Skip to main content
×
×
Home

The psychiatric ward as a therapeutic space: systematic review

  • Constantina Papoulias, Emese Csipke, Diana Rose, Susie McKellar and Til Wykes...
Abstract
Background

Hospital care is still an integral part of mental healthcare services. But the impact of ward design on treatment outcomes is unclear.

Aims

To review the effects of ward design on patient outcomes and patient and staff well-being.

Method

A systematic review of literature was carried out on Medline, Embase and PsycINFO. Papers on psychogeriatric and child and adolescent wards were excluded as these necessitate specific safety features.

Results

Twenty-three papers were identified. No strong causal links between design and clinical outcomes were found. Private spaces and a homely environment may contribute to patient well-being. Different stakeholders may experience ward design in conflicting ways; design has a symbolic and social dimension for patients.

Conclusions

Data on the impact of design on treatment outcomes are inconclusive. Rigorous randomised controlled trials, qualitative studies and novel methods are called for. Different stakeholders' responses to the ward as a symbolic environment merit further investigation.

    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      The psychiatric ward as a therapeutic space: systematic review
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      The psychiatric ward as a therapeutic space: systematic review
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      The psychiatric ward as a therapeutic space: systematic review
      Available formats
      ×
Copyright
Corresponding author
Dr Emese Csipke, Institute of Psychiatry, King's College London, Henry Wellcome Building, De Crespigny Park, London SE5 8AF, UK. Email: emese.1.csipke@kcl.ac.uk
Footnotes
Hide All

Joint first authors.

This article presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1050). The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.

Declaration of interest

None.

Footnotes
References
Hide All
1 Department of Health. 2010/11 National Survey of Investment in Adult Mental Health Services. Department of Health, 2011.
2 House of Commons Health Committee. Post-Legislative Scrutiny of the Mental Health Act 2007. TSO (The Stationery Office), 2013.
3 The Center for Health Design. Evidence-Based Design Accrediation and Certification (EDAC). (http://www.healthdesign.org/edac/about). Accessed 25 November 2013.
4 Department of Health. The NHS Plan: A Plan for Investment, A Plan for Reform. TSO (The Stationery Office), 2000.
5 Department of Health. Health Building Note 03-01: Adult Acute Mental Health Units. TSO (The Stationery Office), 2013.
6 British Medical Association. The Psychological and Social Needs of Patients. Willis Newson, 2011.
7 Ulrich, RS. Effects of interior design on wellness: theory and recent scientific research. J Healthcare Inter Des 1991; 3: 97109.
8 Karlin, BE, Zeiss, RA. Environmental and therapeutic issues in psychiatric hospital design: toward best practices. Psychiatr Serv 2006; 57: 1376–8.
9 Dijkstra, K, Pieterse, M, Pruyn, A. Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: systematic review. J Adv Nurs 2006; 56: 166–81.
10 Moos, RH. Conceptualizations of Human Environments. Am Psychol 1973; 28: 652–65.
11 Holahan, CJ. Environmental change in a psychiatric setting – social-systems analysis. Hum Relat 1976; 29: 153–66.
12 Gesler, W, Bell, M, Curtis, S, Hubbard, P, Francis, S. Therapy by design: evaluating the UK hospital building program. Health Place 2004; 10: 117–28.
13 Higgs, WJ. Effects of gross environmental change upon behavior of schizophrenics: a cautionary note. J Abnorm Psychol 1970; 76: 421–2.
14 Beauchemin, KM, Hays, P. Sunny hospital rooms expedite recovery from severe and refractory depressions. J Affect Disord 1996; 40: 4951.
15 Benedetti, F, Colombo, C, Barbini, B, Campori, E, Smeraldi, E. Morning sunlight reduces length of hospitalization in bipolar depression. J Affect Disord 2001; 62: 221–3.
16 Holahan, C. Seating patterns and patient behavior in an experimental dayroom. J Abnorm Psychol 1972; 80: 115–7.
17 Holahan, CJ, Saegert, S. Behavioural and attitudinal effects of large-scale variation in physical environment of psychiatric wards. J Abnorm Psychol 1973; 82: 454–62.
18 Ittelson, WH, Proshansky, HM, Rivlin, LG. Study of bedroom use on 2 psychiatric wards. Hosp Community Psychiatry 1970; 21: 177–80.
19 Whitehead, CC, Polsky, RH, Crookshank, C, Fik, E. Objective and subjective evaluation of psychiatric ward redesign. Am J Psychiatry 1984; 141: 639–44.
20 Devlin, AS. Psychiatric-ward renovation – staff perception and patient behavior. Environ Behav 1992; 24: 6684.
21 Wykes, T. A hostel ward for ‘new’ long stay patients: an evaluative study of ‘a ward in a house’. In Longterm Community Care: Experience in a London Borough (Psychological Medicine Monograph Supplement 2) (ed. Wing, J. K.): 5997. Cambridge University Press, 1982.
22 McGonagle, IM, Allan, S. A comparison of behaviour in two differing psychiatric long-stay rehabilitation environments. J Psychiatr Ment Health Nurs 2002; 9: 493–9.
23 Edwards, J, Hults, MS. “Open” nursing stations on psychiatric wards. Perspect Psychiatr Care 1970; 8: 209–17.
24 Tyson, GA, Lambert, G, Beattie, L. The impact of ward design on the behaviour, occupational satisfaction and well-being of psychiatric nurses. Int J Ment Health Nurs 2002; 11: 94102.
25 Baldwin, S. Effects of furniture rearrangement on the atmosphere of wards in a maximum-security hospital. Hosp Community Psychiatry 1985; 36: 525–8.
26 Christenfeld, R, Wagner, J, Pastva, G, Acrish, WP. How physical settings affect chronic mental patients. Psychiatr Q 1989; 60: 253–64.
27 Vaaler, AE, Morken, G, Linaker, OM. Effects of different interior decorations in the seclusion area of a psychiatric acute ward. Nord J Psychiatr 2005; 59: 1924.
28 van der Schaaf, PS, Dusseldorp, E, Keuning, FM, Janssen, WA, Noorthoorn, EO. Impact of the physical environment of psychiatric wards on the use of seclusion. Br J Psychiatry 2013; 202: 142–9.
29 Corey, LJ, Wallace, MA, Harris, SH, Casey, B. Psychiatric ward atmosphere: a before and after look at how refurbishing affects staff and patient perceptions of the psychosocial treatment environment. J Psychosoc Nurs Ment Health Serv 1986; 24: 10–6.
30 Southard, K, Jarrell, A, Shattell, MM, McCoy, TP, Bartlett, R, Judge, CA. Enclosed versus open nursing stations in adult acute care psychiatric settings does the design affect the therapeutic milieu? J Psychosoc Nurs Ment Health Serv 2012; 50: 2834.
31 Urbanoski, KA, Mulsant, BH, Novotna, G, Ehtesham, S, Rush, BR. Does the redesign of a psychiatric in-patient unit change the treatment process and outcomes? Psychiatr Serv 2013; 64: 804–7.
32 Sheehan, B, Burton, E, Wood, S, Stride, C, Henderson, E, Wearn, E. Evaluating the built environment in in-patient psychiatric wards. Psychiatr Serv 2013; 64: 789–95.
33 Novotna, G, Urbanoski, KA, Rush, BR. Client-centered design of residential addiction and mental healthcare facilities: staff perceptions of their work environment. Qual Health Res 2011; 21: 1527–38.
34 Curtis, S, Gesler, W, Fabian, K, Francis, S, Priebe, S. Therapeutic landscapes in hospital design: a qualitative assessment by staff and service users of the design of a new mental health in-patient unit. Environ Plan C Govern Pol 2007; 25: 591610.
35 Wood, VJ, Curtis, SE, Gesler, W, Spencer, IH, Close, HJ, Mason, J, et al. Creating ‘therapeutic landscapes’ for mental healthcarers in in-patient settings: a dynamic perspective on permeability and inclusivity. Soc Sci Med 2013; 91: 122–9.
36 Thompson, NC, Hunter, EE, Murray, L, Ninci, L, Rolfs, EM, Pallikkathayil, L. The experience of living with chronic mental illness: a photovoice study. Perspect Psychiatr Care 2008; 44: 1424.
37 Douglas, CH, Douglas, MR. Patient-centred improvements in health-care built environments: perspectives and design indicators. Health Expect 2005; 8: 264–76.
38 Cooper, CM, Yarbrough, SP. Tell me-show me: using combined focus group and photovoice methods to gain understanding of health issues in rural Guatemala. Qual Health Res 2010; 20: 644–53.
39 Wang, C, Burris, MA. Empowerment through photo novella: portraits of participation. Health Educ Q 1994; 21: 171–86.
40 van Hove, G, Struthers, P, Muvua, A. Using photo voice to facilitate interviews and to elucidate meanings. Presented at the International Association for the Scientific Study of Intellectual and Developmental Disabilities (IASSID) World Congress – Empowerment, Rights and Ethics. IASSID, 2008, p. 703 (iassid.org/pdf/Empowermentrights–Ethics.pdf).
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×
Type Description Title
PDF
Supplementary materials

Papoulias et al. supplementary material
Supplementary Table S1-S2

 PDF (44 KB)
44 KB
PDF
Supplementary materials

Papoulias et al. supplementary material
Supplementary Table S1-S2

 PDF (44 KB)
44 KB
PDF
Supplementary materials

Papoulias et al. supplementary material
Supplementary Table S1-S2

 PDF (44 KB)
44 KB

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 72 *
Loading metrics...

Abstract views

Total abstract views: 273 *
Loading metrics...

* Views captured on Cambridge Core between 2nd January 2018 - 21st April 2018. This data will be updated every 24 hours.

The psychiatric ward as a therapeutic space: systematic review

  • Constantina Papoulias, Emese Csipke, Diana Rose, Susie McKellar and Til Wykes...
Submit a response

eLetters

Re: 'The psychiatric ward as a therapeutic space: systematic review'

Oliver Jenkins, ST6 in General Adult Psychiatry
10 October 2014

Papoulias et al(1) have added a great deal to our understanding of the research exploring the effects of ward design on both patients and staff. They highlight the breadth of study designs but also the varying quality of both patient and environmental measures. A further inherent limitation in many of the studies appears to have been the difficulty in controlling for confounding factors such as staffing and patient characteristics.

Given these observations, it was unfortunate that a recent study(2) was not at the time ready for inclusion in this systematic review as it adds to the body of work identified and also addresses some of the criticisms. Our work aimed to assess the impact of a changed ward environment on the levels of inpatient agitation and conflict on an NHS Psychiatric Intensive Care Unit.

Taking advantage of a PICU moving from an old, temporary building to a new, purpose built ward we were able to analyse routine patient data that were markers of agitation and conflict including seclusion episodes, duration of close observation, recorded aggressive incidents and data fromthe Nursing Observed Illness Intensity Scale (NOIIS)(3). At the same time,we had an evidence-based, objective before and after measure of the ward environment: Environment Assessment Inventory (EAI)(4).

This methodology, reviewing data before and after a ward change, enabled us to control for many of the important confounding factors that were highlighted by Papoulias et al(1) as patient profiles, ward staffing and policies were largely unchanged.

The results showed that the key measures of agitation and conflict were reduced on the new ward, and the environmental measure (EAI) enabled us to identify quantifiable improvements and highlight critical design elements that had been improved upon.

