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Impact of the physical environment of psychiatric wards on the use of seclusion

  • P. S. van der Schaaf (a1), E. Dusseldorp (a1), F. M. Keuning (a1), W. A. