocation for the total use of coercive measures in
either of the two locations.
Use ofmechanical restraint andinvoluntary acute
medication
For both UH and RH, mechanical restraint and involun-
tary acute medication were aligned (Figs.2 and 3), and
the post-relocation slopes did not deviate significantly
from the observed trend before the location.
Overall, the numbers for mechanical restraint and
involuntary acute medication numbers at the UH were
nearly halved during the study period, whereas the
numbers for manual restraint remained fairly stable
(from n = 373 to n = 367) ( Table2).
e numbers for mechanical restraint, manual
restraint, and involuntary acute sedation at the RH
decreased (Table2).
Use ofrestrictive practices insomatic wards
Linear regression analyses showed a stable use of
mechanical restraint on patients stationed in the somatic
wards at UH, whereas RH had a minor insignificant
increase (data not shown).
Table 2 All restrictive practices at the University and Regional Psychiatric Hospitals Central Denmark Region before and after
relocation of the University hospital November 16th, 2018
1 November 15th 2017, to November 15th 2018
2 November 16th 2018, to November 16th 2019
University hospital p-value Regional
hospitals p-value
Pre-relocation1Post-relocation2Pre-relocation1Post-relocation2
n (%) n (%) n (%) n (%)
Restrictive practices
Involuntary admission 454 (11) 403 (16) < 0.0001 657 (18) 771 (21) < 0.0001
Involuntary detention 284 (7) 204 (8) 0.161 317 (9) 320 (9) 0.774
Locking of doors for an individual patient 176 (4) 99 (4) 0.326 262 (7) 222 (6) 0.082
Mechanical restraint 788 (19) 373 (14) < 0.0001 360 (10) 345 (10) 0.673
Straps (wrists and ankles) 555 (14) 295 (11) 0.008 246 (7) 272 (8) 0.183
Manual restraint 373 (9) 367 (14) < 0.0001 427 (12) 355 (10) 0.011
Involuntary personal shielding for more than 24 h 8 (0) 7 (0) 0.533 4 (0) 6 (0) 0.514
Involuntary acute medication 1202 (30) 628 (24) < 0.0001 1119 (30) 981 (27) 0.001
Involuntary treatment 82 (2) 54 (2) 0.831 118 (3) 110 (3) 0.657
Involuntary electroconvulsive therapy 15 (0) 8 (0) 0.690 14 (0) 30 (1) 0.014
Involuntary nutrition 20 (1) 45 (2) < 0.0001 6 (0) 18 (1) 0.013
Involuntary treatment of a somatic disorder 94 (2) 86 (3) 0.012 138 (4) 184 (5) 0.006
Other 22 (1) 16 (1) 0.677 8 (0) 17 (1) 0.067
Total number of restrictive practices (N) 4073 2585 3676 3631
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Harpøthetal. International Journal of Mental Health Systems (2022) 16:53
Fig. 1 Restrictive practices at the University and Regional Psychiatric Hospitals Central Denmark Region by pre-and post-relocation of the University
hospital November 16th 2018
Fig. 2 The use of involuntary acute medication and mechanical restraint at the Regional Hospitals in Central Denmark Region 2017–2019 before
and after relocation of the University Hospital November 16th 2018
Page 7 of 11
Harpøthetal. International Journal of Mental Health Systems (2022) 16:53
Discussion
Summary ofresults
We conducted a register-based retrospective quasi-
experimental pre—and post-study with a relocation
group (UH) and a comparison group (RH) to examine
the effect of structural changes on the use of restrictive
practices in Denmark from 2017 to 2019. Our main
findings were as follows; first, the actual number of RPs
decreased at the relocation hospital (UH) compared to
the comparison hospitals (RHs); however, this decrease
was not significantly different from the expected
underlying trend. Secondly, mechanical restraint and
acute involuntary medication were aligned, and there
was no indication that a decrease in mechanical restraint
was substituted with increased use of involuntary acute
medication. To some extent, mechanical restraint was
substituted with manual restraint. Finally, the use of RPs
in the somatic wards (involuntary treatment of somatic
disorder) remained fairly stable at the UH while it
increased slightly at the RHs.