Like many other studies in the systematic review, our findings suggested that the physical environment of the psychiatric ward had some significant effects on patient behaviours. Some of the critical changes included better visibility, increased space for therapeutic activities and more privacy in the form of single rooms. Papoulias et al(1) highlighted the common assessment that improved privacywas a key environmental factor in reducing violence on psychiatric wards and we would too made this interpretation. In the context of recent work by Ulrich et al(5), we concluded from our study that this may be because patient privacy fosters a sense of control that reduces stress levels and in turn agitation and conflict which are closely linked to violence.

We hope that our findings can be set alongside the work to date and provide further evidence for optimising patient care by using evidence-based and objective standards to improve the environment of psychiatric wards.

References

1 Papoulias C, Csopke E, Rose D, McKellar S and Wykes T. The psychiatric ward as a therapeutic space: systematic review. Br J Psychiatry 2014; 205: 171 - 176

2 Jenkins O, Dye S and Foy C. A study of agitation, conflict and containment in association with change in ward physical environment . Journal of Psychiatric Intensive Care, available on CJO 2014. doi:10.1017/S1742646414000065.

3 Bowers L, Brennan G, Ransom S, Winship G and Theodoridou C. The Nursing Observed Illness Intensity Scale (NOIIS). Journal of Psychiatric and Mental Health Nursing 2011 18(1), pp. 28-34.

4 Dix R, Pereira S, Chaudry K, Dale C and Halliwell J. A PICU / LSU environment assessment inventory. Journal of Psychiatric Intensive Care 2005, 1(2), pp. 65-69.

5 Ulrich RS, Bogren L and Lundin S. Towards an evidence-based design theory for reducing aggression in psychiatric facilities. Paper presented at the conference, Arch12: Architecture, Research Care, Health 2012, Gothenberg: Chalmers University.

... More

Conflict of interest: None declared

Write a reply

Nick Bouras, Emeritus Professor
09 October 2014

The systematic review by Papoulias et al 1 on 'the psychiatric ward as a therapeutic space' is welcome, reminding us of the important effects which environmental factors may have on inpatients. The physical environment is likely however to be particularly significant in settings where length of stay is long, whether in or out of hospital. The 1995 study by Halpern 2 demonstrates mental health effects of the built environment on residents of a housing estate, and the concerns of Papoulias et al should be explored in residential mental health facilitiesin the community.

For psychiatric inpatients, patient characteristics (including diagnosis) and psychosocial environmental factors are powerful determinants of what happens in the hospital, including behaviour disturbances, service user opinions, and also sometimes illness outcomes 3, 4. Clark 5 was one of those who showed that different wards for different varieties of patient should with advantage have different sorts of environment, drawing on the extensive previous research in this field (for instance 6). A major problem with today's inpatient wards is that everyone has to be admitted to, and as like as not, stay in, the same environment, whether or not it suits them and their illness. This reminds clinicians with long memories of the features of the old observations wards, to which anyone putatively mentally ill could be admitted, primarily for triage and transfer to the setting which suited them best. Today, there is, in these terms, only the triage.

1.Papoulias C. Csipke E. Rose D. McKellar S. Wykes T. The psychiatric ward as a therapeutic space: systematic review. British Journal of Psychiatry 2014, 205, 171-176; doi:10.1192/bjp.bp.114.1448732.Halpern D Mental Health and the Built Environment, 1995, Taylor and Francis, London3.Bouras N. Trauer T. Watson JP Ward environment and disturbed behaviour.Psychological Medicine, 1982, 12, 309 -3194.Watson JP and Bouras N Psychiatric ward environments and their effects on patients. In Clinical Psychiatry, Granville-Grossman K (ed.) 1988, 135 - 1605.Clark D Administrative Therapy, 1964, Tavistock, London6.Stanton A H. and Schwartz MS The Mental Hospital, 1954, Basic Books, New York

Jim Watson, Emeritus Professor Guy's and St Thomas' Hospitals and Nick Bouras, Emeritus Professor, King's College London, Institute of Psychiatry, Psychology and Neurosciences

... More

Conflict of interest: None declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *