broken window theory and antisocial behaviour

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Using the broken windows theory to tackle antisocial behaviour

For housing associations in particular, antisocial behaviour is an important issue to address and makes up a significant portion of our neighbourhood team's workload. Back in 2011 we decided that there had to be a more efficient way to tackle low level antisocial behaviour without resorting to paying for external mediators, or risking escalation and more serious issues. It seemed that, with the right training and support, we could set up a mediation service ourselves.

We knew that mediators would have to be volunteers otherwise the programme wouldn't provide any more value for money. We also decided that they'd have to either live or work within our communities, so we turned to residents and staff to fill the roles.

We refer all low-level cases for mediation so that problems are nipped in the bud. Both parties must agree to enter into mediation – it's a voluntary service and will only work if there is a genuine desire to resolve underlying issues. Neighbourhood staff complete a comprehensive referral form and a gatekeeper vets all submissions and allocates them to a mediator. Cases are the logged and each case has its own individual case reference number.

Broken windows theory

By properly addressing minor problems at first instance, in a down-to-earth, human and practical way, we reduce the build-up of low-level cases and potential escalation into full-blown trickier cases. The broken windows theory may be an old one but it still rings true:

.css-cumn2r{height:1em;width:1.5em;margin-right:3px;vertical-align:baseline;fill:#C70000;} Consider a building with a few broken windows. If the windows are not repaired, the tendency is for vandals to break a few more windows. Eventually, they may even break into the building, and if it's unoccupied, perhaps become squatters or light fires inside.

If partner agencies work together to minimise crime and maintain safe, clean and desirable communities, further antisocial behaviour is much less likely to occur. If we ignore the seemingly minor issues like barking dogs and neighbour disputes, they can escalate and become the norm for a community.

But it's not just theory, it's working. A young disabled resident was housebound and terrified of dogs. Her neighbours worked full-time leaving two dogs in the house during the day. The dogs barked whenever parcels were delivered and the situation quickly escalated with the resident getting very distressed. The previously friendly households began arguing regularly.

After some persuasion the neighbours agreed to mediation. The dog owners were horrified to find out the extent of their neighbour's distress, and arranged for a sitter to come and watch the dogs more often. Their parcels were also delivered elsewhere. They also offered their neighbour a visit so she could meet the dogs and start to conquer her fear. Though a relatively minor issue, if left to fester, this dispute could have caused long-term damage to the surrounding community.

Housing providers can no longer silo themselves into providing only 'core' services. As our funding, policy and planning environments continue to change, we must adapt to survive. Communities aren't built; they're grown. They need support from housing associations, schools, healthcare organisations and financial advice services to do so.

A holistic and preventative approach is the only way forward. We should undoubtedly be doing all we can to address the current housing shortage, and develop new homes for those who need them; but there's no point if in 10 years' time, teams like mine are back on the scene addressing the same problems we're addressing today.

Isabella Russell is antisocial behaviour officer at Moat. Follow her on Twitter @ASBOfficer

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An empirical application of “broken windows” and related theories in healthcare: examining disorder, patient safety, staff outcomes, and collective efficacy in hospitals

BMC Health Services Research volume 20 , Article number: 1123 ( 2020 ) Cite this article

Broken windows theory (BWT) proposes that visible signs of crime, disorder and anti-social behaviour – however minor – lead to further levels of crime, disorder and anti-social behaviour. While we acknowledge divisive and controversial policy developments that were based on BWT, theories of neighbourhood disorder have recently been proposed to have utility in healthcare, emphasising the potential negative effects of disorder on staff and patients, as well as the potential role of collective efficacy in mediating its effects. The aim of this study was to empirically examine the relationship between disorder, collective efficacy and outcome measures in hospital settings. We additionally sought to develop and validate a survey instrument for assessing BWT in hospital settings.

Cross-sectional survey of clinical and non-clinical staff from four major hospitals in Australia. The survey included the Disorder and Collective Efficacy Survey (DaCEs) (developed for the present study) and outcome measures: job satisfaction, burnout, and patient safety. Construct validity was evaluated by confirmatory factor analysis (CFA) and reliability was assessed by internal consistency. Structural equation modelling (SEM) was used to test a hypothesised model between disorder and patient safety and staff outcomes.

The present study found that both social and physical disorder were positively related to burnout, and negatively related to job satisfaction and patient safety. Further, we found support for the hypothesis that the relationship from social disorder to outcomes (burnout, job satisfaction, patient safety) was mediated by collective efficacy (social cohesion, willingness to intervene).