The eect ofimproved structural surroundings onthetotal
use ofRP
Our results should not be interpreted to indicate
that improvement in structural surroundings had no
effect. Even though our results were not statistically
significant in the linear regression analysis, we argue
that the improved structural surroundings reinforced
or maintained the declining use of RPs observed at the
UH. Firstly, organizational changes are often marred
by considerable challenges, especially in their early
stages, and often, changes fail to meet the stated goals
[29]. is may, in part, be attributed to the impact of
change in work practices and environments challenging
humans’ fundamental need for stability [30]. Moreover,
changes in work practices and environment have been
shown to reduce organizational commitment and
productivity and increase work-related stress [31]. Our
study did not measure these parameters, nor did we
include any data concerning staff turnover. However,
the relocation caused considerable organisational
upheaval and staff turnover. e staff turnover mainly
consisted of staff changing from one position (ward/
outpatient clinic) at the old UH to another at the new
UH, which meant that the input of "new staff" was very
low. us, the main change due to the relocation was
the disruption of multidisciplinary teams and groups,
which could be argued to affect clinical performance
negatively [32]. On the other hand, it might be
hypothesized that the continued decrease of restrictive
practices during relocation might be linked to robust
organizational resilience [33].
ese disruptions posed a greater risk of increasing
RPs rather than decreasing them, indicating that the
Fig. 3 The use of involuntary acute medication and mechanical restraint at the University Hospital the University in Central Denmark Region
2017–2019 before and after relocation of the University Hospital November 16th 2018
Page 8 of 11
Harpøthetal. International Journal of Mental Health Systems (2022) 16:53
changed structural surroundings here may have played
a key role in continuing the downward trend. Secondly,
RH and UH are part of the same organisation and
are governed by identical procedural and dynamical
factors. us, the main differences between RH and
UH during the study were the structural change of
relocation at UH.
irdly, one of the aims of the new UH hospital was to
increase safety and security by reducing violence. us,
the new UH was designed to reduce crowding, provide
private space, and promote well-being by using natural
light, all of which have been suggested as instrumental
when reducing violence in psychiatric wards [34, 35].
Rohe et al., who examined the effect of a hospital
relocation on mechanical restraint in a before and
after study without a control group, found a significant
decrease in the number of patients subjected to
mechanical restraint after relocation and attributed it to
the following: the considerable structural improvements
(i.e., single rooms, more light) in the new hospital,
increased training of staff in de-escalation measures
and changes in legislation during the study period [36].
Similar results and deliberations have been found by
others who studied the effects of relocations in psychiatry
[11, 37]. Furthermore, a recent rapid systematic review
found "preliminary evidence that physical design features
of mental health facilities can reduce the use of seclusion
and physical restraint” [13].
e overall RPs per patient subjected to RPs admission
were higher at the UH compared to RH. According to
the Danish Mental Health Act, RPs must be prescribed
by a psychiatrist. e number of MDs per patient
was considerably higher at the UH than at the RH.
In line with Roemer’s law which states that there is
a relationship between hospital bed availability and
inpatient hospitalization rates, our study might indicate
an iatrogenic impact of MD on restrictive practices as
these can only be prescribed by an MD [38]. According to
hospital planning, the UH is regulated to treat the most
treatment-resistant and complex patients from the entire
CDR. However, our data do not allow us to examine and
describe to what extent this actually affects the patient
population at the UH, and, ultimately, the use of RPs.
