The effectiveness of the Motion Room in the prevention of violent behavior and physical restraint in acute psychiatric inpatient units: a cross-sectional survey incorporating a pre-post design

Enkeleda Gjini1, Emanuela Prendi1, Stefano Terzoni2, Vittorio Oliverio3, Alberto Bisesti4, Margherita Lorusso5, Federico Ruta6, Armando D’Agostino7, Paolo Ferrara4,5

1Department of Biomedical Sciences, University “Nostra Signora del Buon Consiglio”, Tirana, Albania; 2Department of Biomedical Sciences for Health, University of Milan “La Statale”, Milan, Italy; 3Department of Mental Health, San Paolo teaching hospital, Milan, Italy; 4San Paolo teaching hospital, ASST Santi Paolo e Carlo, Milan, Italy; 5San Paolo bachelor school of Nursing, San Paolo teaching hospital, Milan, Italy; 6General Direction, Health Agency BAT, Andria, Italy; 7Department of Health Sciences for Health, University of Milan, Department of Mental Health and Addiction, ASST Santi Paolo e Carlo, Milan, Italy.

Summary. Background. Violent behaviours continue to be a significant problem worldwide. The introduction of Motion Rooms, particularly within acute psychiatric settings, can provide a safe and therapeutic intervention that, by promoting emotional self-regulation, reduces emotional distress and aggressive behaviors. Aim. To assess the effects of a therapeutic intervention through the use of the Motion Room on the risk of violent behavior and the use of physical restraint. Materials and methods. A longitudinal design was used to evaluate the effectiveness of the Motion Room in an acute psychiatric unit. The Italian version of the Broset Violence Checklist (BVC-ita) was used for the assessment of the risk of aggression before (T0) and 2 hours after intervention (T1). Results. 102 patients were enrolled, 96 (94.12%) completed the intervention. The number of subjects at moderate/high risk decreased significantly at T1 (p=0.01). In the two hours following the intervention, one patient was subjected to physical restraint. Conclusions. Our results suggest that sensory rooms can be a strong support for nursing staff in preventing aggressive behavior in an acute psychiatric ward. Further research with broader sampling and randomized studies is needed.

Key words. Aggressive behaviour, Motion Rooms, physical restraint, sensory stimulation.

L’efficacia della Motion Room nella prevenzione dei comportamenti violenti e della contenzione fisica nel servizio psichiatrico di diagnosi e cura: studio cross-sectional con disegno pre-post.

Riassunto. Introduzione. I comportamenti violenti continuano a rappresentare una criticità soprattutto in setting psichiatrici acuti, all’interno dei quali l’individuazione dei soggetti a rischio e l’attuazione di strategie preventive sono fondamentali per garantire la sicurezza dei pazienti e del personale. Le Motion Rooms sono spazi terapeutici che, attraverso la stimolazione sensoriale, mirano a favorire, grazie all’autoregolazione emotiva, la de-escalation dell’aggressività. Scopo. Valutare l’impatto della Motion Room all’interno del Servizio Psichiatrico di Diagnosi e Cura sul rischio di comportamenti violenti e sull’uso della contenzione fisica. Materiali e metodi. È stato condotto uno studio cross-sectional; sono stati arruolati tutti i pazienti sottoposti a un intervento all’interno della Motion Room nel periodo di studio. La versione italiana della Brøset Violence Checklist (BVC) è stata somministrata prima (T0) e 2 ore dopo l’intervento (T1). Le analisi statistiche sono state condotte con SPSS v.23. Risultati. Sono stati arruolati 102 pazienti, 96 (94,12%) hanno portato a termine l’attività proposta. Il numero di soggetti a rischio moderato/alto è diminuito significativamente due ore dopo l’intervento (p=0,01). Nelle due ore successive all’accesso un paziente è stato sottoposto a contenzione fisica. Conclusioni. I risultati emersi suggeriscono che le stanze sensoriali possono rappresentare un valido supporto per l’infermiere nella prevenzione dei comportamenti aggressivi nei Servizi Psichiatrici di Diagnosi e Cura (SPDC). Sono auspicabili approfondimenti con campioni più ampi e studi randomizzati.

Parole chiave. Comportamenti aggressivi, contenzione fisica, stanze multisensoriali, stimolazione sensoriale.

Background

Within the healthcare landscape, violent behaviour continues to be a significant problem, particularly in acute psychiatric settings1. In fact, the prevalence of aggressive behaviour is estimated at 8% to 76%, with a weighted average of 54%2. Violent conduct as an expression of a person’s aggression is a multifactorial phenomenon and, as such, can be influenced by intrinsic risk factors – i.e., specific to the person – and extrinsic factors, such as environmental and organizational aspects of care places2. The priority for organizations and health professionals is therefore to quickly identify those at risk and, consequently, implement preventive measures to ensure the collective safety of patients, operators and carers.

Living and dealing with violent behavior can be a challenging experience, physically and mentally: operators who are victims of aggression can report physical but also psychological consequences such as anger, anxiety, fear and guilt that in the long term can be associated with burnout and the desire for professional abandonment2. At the same time, aggressors are often subjected to physical and pharmacological restraint measures. The literature provides evidence to support the fact that physical restraint, practice still widespread for the management of violent instances3, is the cause of extensive clinical, ethical and legal discussions4,5 and has a series of consequences: in addition to the adverse physical effects, such as circulatory complications, skin lesions, nerve compression paralysis, respiratory compromise, muscle dysfunction, and in extreme cases even death, there are a series of psychological effects that can then lead to post-traumatic stress disorder6. Furthermore, the appearance of loss of trust in health personnel, as well as increased distrust, or lack of confidence in them, and non-compliance with treatment7,8.

The adoption of de-escalation approaches can be a significant breakthrough in ensuring the dignity and safety of patients while reducing the risks associated with physical restraint9,10. One approach shown to be effective is sensory stimulation11. The literature suggests that sensory intervention can calm, soothe and regulate the emotional distress of patients with mental disorders12,13. Through sensory stimulation, positive responses are elicited that can stabilize the individual’s mood, promote relaxation, improve self-care skills, and strengthen the nurse-patient relationship13. The introduction of Motion Rooms (also known as Sensory Rooms or Mental Rooms) within acute psychiatric settings can provide a safe and comfortable therapeutic space that promotes emotional self-regulation, reduces distress and disruptive behaviors; this through the use of visual, auditory, olfactory, tactile, gustatory, vestibular and proprioceptive equipment that can help promote the regulation of emotions11,14; these can include lights, visual projections, music, auditory experiences, tactile or olfactory stimulation, vibrations and anything else that can stimulate the senses. In the study by Doroud et al.15, the use of sensory rooms was associated with reduced stress, anxiety, and aggressive behaviours in patients, as well as improved general well-being and self-regulation capacity. Within a Motion Room, the individual has the opportunity to develop an understanding of their sensory responses and use this increased self-awareness to aid emotional regulation, thereby improving their daily functioning and reducing the risk of manifesting emotional dysregulation behaviours16, such as, first and foremost, aggressive conduct.

Despite the favourable premises, consolidated data on the effectiveness of mental rooms are currently not available16. The absence of scientific evidence represents an important gap that justifies further studies to evaluate its effects on different outcomes, the risk of violent behaviour and the use of physical restraint.

Methods

The study

We conducted an observational study to describe the use of the Motion Room within the Psychiatric Diagnosis and Treatment Service for acute inpatients. A longitudinal design (T0= pre-intervention assessment; T1= 2-hour post-intervention assessment) was used to evaluate its effectiveness in reducing the risk of violent behaviour. Data collection was conducted from March 1 to July 21, 2025. Subjects admitted to the Psychiatric Diagnosis and Treatment Service of the San Paolo Hospital in Milan who, during the study period, requested or accepted the nurses’ proposal to carry out activities within the department’s Motion Room, a new multisensory room equipped to facilitate the de-escalation of patients’ aggression, were enrolled. The inclusion criteria were:

• adult patients;

• state of increasing psychomotor agitation perceived by the patient or by the judgment of the staff;

• acceptance of the proposed intervention;

• absence of physical or pharmacological restraint (for management of psychomotor activation or aggression) in the 2 hours prior to the proposal.