Conclusions

Peer Review reports

A long tradition exists in criminology and social-psychology research on the concept of neighbourhood disorder and in what ways disorder relates to anti-social behaviour and poor outcomes [ 1 ] . Interest in neighbourhood disorder is readily apparent in Broken Window Theory (BWT) [ 2 ], as well as in alternative perspectives of disorder involving shared expectation and cohesion—more broadly known as collective efficacy [ 3 , 4 , 5 ]—that are consistent with social disorganisation theory. The current study draws from these various theories and insights into neighbourhood disorder and applies them to hospital settings. At this point, we must make clear our intentions in applying neighbourhood disorder theories to healthcare. It is perilous to expect theories of neighbourhood disorder can be perfectly replicable in an organisational setting, nor do we consider that all elements of the theories are applicable to hospital settings (such as the concept of fear) [ 6 ] . We particularly reject the flawed ramifications of these theories that saw victimisation and blame attributed to individual neighbourhood members. However, here, we consider that concepts from neighbourhood studies may have considerable promise to shed new light on the relationships between the physical and social environments of hospitals on the one hand, and the health, wellbeing and behaviour of staff and patients, on the other [ 7 ] . We begin by reviewing the history and evolution of these theories before considering their application to healthcare.

Broken windows: a theory of disorder in neighbourhoods

Broken windows theory (BWT), as a social-psychological theory of urban decline, was originally developed almost 40 years ago by Wilson and Kelling [ 2 ]. Proponents of this theory argue that both physical disorder (e.g., broken windows, graffiti, litter) and social disorder (e.g., vandalism, antisocial activities) provide important environmental cues to the kinds of negative actions that are normalised and tolerated in an area, fuelling further incivility and more serious crime. For example, signs of disorder can signal potential safety issues to residents of a neighbourhood, leading to their withdrawal from public spaces, and thereby a reduction in informal social control, further perpetuating the effects of disorder [ 2 ].

Defining disorder

Although debates have occurred in the literature as to what counts as disorder, it has usually been defined as representing “minor violations of social norms” ([ 8 ] p4923). Some researchers have made a distinction between physical and social disorder, with physical disorder relating to the overall appearance of an area and social disorder directly involving people [ 9 ]. Thinking about disorder in this way, neighbourhoods with high levels of physical disorder were defined as: noisy, dirty, and run-down; buildings are in disrepair or abandoned; and vandalism and graffiti are common [ 10 ]. On the other hand, signs of social disorder in neighbourhoods may include the presence of people hanging out on the streets, drinking, or taking drugs [ 10 ]. Researchers highlight the importance of measuring perceptions of physical and social disorder as separate factors [ 9 , 11 ] with recent studies finding differential impacts of the two types of disorder [ 12 ].

Rethinking disorder: the role of collective efficacy

The BWT originally proposed by Wilson and Kelling [ 2 ] suggested a causal relationship with disorder leading to crime, which had a significant bearing upon subsequent controversial policy developments, such as ‘zero-tolerance policing’ [ 13 ] and ‘stop-and-frisk’ programs [ 14 ]. Under this approach, police pay attention to every facet of the law, including minor offences, such as public drinking and vandalism, with the aim of preventing more serious crimes from occurring [ 13 ]. The level of support these policing strategies have received has been surprising, given that BWT has not received a commensurate amount of study to date, and the research on crime that does exist is equivocal [ 12 ]. In particular, there has been an ongoing debate in the academic literature over whether BWT posits a direct or indirect relationship between disorder and crime. Most prominently, Sampson and Raudenbush [ 4 ] reconsidered the claims of BWT and argued instead that physical and social disorder were not generally causal antecedents to more serious crimes. Consistent with social disorganisation theory [ 3 ], Sampson and Raudenbush [ 4 ] suggested that collective efficacy has a significant influence on criminality in neighbourhoods. They defined collective efficacy as “social cohesion among neighbours combined with their willingness to intervene on behalf of the common good” ([ 5 ] p918). Empirical results supported their conceptual ideas in that the positive relationship between disorder and crime was mediated by collective efficacy [ 4 ].

Other lines of research have found a direct association between disorder and crime even when controlling for collective efficacy (e.g., [ 15 ]). For example, Plank et al. [ 16 ] studied disorder and collective efficacy in a school setting. They found a robust association between both disorder and violence (i.e., crime) while controlling for collective efficacy. They concluded that “fixing broken windows and attending to the physical appearance of the school cannot alone guarantee productive teaching and learning, but ignoring them greatly increases the chances of a troubling downward spiral” ([ 16 ] p244). In summary, the results are mixed as to the extent that there is direct effect of disorder on crime or other poor outcomes, but the evidence clearly suggests that there is at least an indirect effect. The key problem is what people do with this information. There is no justification for blaming individuals or demonising groups or neighbourhoods for their behaviour. We do not in any way condone seriously erroneous and consequential victimisation of people or groups as a result of the application of BWT. But we do think this is an area worthy of study.

Applying broken windows theory to healthcare

Following recent interest in applying BWT to smaller, more circumscribed environments, such as workplaces [ 17 , 18 ], researchers have started to consider the application of BWT to healthcare settings [ 7 , 19 , 20 ]. There are several well-studied trends in health services research that support this application. Theories and studies of increasing popularity include: the normalisation of deviance [ 21 ], behavioural modelling in hand hygiene [ 22 ], hospital workplace violence [ 23 ], and the association between staff’s safe work practices and their perceiving their work area as cluttered and disorderly [ 24 ].

Disorder in hospitals may include negative deviations, trade-offs or workarounds that manifest continuously in complex, dynamic and time-pressured environments, which can contribute to poor staff outcomes [ 25 , 26 , 27 ]. While trade-offs and workarounds occur in every setting, and they may have many benefits including signalling productive flexibility and staff capacity for manoeuvring, they can also represent risk in healthcare. For example, some researchers have shown that small deviations such as violating recommended processes for use of local anaesthesia can be detrimental, potentially even leading to death [ 28 ]. In line with BWT logic, there is evidence to suggest that the physical hospital environment influences the health and wellbeing of staff and patients [ 29 ]. Similarly, evidence shows that social disorder (e.g., bullying, violence) can influence staff in healthcare organisations [ 23 , 30 ]. All of these examples highlight the potential negative perpetuating effects of disorder in healthcare organisations and how disorder may detrimentally affect patients, such as through poor patient safety outcomes (see Fig. 1 [ 7 ]). Despite the elevated interest in BWT, we could find no empirical study of disorder in hospitals, nor any examination of the role of collective efficacy on staff outcomes or patient safety.

Proposed model of disorder in hospitals Source: Churruca, Ellis et al., 2018 [ 7 ]

Aims of the present study

The primary purpose of the present study is to empirically examine the relationship between hospital disorder and three key outcomes: staff burnout, staff job satisfaction, and patient safety. We also sought to address the contention in the literature regarding the role of collective efficacy (defined here as social cohesion among hospital staff and their willingness to intervene to address problems) between hospital disorder and outcomes. The first aim was to develop a short but valid and reliable survey instrument for measuring physical disorder, social disorder, social cohesion and willingness to intervene in hospital settings. Based on previous research, physical and social disorder were kept as separate constructs. We then sought to test the following three research questions:

Is there a significant association between hospital disorder (physical disorder, social disorder) and staff outcomes (burnout, job satisfaction)?

Is there a significant association between hospital disorder (physical disorder, social disorder) and patient safety?

What is the function of “collective efficacy” (social cohesion, willingness to intervene) in hospitals? Specifically, does staff collective efficacy mediate the relationship between disorder and outcomes? Figure 2 demonstrates the simplified hypothesised mediation model.

Hypothesised mediation model

Participants and setting

The study employed a cross-sectional survey of staff from four major hospitals in Australia. All hospital sites were public hospitals in metropolitan areas with over 200 beds. The sites were selected based on the similarity in the types of services offered (e.g., emergency department, intensive care, surgical, medical, geriatric care) and that they were located within areas of varying relative socio-economic disadvantage [ 31 ]. All hospital staff were invited to participate in the study through an invitation sent to their work email address. The email included a link to an online version of the survey via Qualtrics [ 32 ].

Survey development

The Disorder and Collective Efficacy survey (DaCEs) for hospital staff was developed for the present study based on an extensive review of the BWT literature. An initial pool of items was formed to assess the hypothesised constructs of the DaCEs: Physical disorder (19 items), social disorder (13 items), and collective efficacy, represented by social cohesion (12 items) and willingness to intervene (10 items). Some of the items were adapted from existing scales [ 16 , 24 , 33 , 34 , 35 ], and others were purpose-developed by the research team (see Supplementary File 1 ). Items were modified to make them relevant to a hospital context. All items were answered on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). A panel of experts in healthcare ( n = 10; hospital staff and researchers) reviewed and provided feedback on the wording of items mapping onto each of the hypothesised constructs and checked for possible misinterpretations of questions, instructions and response format. Minor adjustments were made to the initial item pool (see Supplementary File 1 ). The aim was then to refine the item pool to produce a survey that would be short enough to be completed by busy hospital workers, but which has satisfactory psychometric properties.

Staff outcomes

The survey included existing validated scales to measure staff burnout and job satisfaction. Burnout was measured through a 10-item version of the Maslach Burnout Inventory (MBI) [ 36 , 37 , 38 ]. Two subscales of burnout—emotional exhaustion and depersonalisation—were used for the current survey as the third subscale, personal accomplishment, was deemed less relevant to nonclinical staff. Burnout items were answered on a seven-point Likert scale (1 = strongly disagree to 7 = strongly agree). The job satisfaction section of the Job Diagnostic Survey (5 items) was selected to capture individual’s feelings about their job [ 39 ]. Job satisfaction items were answered on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree).

Patient safety

An item taken from the Hospital Survey of Patient Safety Culture (HSOPSC) was used as an indicator of patient safety [ 40 ]. This item is an outcome measure for patient safety that asks staff to provide an overall patient safety grade for their hospital (1 = excellent to 5 = failing).

Data analysis

Participants missing more than 10% of survey data were excluded. Remaining missing values were imputed using the Expectation Maximisation (EM) Algorithm within SPSS, version 25 [ 41 ]. Some items were then reversed coded so that higher item-response scores indicated a greater extent of job satisfaction, burnout, disorder, willingness to intervene, and patient safety (See Supplementary File 1 for individual recoded items). Frequency distributions were calculated to test whether items violated the assumption of univariate normality (i.e., skewness index ≥3, kurtosis index ≥10). As a number of the items were skewed (i.e., skewness index ≥3), the chi-square significance value was corrected for bias using the Bollen-Stine bootstrapping method [ 42 ] based on 1000 bootstrapped samples.

Items were evaluated psychometrically via confirmatory factor analysis (CFA), using a two-stage process. First, to refine the initial item pool, four one-factor congeneric models (of physical disorder, social disorder, social cohesion and willingness to intervene items) were run using AMOS, version 25 [ 43 ]. Here, our analytic plan involved removing one item at a time from each model using the following strategy: (i) removing items with the lowest factor loadings while maintaining the theoretical content and meaning of the proposed construct; (ii) removing items as long as each construct contained at least four observed variables; and (iii) items were removed as long as the resulting model demonstrated an improved model fit [ 44 , 45 ]. Differences in model fit were assessed using the chi-square difference test [ 46 ]. Second, two two-factor models were used to assess the factor structure of items related to disorder (i.e., physical disorder, social disorder) and collective efficacy (i.e., social cohesion, willingness to intervene) using the reduced item sets. Each item was loaded on the one factor it purported to represent. Further item refinement was undertaken as required through inspection of factor loadings, standardised residuals and modification indices to reduce each scale to three or four items. Goodness-of-fit was assessed using the Tucker Lewis Index (TLI), Comparative Fit Index (CFI) and Root Mean Square Error of Approximation (RMSEAs), and chi-square, with significance value supplemented by the Bollen-Stine bootstrap test. The TLI and CFI yield values ranging from zero to 1.00, with values greater than .90 and .95 being indicative of acceptable and excellent fit to the data [ 47 ]. For RMSEAs, values less than .05 indicate good fit, and values as high as .08 represent reasonable errors of approximation in the population [ 48 ]. For the Bollen-Stine test, non-significant values indicate that the proposed model is correct. Reliability of each of the subscales was assessed through Cronbach’s alpha (using SPSS, version 25) and composite reliability (using AMOS, version 25).

The hypothesised mediation model (Fig. 2 ) was assessed using structural equation modelling (SEM) in AMOS, version 25 [ 43 ]. First, we tested the direct effects from disorder (physical and social) to each outcome (burnout, job satisfaction, patient safety), followed by the indirect effect from disorder to outcomes, through collective efficacy (social cohesion, willingness to intervene). A parametric bootstrapping approach was used to test mediation. Under the bootstrapping approach, indirect effects are of interest and based on bootstrapped standard errors (with 1000 draws) [ 49 , 50 ]. Model fit was evaluated using CFI, TLI, RMSEA, and chi-square.

Descriptive statistics, distribution, reliability and confirmatory factor analysis

Participants were 415 staff from four hospitals in Australia. Once participants with more than 10% of survey data missing were excluded, the remaining sample was reduced to 340. Of the 340 participants, most were female (77.5%), worked as a nurse (34.2%), and had been working in the same hospital for three or more years (76.1%). The characteristics of the survey respondents are presented in Table 1 .

Descriptive statistics and data pertaining to assumptions of normality for all items are presented in Supplementary File 1 . The vast majority of the social disorder, social cohesion and willingness to intervene items demonstrated a skewness index greater than three, while only three items demonstrated a kurtosis index greater than 10 (SD7, SD10, SC6). As a result, Bollen-Stine bootstrapping was conducted in order to improve accuracy when assessing parameter estimates and fit indices.

To refine the initial item pool, first four one-factor congeneric models were run for items designed to measure physical disorder, social disorder, social cohesion and willingness to intervene. Based on an examination of modification indices and standardised factor loadings, items were removed one at a time, until the four strongest items remained. As shown in Table 2 , the reduced four-item constructs demonstrated much improved model fit statistics relative to the full models with all items. Chi-squared difference tests for all four constructs were significant, indicating that the reduced item constructs were significantly better models. The results of the chi-squared difference tests were: Physical disorder, (χ 2 difference = 139, df = 18, p < .001), social disorder (χ 2 difference = 680, df = 63, p < .001), social cohesion (χ 2 difference = 302, df = 52, p < .001), and willingness to intervene (χ 2 difference = 243, df = 33, p < .001).

Two two-factor models of disorder (physical disorder, social disorder) and collective efficacy (social cohesion, willingness to intervene) were then tested through CFA each using eight of their respective items. Each item was loaded on the one factor it purported to represent. Where required, further item refinement was undertaken through inspection of factor loadings, standardised residuals and modification indices. The two-factor model of disorder, including four physical disorder items and four social disorder items produced an adequate fit to the data, χ 2 (19) = 54.06, TLI = .96, CFI = .97, RMSEA = .08, though the Bollen-Stine bootstrap was significant ( p = .005). Inspection of the standardised factor loadings for items PD3 and SD3 suggested that their removal may improve model fit. The removal of these two items resulted in an improved model fit, χ2 (8) = 18.28, TLI = .979, CFI = .989, RMSEA = .062, and the Bollen-Stine bootstrap ( p = .057). The standardised factor loadings for the six items remaining ranged from .71 to .90. The correlation between physical disorder and social disorder was low, but significant ( r = .17, p = .007). Next, a two-factor model of collective efficacy consisting of four social cohesion items and four willingness to intervene items were tested. This model produced an excellent fit to the data, χ2 (19) = 25.36, TLI = .99, CFI = 1.00, RMSEA = .06, and the Bollen-Stine bootstrap was not significant ( p = .458). The standardised factor loadings for the six items ranged from .68 to .90, and the correlation between social cohesion and willingness to intervene was strong, r = .69, p < .001. The retained items from the two-factor models are presented in Table 3 , along with their factor loadings. Cronbach’s alpha and composite reliability for the final items is also shown in Table 3 , demonstrating that all four scales demonstrated acceptable levels of reliability.