Substituting restrictive practices
Restrictive practices are often divided into four
categories: therapy by use of RP (prescription of
medication), use RP without primary purpose (chemical
restraint), separation (e.g., seclusion), and mechanical
restriction (e.g., restraint by belts and straps). Tradition,
legislation, and culture seem to determine preferences
when using restrictive practices [39, 40]. In line with
a Danish study examining the effect of Safewards on
RP [41], we found that the prescription of involuntary
medication and mechanical restraint was aligned with
a simultaneous decrease in both mechanical restraint
and involuntary acute medication. Similarly, a Danish
study found that a reduction in the use of mechanical
restraint did not increase the overall use of antipsychotics
and benzodiazepines [42]. Contrastingly, a nationwide
Dutch study found that even though seclusion decreased
significantly, “forced medication” increased; however,
the pattern was not uniform as the rates varied between
hospitals [43]. Our study does not include any data on
other compensating reactions, such as increasing use
of informal coercion or sedatives [44]. Still, we have no
reason to believe these should differ at RH and UH.
e use of manual restraints remained stable at the
UH, while the use of mechanical restraint and acute
involuntary medication decreased; thus, we did not
find that “a ban of one kind of measure seems to lead to
an increase of others” [39]. It has been put forward that
the nursing staff finds manual restraint challenging to
perform, confrontational, and negatively affects the
relationship with the patient [45]. To prevent protracted
manual restraints, the Danish National Board of Health
issued a maximum length of manual restraint of 30min
in 2020 [46]. e least restrictive and most effective
RP may be decided by individual patient preferences,
legislation, culture, and the context of action. is lack
of clarity can be attributed to a lack of sound scientific
evidence, especially a lack of a system for description
and measurement. A way forward has been described
with the Dundrum Restriction and Intrusion Liberty
Ladders (DRILL) that supports clinicians in reviewing
their practices and those of their peers and when
demonstrating proportionality to outside reviewers [1].
The use ofcoercion insomatic wards
Overall, the use of RP did not decrease in CDR during
the study period; this cannot be explained by “boarding”
in somatic emergency wards [47] as there are psychiatric
emergency wards in all CDR psychiatric hospitals. We
propose it might be due to the possible lag of training in
de-escalation and specific treatment needs of psychiatric
patients, as somatic wards did not participate in the
implementation of Safewards. It is also possible that
restrictive practices are used for very different conditions
in somatic wards, such as delirium, organic and
withdrawal states.
Strengths andlimitations
Results concerning the possible long-term Hawthorne
effects are scarce, and only a few studies have
demonstrated effects beyond six months [48].
Nevertheless, it cannot be ruled out that the decreasing
Page 9 of 11
Harpøthetal. International Journal of Mental Health Systems (2022) 16:53
use of RPs at the UH might be attributed to the
Hawthorne effect.
RP and aggression prevention models in psychiatric
wards are characterized by multifaceted and
multidisciplinary approaches [4, 11, 49, 50]. e design
features at the new UH aimed at reducing stress were
implemented simultaneously. Furthermore, relocating
and innovating an entire hospital has all the features of
a complex intervention [51]. Consequently, this study
can provide conclusions on individual measures such as
ligature points, increased daylight and other measures.
Even though our study includes all admissions and
restrictive practices from the self-contained CDR, which
includes approximately 23% of the Danish population,
our results can only be generalized to other countries
with considerable caution due to the considerable
international differences in legislation, clinical practices,
and use of restrictive practices [52].
e UH (relocation group) and RHs (comparison
group) were not entirely comparable, as the use of RPs
at the RHs was lower (restrictive practices/admission)
before the relocation compared to the UH. However, the
UH is situated in a larger city and is obligated to treat the
most complicated and treatment-resistant patients in
Central Denmark Region, both of which might increase
the actual use and decrease the possibilities of reducing
RPs. Despite this, the UH succeeded in a continuous
reduction of RPs during the study period as opposed
to stagnation in the use of RPs at the RH. RH and UH
are part of the same administrative organization and
are governed by identical procedural and dynamical
factors. us, the main difference between RH and UH
during the study was the structural change of relocation
at UH. Also, the UH and RH were comparable on
clinical measures that may affect the use of RPs, such
as readmissions, diagnostic admission patterns, and the
proportion of patients with substance use disorder [53].
We collected data from a regional database for
RP measures, which is continuously and thoroughly
validated according to guidelines issued by e Danish
Health Data Authority [54]. Furthermore, it is legally
mandated to report all restrictive practices. us,
selection bias and loss to follow-up are negligible.
Implications forclinical practice andresearch
As several reviews have highlighted the relationship
between the structural environment and health outcomes
[6, 13, 55], clinicians need to be mindful of the effect of
their physical surroundings in this vulnerable patient
group [56]. Leaders need to be conscious of the impact
of design decisions on treatment, therapeutic safety and
security, and patient autonomy. Decisions on building or
remodelling psychiatric facilities should be based on a
complete framework [6]. is study’s alignment between
mechanical restraint and involuntary acute medication
supports the proposal that restrictive practices can be
reduced simultaneously without a substitution effect
between the two [1].
Most models and studies that aim to reduce the use of
RPs primarily focus on intramural factors, such as the
culture in wards, the physical environment, training of staff,
risk- assessment of inpatient violence, and the inclusion
of patients in care decisions [4, 11]. However, a Danish
study including 235 admitted patients found that RPs were
predominantly prescribed during the very first hours of
admission and that the risk of being subjected to RPs was
significantly higher if a patient was involuntarily admitted
(OR = 6.4 (3.4–11.9)), or were intoxicated by substances at
admission (OR = 3.7 (1.7–8.2)). us extramural factors,
such as outpatient treatment, accessibility to municipality
services and substance abuse treatment, may impact the
risk of being subjected to RPs once admitted [57]. us, our
study indicates an untapped potential for the prevention
of RPs as the proportion of RPs during the first 24 h of
admission increased at both RH and UH during the study
period.
is retrospective study aims to answer a narrow
question and does not consider other possible impacts,
nor does it consider how the new hospital interacted with
the context in which it was implemented. To fully evaluate
and understand the effects of a hospital relocation, we
need to develop a theoretical framework, evidence-based
indicators and methods [55].
Conclusion
e naturalistic features of the design preclude any
definitive conclusion whether relocation to a new purpose-
built hospital decreased the use of RPs. However, we
argue that improving the structural environment at the
UH had a sustained effect on the already declining use of
RPs, particularly mechanical restraint and involuntary
medication.
Acknowledgements
We are grateful to the Aarhus University Hospital Psychiatry staff, especially
Mads Sinding Jørgensen, Niels Bjørn Aller, Jørn Nielsen, and Inge Voldsgaard.
Author contributions
The study protocol was designed by AH, HK, MDT and LUS with input from BN
and AHC. AH and BN performed the data collection with input from AH, AHC
and LUS. AH, BN and AHC performed data analyses with input from HK and LU.
AH, MDT and LU drafted the manuscript. AHC, AH and LUS drafted the tables
and figures with input from HK and MDT. AH, LUS, HK, AHC, BN, and MDT
contributed substantially to the interpretation of findings and manuscript
revision. All authors read and approved the final manuscript.
Funding
This work was funded by the Central Denmark Region Psychiatric Research
Foundation (1-30-74-74-19) and the Department of Forensic Psychiatry,
Aarhus University Hospital Psychiatry. Funders were not involved at any study
Page 10 of 11
Harpøthetal. International Journal of Mental Health Systems (2022) 16:53
design stage, data collection or analysis, interpretation of data, writing of, or
the decision to submit this manuscript for publication.
Availability of data and materials
Data are not available.
Declarations
Ethics approval and consent to participate
The study was registered at the Central Denmark Region Research Database
(file number: 1-16-02-9-20) and approved by the Danish Patient Safety
Authority (file number:31-1521-146). No patients have been contacted.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests related to the manuscript.
Author details
1 Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry,
Skejby, Denmark. 2 Trinity College, Dublin University, Dublin, Ireland. 3 National
Forensic Mental Health Service, Dundrum, Ireland. 4 DEFACTUM, Central
Denmark Region, Aarhus, Denmark. 5 Department of Clinical Medicine, Faculty
of Health, Aarhus University, Aarhus, Denmark.
Received: 3 May 2022 Accepted: 24 October 2022
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