Subjects who had conditions that contraindicated the activity (e.g. patients subjected to physical restraint in conditions of severe and uncontrolled psychomotor agitation) were excluded.

Ethical considerations

All data were collected and processed, guaranteeing the anonymity and confidentiality of the participants. The study was conducted in compliance with the principles of the Helsinki Declaration and the current Italian privacy legislation (Legislative Decree 196/2003) and submitted to the prior opinion of the Strategic Management and the Hospital Nursing Management.

Statistical considerations

Continuous variables were described using standard deviation, median, and quartiles when not normally distributed. Categorical variables were described with frequencies and percentages. The chi-square test was used to compare the frequencies of at-risk and non-at-risk subjects across the two measurement times. The significance threshold for all analyses was set at 5%. At the end of the data collection period, they were entered into an Excel file and subsequently analysed using SPSS 23.0 (SPSS, Inc., Chicago, IL, Usa).

Description of the tool

A data collection sheet was created, including the following sections:

• sociodemographic and clinical data: age, sex, diagnosis and reason for hospitalization; use of additional pharmacological therapies and physical restraint 2 hours after the intervention, the Italian version of the Broset Violence Checklist (BVC-ita)17 before (T0) and 2 hours after the intervention (T1) for the assessment of the patient’s state of psychomotor agitation;

• data relating to the intervention: modality (individual or group), shift, duration, type of activity carried out (lighting equipment, punching bag or both), completion or not of the activity and the reason for any interruption;

• reporting of the possible use of physical restraint or the intake of additional pharmacological therapies for the management of psychomotor aggression in the 2 hours following surgery.

The intervention: the Motion Room

The Motion Room is a space dedicated to a non-pharmacological behavioural de-escalation intervention, introduced in February 2025 at the Psychiatric Diagnosis and Treatment Service of the San Paolo teaching Hospital (ASST Santi Paolo e Carlo, Milan). The environment is designed to provide controlled sensory and motor stimuli, aiming to promote emotional regulation in patients at risk of psychomotor agitation or aggression. The floor is covered with rubber mats that provide anti-trauma functionality and tactile sensory stimulation. The padded walls help to reduce the transmission of sounds from both inside and outside, increasing the perception of privacy and security. The room is equipped with a glass window adjacent to the door to ensure visibility and continuous nursing supervision. In contrast, a large side window provides natural lighting, creating a welcoming, non-coercive environment. Inside the room (which measures about 15 square meters), there are two main devices: a “Reax Boxe” punching bag and a Reaxing “Train to React” interactive light wall; both designed to promote physical activation, concentration, and the controlled channelling of energy. The proposed exercises can be modulated in intensity and duration based on the patient’s psychophysical condition and are supervised by nursing staff who are previously trained in their use. The Reax Boxe is an interactive punching bag with built-in LED lights that illuminate at different points on the bag, indicating where to hit. It can be connected to the Reaxing system to create responsive boxing workouts that combine punches and kicks with visual stimuli. The main objective of the Reaxing light wall is to train body and mind together, stimulating responsiveness, coordination, strength and agility through exercises that include visual, sound or tactile stimuli. It has a touchscreen from which one can choose programs, exercises, or tests. It uses light and/or acoustic signals that indicate what to do and when to do it.

Results

Sociodemographic characteristics of the sample

One hundred two patients were enrolled during the study period; median age was Me=35.0 years [25; 38.75]; 27 (26.47%) were female, 75 (73.53%) were male. Fifty-one subjects had a Psychotic spectrum disorder (50%). The main reason for hospitalization in the psychiatric unit was a condition of psychomotor agitation (n=40, 39.22%), followed by Psychotic decompensation (n=28, 27.45%) and self-injurious ideation or conduct (n=25, 24.51%). At T0, 11 patients (10.78%) had a moderate risk (BVC-ita score 1-2) of aggressive behaviour, 1 had a high risk (BVC=3).