Research question 1: is there a significant association between hospital disorder and staff outcomes?

In order to examine the relationship between hospital disorder and staff outcomes, four separate models were run (i.e., models were run separately for physical disorder and social disorder, each with burnout and job satisfaction as dependent variables). Findings are presented in Supplementary File 2 . The results showed that physical disorder was significantly associated with higher burnout (β = .26, p < .001) and lower job satisfaction (β = −.40, p < .001). Similarly, social disorder was significantly associated with higher burnout (β = .23, p < .001) and lower job satisfaction (β = −.54, p < .001).

Research question 2: is there a significant association between hospital disorder and patient safety?

Two separate models were run for physical disorder and social disorder (Supplementary File 2 ). Physical disorder was significantly associated with lower patient safety scores (β = −.15, p = .008). Likewise, a greater extent of social disorder was significantly associated with lower levels of patient safety (β = −.26, p < .001).

Research question 3: does staff collective efficacy mediate the relationship between disorder and outcomes?

We then tested three separate mediation models for each outcome measure where the relationship between disorder and outcomes was mediated by collective efficacy via bootstrapping. For burnout, the model fit the data well, χ2 (81) = 142.75, TLI = .97, CFI = .98, RMSEA = .05. The findings presented in Fig. 3 show that there were significant negative paths from: social disorder to social cohesion (β = −.45, p = .003); social disorder to willingness to intervene (β = −.49, p = .002); social cohesion to burnout (β = −.23, p = .022); and willingness to intervene to burnout (β = −.33, p = .004). However, the paths from physical disorder to social cohesion (β = −.11, p = .077) and from physical disorder to willingness to intervene (β = −.04, p = .466) were not significant. Alongside these parameters, there was a significant direct effect from physical disorder to burnout (β = .18, p = .001), but not from social disorder to burnout (β = −.07, p = .351). Importantly, bootstrapped analyses for indirect effects indicated a significant indirect path from social disorder to burnout via social cohesion and willingness to intervene (β = .26, p = .001). However, the indirect path from physical disorder to burnout was not significant (β = .04, p = .205).

Model of disorder and burnout, mediated by collective efficacy

For job satisfaction, the model provided an adequate fit to the data, χ2 (125) = 274.69, TLI = .95, CFI = .96, RMSEA = .06 (Fig. 4 ). The findings show that there was a significant path from social cohesion to job satisfaction (β = .34, p = .002) and from willingness to intervene to job satisfaction (β = .38, p = .001). The direct effects from physical disorder to job satisfaction (β = −.06, p = .233) and from social disorder to job satisfaction (β = −.04, p = .575) were not significant. Bootstrapped analyses for indirect effects indicated a significant indirect path from social disorder to job satisfaction via social cohesion and willingness to intervene (β = −.34, p = .001). However, the indirect path from physical disorder to burnout was not significant (β = −.05, p = .171).

Model of disorder and job satisfaction, mediated by collective efficacy

For patient safety, the model fit provided a satisfactory fit to the data, χ2 (81) = 171.26, TLI = .96, CFI = .97, RMSEA = .06. The findings are presented in Fig. 5 and show that there was a significant path from willingness to intervene to patient safety (β = .23, p = .041). The path from social cohesion to patient safety just failed to reach significance (β = .20, p = .057). The direct effects from physical disorder to patient safety (β = −.08, p = .155) and from social disorder to patient safety (β = −.04, p = .612) were not significant. The indirect effects indicated a significant indirect path from social disorder to patient safety via social cohesion and willingness to intervene (β = −.20, p = .001). However, the indirect path from physical disorder to burnout was not significant (β = −.03, p = .174).

Model of disorder and patient safety, mediated by collective efficacy

This study is one of the first to empirically evaluate neighbourhood disorder theories in healthcare. Consistent with the original BWT, we found that perceptions of social and physical disorder were associated with potential safety issues [ 2 ], in this case, low patient safety ratings in hospitals. Past research on neighbourhood disorder supports the association between perceived neighbourhood disorder and poor mental health [ 51 ], corresponding with the present study’s findings that hospital disorder was associated with low job satisfaction and high burnout. These findings shed light on the potential relationship between culture and disorder in hospitals. We recognise that BWT has received considerable criticism over the years [ 1 ], particularly in response to controversial policy developments that were based on the BWT perspective. At this point, we must make clear that we do not advocate such policies, and find them abhorrent. However, we do contend that it seems likely that disorder is a marker for a poorer workplace culture compared to a workplace that is perceived as more orderly by hospital staff. This represents further converging evidence that having a productive, functional, more orderly culture is good for both staff and patients and not having a collective, efficacious, productive, collaborative culture is not [ 52 ].

Consistent with previous research, our study findings demonstrate the differential effects of physical and social disorder on outcome measures [ 11 , 53 ]. While both types of disorder were found to be directly related to all outcomes, once collective efficacy was added to the model, the relationship between social disorder and each of the outcomes became non-significant. In summary, consistent with the assertions of Sampson and Raudenbush [ 4 ] and in concordance with social disorganisation theory, we found that the relationship between social disorder and all outcome measures was significantly mediated by collective efficacy; however, this was not the case for physical disorder. As for the potential reasons for these findings, from a research standpoint, social disorder and physical disorder are qualitatively different: neighbourhood social disorder has been described as “episodic behaviour” involving individuals “which only lasts for a limited amount of time”, whereas neighbourhood physical disorder instead refers to “the deterioration of urban landscapes” and “does not necessarily involve actors” ([ 53 ] p5). Similarly, in a hospital setting, physical disorder may be perceived by staff as a more stable and constant presence in the hospital environment. In other words, hospital staff may be “inoculated” ([ 12 ] p411) to the presence of physical disorder in the hospital environment, with collective efficacy being less likely to alter or affect the relationship between physical disorder and outcomes.

A further explanation as to why the relationship between social disorder and all three outcome measures were mediated by collective efficacy, but not for physical disorder, is because when social disorder manifests in hospitals (e.g., non-compliance, wasting time), healthcare staff must work together to ‘pick up the slack’ to avoid serious threats to the safety and quality of care delivered. For example, if certain staff are absent or late in a particular hospital ward, the rest of the staff in that ward must work together to negate the likelihood of patient safety issues. Working as a team to make up for the social disorder may prevent any one individual staff member experiencing burnout and low job satisfaction. Indeed, this is consistent with past research showing that collaboration in hospitals has a positive effect on staff and patient outcomes, including patient safety, burnout, and job satisfaction [ 54 ]. This differs to physical disorder (e.g., run-down hospital, vandalism) where it is not necessarily seen as the responsibility of hospital staff to work collaboratively and address this form of disorder. That is, while staff must work together to address issues of social disorder such as someone being absent or late, physical disorder is more likely to be seen to be needing to be dealt with on the organisational level. For example, a hospital being in need of repair needs intervention from the government, NHS Trust, Board of Governors or local health district which can provide the necessary resources to redevelop the infrastructure.

This study thereby contributes to the broader BWT and related neighbourhood disorder field as it highlights the importance of keeping social and physical disorder as separate constructs when assessing disorder. Further, this study highlights the importance of encouraging collective efficacy among hospital staff as it can act as a barrier between social disorder and poor staff outcomes and patient safety issues.

Strengths and limitations

A strength of this study was the development of an initial psychometric profile for the measure of disorder and collective efficacy for hospitals, with its psychometric properties being assessed across four hospital sites in Australia. As to limitations, the study was based on self-reports of staff and, as with all research of this kind, is reflective of the perceptions of the agents involved. We did not include patients’ self-reports or observational research. The data was collected at one time point and therefore cannot identify any causal influence of physical and social disorder on outcomes which would require longitudinal studies involving repeated sampling on the same set of study participants. The findings concerning patient safety would need to be replicated in view of the fact that only one item was used to assess patient safety and therefore the measure has unestablished reliability. The DaCEs also warrants further cross-validation of its factor structure, as the final items were selected on the basis of results from our four included hospitals, and may not be generalisable to all hospital systems. Optimally, CFA should be randomly divided into subgroups (calibration and validation samples) to validate and verify the factor structure of the tool [ 55 ]. However, the current study was limited by the relatively modest sample size, and further work would be needed to verify the validity of the tool.

As one of the first studies to empirically test theories of neighbourhood disorder in healthcare, we found that a positive, orderly, productive culture is likely to lead to wellbeing for staff and better safety for patients, and vice versa. This is a modified study of BWT and related theories in hospitals, and one of the few studies to assess associations between different forms of disorder, collective efficacy, and staff and patient outcomes. Our hypothesised mediation model was supported, showing that the relationship between social disorder and outcomes (job satisfaction, burnout, patient safety) was mediated by collective efficacy. Having established and tested the robustness of the model, we offer it for new applications and future studies on this topic and highlight the importance of studying physical and social disorder as separate constructs. This study demonstrates the potential benefits of encouraging collective efficacy among hospital staff as it can act as a barrier to poor staff wellbeing and patient safety issues when there is social disorder.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Broken windows theory

Disorder and Collective Efficacy Survey

Confirmatory factor analysis

Structural equation modelling

Maslach Burnout Inventory

Hospital Survey of Patient Safety Culture

Expectation Maximisation

Tucker Lewis Index

Comparative Fit Index

Root Mean Square Error of Approximation

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Acknowledgements

The authors thank all hospital staff that participated in the survey.