Table 1 summarises the sociodemographic and clinical characteristics of the sample.




Using the Motion Room

Eighty-one subjects (79.41%) used the Motion Room alone, and 21 (20.59%) used it as part of a group activity. The activity was mainly carried out during the afternoon shift (n=70, 68.63%). The median duration was 30 minutes [30; 60] (min 10, max 90). The predominant activity chosen by the participants was sensory stimulation through a physical activity program, including punching the punching bag (n=49) (table 2).




Ninety-six participants (94.12%) completed the proposed activity; 6 interrupted it earlier. The main reason for the interruption was fatigue reported by the participants (n=5); in 1 case, the nurse suspended the operation after perceiving an increase in the patient’s agitation. In no case was it necessary to administer additional pharmacological therapies or to implement physical restraint during or immediately after the activity.

Comfort room: effectiveness outcomes

In the 2 hours following the end of the activity (T1), despite no changes in the prescribed pharmacological therapy, 10 subjects (9.80%) initiated additional pharmacological therapies, and 1 (0.98%) was subjected to physical restraint for psychomotor agitation and heteroaggression. About the impact of activity on the risk of aggressive behaviour, the number of subjects at risk (score >0) decreased significantly two hours after the activity (p=0.01) (table 3).




The reduction in the proportion of patients at risk of aggressive behaviour (BVC >0) from T0 to T1 was statistically significant (χ²=٥.٨٣, p=٠.٠١) and showed a small-to-moderate effect size (phi=٠.١٧, ٩٥٪ CI ٠.٠٤-0.31).

Conclusions

Prompt identification of patients at risk of hetero-directed violence, and consequent implementation of preventive measures to ensure the safety of both patients and professionals, is one of the priorities of health systems18, particularly within the contexts most at risk, such as mental health2,19. The results of this study suggest that the creation of the Motion Room and its use, guided by nursing staff within a therapeutic program, can have a positive impact on multiple outcomes of interest, such as reducing the risk of violent behaviour.

The data collected show minimal use of physical restraint (0.98%) in subjects undergoing surgery; during the same period in 2024 (from March 1 to July 25), prior to the implementation of the Motion Room, the mean prevalence of physical restraint in the unit under study was approximately 12%. In contrast, in the literature, results are heterogeneous: some studies2 observed a significant reduction in restraints with the use of mental rooms, whereas a systematic review16 notes that the evidence in adults is not yet robust or generalizable. It can be inferred that the reduction in the use of coercive practices probably depends not only on the use of a mental health room but also on organisational factors such as the presence of operational protocols, the level of staff training, and integration with other therapeutic strategies15,20, which may vary across contexts.

Another aspect to be emphasized is the limited use of additional drug therapies (9.80%), a percentage lower than that reported in other acute psychiatric wards, where the use of sedative drugs often reaches values between 30% and 50% of hospitalized patients14. This difference is particularly significant and suggests that using the Motion Room can help reduce the need for additional drug therapy, with potential benefits for patient health and service sustainability. The sub-analysis conducted showed a significant reduction in subjects at risk of aggressive behavior in the post-intervention, i.e. after 2 hours from the end of the use of the Motion Room; the number of patients at moderate/high risk according to BVC has increased from 12 to only 3; this data, despite its preliminary nature given the limited sample size, undoubtedly represents a sign of effectiveness. However, it should be emphasized that our analysis does not allow us to attribute with certainty the risk reduction solely to the intervention, concomitant variables, such as environmental factors not considered, could have played a role in this decrease in the score; however, in a study conducted in an acute psychiatric ward dedicated to minors, similar results were found, highlighting how Motion Rooms help reduce the risk of aggressive escalation21.

Half of the sample had a diagnosis of psychotic disorder, and the most frequent reasons for hospitalization were psychomotor agitation, psychotic decompensation and the presence of self-injurious ideation or behaviour. On the one hand, this data provides the sample with good representativeness of the context of acute psychiatric hospitalization. However, it introduces a methodological complexity: diagnostic heterogeneity can confound interpretation of the results, as the impact of the Motion Room may vary by patient’s primary diagnosis. This finding aligns with the literature, which shows that responses to multisensory interventions are not uniform across diagnostic categories. It will therefore be necessary to evaluate the intervention’s effectiveness in the future using larger samples that can represent the full range of major psychiatric disorders. In addition, studies conducted in acute psychiatric settings report that patients with psychotic disorders use comfort rooms more in a phase of increasing agitation, obtaining a decrease in distress and a temporary increase in the sense of control20,22; in mood or personality disorders, on the other hand, the activity seems to be chosen more as occupational therapy and emotional regulation21. This result suggests different intervention objectives for the Motion Room, depending on the reference diagnosis.

An important fact that emerged concerns the methods of access to the Motion Room. The data collected showed that the shift during which patients performed the activity the most was the afternoon shift (68.63% of accesses). This finding could be explained by the fact that, as suggested by Molloy et al.11, in the postprandial period, patients frequently exhibit increased distress and psychomotor tension. Regardless of the reference shift, the activity had a high completion rate (94.12%). This argues in favour of the intervention’s high acceptability and tolerability and is in line with findings from the literature20,22. Another interesting fact is the preference expressed by the majority of patients (79.41%) for single access to the room, which seems to reflect the need to take advantage of an intervention within a protected context that is devoid of social stimuli, in addition to the nursing staff, which could generate increased levels of anxiety or tension for the patient. This concept appears consistent with the literature: sensory interventions are, in fact, more effective when they allow a personalized, patient-centred experience4,16.

This research has limitations: first, the small sample size and the monocentric nature of the research do not allow the results to be generalized to the entire population. Furthermore, the nature of the study, with the absence of a control group, does not allow for establishing a causal link between the use of the Motion Room and the decrease in aggression or the need to resort to restraint measures. Finally, recruitment based on patient request or acceptance introduces a potential selection bias that should be considered; patients who agreed to the intervention may have been more cooperative or less prone to violent behavior than those who refused.

Despite these limitations, the results suggest that Motion Rooms serve as a complementary tool to support nurses in managing psychiatric acuity in the hospital setting. In the future, multicenter studies with larger samples and more robust experimental designs are needed to strengthen the validity of these conclusions. It would also be interesting to extend the research in contexts other than the Psychiatric Diagnosis and Treatment Service, such as the Child Neuropsychiatry Unit, psychiatric therapeutic communities or the penitentiary environment. These results, if confirmed by further research, could contribute to a significant cultural change in clinical practice, favouring non-coercive approaches that focus on the person and respect for one’s dignity, from the perspective of an increasingly humane, safe and effective psychiatry.

Conflict of interests: the authors have no conflict of interests to declare.

References

1. Hvidhjelm J, Berring LL, Whittington R, Woods P, Bak J, Almvik R. Short-term risk assessment in the long term: a scoping review and meta-analysis of the Brøset Violence Checklist. J Psychiatr Ment Health Nurs 2023; 30: 637-648.

2. Weltens I, Bak M, Verhagen S, et al. Aggression on the psychiatric ward: prevalence and risk factors. A systematic review of the literature. PLoS One 2021; 16: e0258346.

3. Belayneh Z, Chavulak J, Lee DA, Petrakis M, Haines TP. Prevalence and variability of restrictive care practice use (physical restraint, seclusion and chemical restraint) in adult mental health inpatient settings: a systematic review and meta-analysis. J Clin Nurs 2024; 33: 1256-81.

4. Forsyth AS, Trevarrow R. Sensory strategies in adult mental health: a qualitative exploration of staff perspectives following the introduction of a sensory room on a male adult acute ward. Int J Ment Health Nurs 2018; 27: 1689-97.