This work is supported in part by National Health and Medical Research Council grants held by JB (APP9100002, APP1176620 and APP1135048). The funding body had no role in the design of the study and collection, analysis, and interpretation of data.

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LAE, KC, JCL and JB conceived the study. LAE, KC, JCL and CP designed the DaCEs and drafted the paper. LAE, YT and CP performed the analysis. All authors read and approved the final manuscript.

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Ellis, L.A., Churruca, K., Tran, Y. et al. An empirical application of “broken windows” and related theories in healthcare: examining disorder, patient safety, staff outcomes, and collective efficacy in hospitals. BMC Health Serv Res 20 , 1123 (2020). https://doi.org/10.1186/s12913-020-05974-0

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An empirical application of "broken windows" and related theories in healthcare: examining disorder, patient safety, staff outcomes, and collective efficacy in hospitals

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Background: Broken windows theory (BWT) proposes that visible signs of crime, disorder and anti-social behaviour - however minor - lead to further levels of crime, disorder and anti-social behaviour. While we acknowledge divisive and controversial policy developments that were based on BWT, theories of neighbourhood disorder have recently been proposed to have utility in healthcare, emphasising the potential negative effects of disorder on staff and patients, as well as the potential role of collective efficacy in mediating its effects. The aim of this study was to empirically examine the relationship between disorder, collective efficacy and outcome measures in hospital settings. We additionally sought to develop and validate a survey instrument for assessing BWT in hospital settings.

Methods: Cross-sectional survey of clinical and non-clinical staff from four major hospitals in Australia. The survey included the Disorder and Collective Efficacy Survey (DaCEs) (developed for the present study) and outcome measures: job satisfaction, burnout, and patient safety. Construct validity was evaluated by confirmatory factor analysis (CFA) and reliability was assessed by internal consistency. Structural equation modelling (SEM) was used to test a hypothesised model between disorder and patient safety and staff outcomes.

Results: The present study found that both social and physical disorder were positively related to burnout, and negatively related to job satisfaction and patient safety. Further, we found support for the hypothesis that the relationship from social disorder to outcomes (burnout, job satisfaction, patient safety) was mediated by collective efficacy (social cohesion, willingness to intervene).

Conclusions: As one of the first studies to empirically test theories of neighbourhood disorder in healthcare, we found that a positive, orderly, productive culture is likely to lead to wellbeing for staff and the delivery of safer care for patients.

Keywords: Broken windows theory; Collective efficacy; Culture; Disorder; Hospital; Safety.

Conflict of interest statement

The authors declare that they have no competing interests.

Proposed model of disorder in…

Proposed model of disorder in hospitals Source: Churruca, Ellis et al., 2018 [7]

Hypothesised mediation model

Model of disorder and burnout,…

Model of disorder and burnout, mediated by collective efficacy

Model of disorder and job…

Model of disorder and job satisfaction, mediated by collective efficacy

Model of disorder and patient…

Model of disorder and patient safety, mediated by collective efficacy

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Broken Windows Theory

Reviewed by Psychology Today Staff

The broken windows theory states that visible signs of disorder and misbehavior in an environment encourage further disorder and misbehavior, leading to serious crimes. The principle was developed to explain the decay of neighborhoods, but it is often applied to work and educational environments.

What Is the Broken Windows Theory?

Do Broken Windows Policies Work?

The broken windows theory, defined in 1982 by social scientists James Wilson and George Kelling, drawing on earlier research by Stanford University psychologist Philip Zimbardo, argues that no matter how rich or poor a neighborhood, one broken window would soon lead to many more windows being broken: “One unrepaired broken window is a signal that no one cares, and so breaking more windows costs nothing.” Disorder increases levels of fear among citizens, which leads them to withdraw from the community and decrease participation in informal social control.

What do “broken windows” mean?

The broken windows are a metaphor for any visible sign of disorder in an environment that goes untended. This may include small crimes, acts of vandalism, drunken or disorderly conduct, etc. Being forced to confront minor problems can heavily influence how people feel about their environment, particularly their sense of safety.

What is an example of the broken windows theory?

With the help of small civic organizations, lower-income Chicago residents have created over 800 community gardens and urban farms out of burnt buildings and vacant lots. Now, instead of having trouble finding fresh produce, these neighborhoods have become go-to food destinations. This example of the broken windows theory benefits the people by lowering temperatures in overheated cities, increasing socialization, reducing stress , and teaching children about nature.

Who created the broken windows theory?

George L. Kelling and James Q. Wilson popularized the broken windows theory in an article published in the March 1982 issue of The Atlantic . They asserted that vandalism and smaller crimes would normalize larger crimes (although this hypothesis has not been fully supported by subsequent research). They also remarked on how signs of disorder (e.g., a broken window) stirred up feelings of fear in residents and harmed the safety of the neighborhood as a whole.

Where were broken windows policies first implemented?