5. Kersting XAK, Hirsch S, Steinert T. Physical harm and death in the context of coercive measures in psychiatric patients: a systematic review. Front Psychiatry 2019; 10: 400.

6. Berger S, Grzonka P, Amacher SA, Hunziker S, Frei AI, Sutter R. Adverse events related to physical restraint use in intensive care units: a review of the literature. J Intensive Med 2023; 4: 318-25.

7. Chieze M, Hurst S, Kaiser S, Sentissi O. Effects of seclusion and restraint in adult psychiatry: a systematic review. Front Psychiatry 2019; 10: 491.

8. Ortiz-Sandoval I, Martínez-Quiles MD, López-Pérez J, Simonelli-Muñoz AJ. Triggers of agitation in psychiatric hospitalization ward according to professional experience questionnaire. Int J Environ Res Public Health 2022; 19: 2014.

9. Alhaj HA, Trist A. The effects of sensory modulation on patient’s distress and use of restrictive interventions in adult inpatient psychiatric settings: a critical review. Advances in Biomedical and Health Sciences 2023; 2: 105-11.

10. Perers C, Bäckström B, Johansson BA, Rask O. Methods and strategies for reducing seclusion and restraint in child and adolescent psychiatric inpatient care. Psychiatr Q 2022; 93: 107-36.

11. Molloy L, Chidarikire S, Pullman J, Havilla S, Patton D, Beckett P. The impact of sensory modulation interventions on practice in acute inpatient mental health settings: a meta-ethnography. Issues Ment Health Nurs 2024; 45: 580-8.

12. Andersen C, Kolmos A, Andersen K, Sippel V, Stenager E. Applying sensory modulation to mental health inpatient care to reduce seclusion and restraint: a case control study. Nord J Psychiatry 2017; 71: 525-8.

13. Ma D, Su J, Wang H, et al. Sensory-based approaches in psychiatric care: a systematic mixed-methods review. J Adv Nurs 2021; 77: 3991-4004.

14. West M, Melvin G, McNamara F, Gordon M. An evaluation of the use and efficacy of a sensory room within an adolescent psychiatric inpatient unit. Aust Occup Ther J 2017; 64: 253-63.

15. Doroud N, Cappy M, Grant K, Scopelliti M, McKinstry C, McMahon D. Sensory Rooms within mental health settings: a systematic scoping review. Occupational Therapy in Mental Health 2024; ٤١: 38-58.

16. Haig S, Hallett N. Use of sensory rooms in adult psychiatric inpatient settings: a systematic review and narrative synthesis. Int J Ment Health Nurs 2023; 32: 54-75.

17. Terzoni S, Ferrara P, Lo Giudice A, Destrebecq A. Validazione italiana della Brøset Violence Checklist (BVC) per la valutazione a breve termine del rischio di comportamenti violenti di pazienti in un’unità psichiatrica. L’infermiere 2016; 53: e1-e6.

18. Salzmann-Erikson M. An integrative review on psychiatric intensive care. Mental Health Nursing 2023; 44: 1035-49.

19. Salzmann-Erikson M, Yifter L. Risk factors and triggers that may result in patient-initiated violence on inpatient psychiatric units: an integrative review. Clin Nurs Res 2020; 29: 504-20.

20. Björkdahl A, Perseius KI, Samuelsson M, Lindberg MH. Sensory rooms in psychiatric inpatient care: staff experiences. Int J Ment Health Nurs 2016; 25: 472-9.

21. Seckman A, Paun O, Heipp B, et al. Evaluation of the use of a sensory room on an adolescent inpatient unit and its impact on restraint and seclusion prevention. J Child Adolesc Psychiatr Nurs 2017; 30: 90-7.

22. Hedlund Lindberg M, Samuelsson M, Perseius KI, Björkdahl A. The experiences of patients in using sensory rooms in psychiatric inpatient care. Int J Ment Health Nurs 2019; 28: 930-9.