The broken windows theory was put forth at a time when crime rates were soaring, and it often spurred politicians to advocate policies for increasing policing of petty crimes—fare evasion, public drinking, or graffiti—as a way to prevent, and decrease, major crimes including violence. The theory was notably implemented and popularized by New York City mayor Rudolf Giuliani and his police commissioner, William Bratton. In research reported in 2000, Kelling claimed that broken-windows policing had prevented over 60,000 violent crimes between 1989 and 1998 in New York City, though critics of the theory disagreed.

Does Broken Windows Policies Work?

Although the “Broken Windows” article is one of the most cited in the history of criminology , Kelling contends that it has often been misapplied. The implementation soon escalated to “zero tolerance” policing policies, especially in minority communities. It also led to controversial practices such as “stop and frisk” and an increase in police misconduct complaints.

Most important, research indicates that criminal activity was declining on its own, for a number of demographic and socio-economic reasons, and so credit for the shift could not be firmly attributed to broken-windows policing policies. Experts point out that there is “no support for a simple first-order disorder-crime relationship,” contends Columbia law professor Bernard E. Harcourt. The causes of misbehavior are varied and complex.

Is the broken windows model effective?

The effectiveness of this approach depends on how it is implemented. In 2016, Dr. Charles Branas led an initiative to repair abandoned properties and transform vacant lots into community parks in high-crime neighborhoods in Philadelphia, which subsequently saw a 39% reduction in gun violence. By building “palaces for the people” with these safe and sustainable solutions, neighborhoods can be lifted up, and crime can be reduced.

Can repairing “broken windows” make the economy grow?

When a neighborhood, even a poor one, is well-tended and welcoming, its residents have a greater sense of safety. Building and maintaining social infrastructure—such as public libraries, parks and other green spaces, and active retail corridors—can be a more sustainable option and improve the daily lives of the people who live there.

Does a broken windows approach lead to more aggressive policing?

According to the broken windows theory, disorder (symbolized by a broken window) leads to fear and the potential for increased and more severe crime. Unfortunately, this concept has been misapplied, leading to aggressive and zero-tolerance policing. These policing strategies tend to focus on an increased police presence in troubled communities (especially those with minorities and lower-income residents) and stricter punishments for minor infractions (e.g., marijuana use).

What is meant by zero tolerance?

Zero-tolerance policing metes out predetermined consequences regardless of the severity or context of a crime. Zero-tolerance policies can be harmful in an academic setting, as vulnerable youth (particularly those from minority ethnic/racial backgrounds) find themselves trapped in the School-to-Prison Pipeline for committing minor infractions.

What type of policing reduces crime?

Aggressive policing practices can sour relationships between police and the community. However, problem-oriented policing—which identifies the specific problems or “broken windows” in a neighborhood and then comes up with proactive responses—can help reduce crime. This evidence-based policing strategy has been shown to be effective.

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Revisiting Broken Windows: The Role of Neighborhood and Individual Characteristics in Reaction to Disorder Cues

Beate Volker

Sociological Science, October 11, 2017 DOI 10.15195/v4.a22

The influential “broken windows” theory proposes that disorder cues in neighborhoods trigger littering and other antisocial behavior. Until now, the theory has been empirically tested only on a small scale and restricted to just one specific area. In this study, I investigated the effect of disorder cues on individual behavior once more, replicating and extending the original field experiments by Keizer, Lindenberg, and Steg (2008 and 2013). The data from 12,528 individuals were collected in 84 field experiments conducted in 33 neighborhoods. The results, based on multilevel techniques for binary data, show that the absolute effect of cues is smaller than originally thought and that neighborhood and individual characteristics moderate cue effects.

Author Information

Supplemental Material

Process Info

Beate Volker: Department of Sociology, University of Amsterdam Email: [email protected]

Acknowledgements: This study greatly benefitted from the seminar of the program group “Institutions, Inequalities, and Life Courses” at the University of Amsterdam; the participants of the symposium “Order in Context” at Utrecht University on March 31, 2016; and from comments by Henk Flap.

Broken Windows Theory , Context Effects , Cue Effects , Field Experiments

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Using the broken windows theory to tackle antisocial behaviour
The broken windows theory may be an old one but it still rings true: Consider a building with a few broken windows. If the windows are not repaired, the tendency is for vandals to break...
An empirical application of “broken windows” and related
Proponents of this theory argue that both physical disorder (e.g., broken windows, graffiti, litter) and social disorder (e.g., vandalism, antisocial activities) provide important environmental cues to the kinds of negative actions that are normalised and tolerated in an area, fuelling further incivility and more serious crime.
An empirical application of "broken windows" and related
While we acknowledge divisive and controversial policy developments that were based on BWT, theories of neighbourhood disorder have recently been proposed to have utility in healthcare, emphasising the potential negative effects of disorder on staff and patients, as well as the potential role of collective efficacy in mediating its effects.
Broken Windows Theory
The broken windows are a metaphor for any visible sign of disorder in an environment that goes untended. This may include small crimes, acts of vandalism, drunken or disorderly conduct, etc....
Revisiting Broken Windows: The Role of Neighborhood and
The influential “broken windows” theory proposes that disorder cues in neighborhoods trigger littering and other antisocial behavior. Until now, the theory has been empirically tested only on a small scale and restricted to just one specific area.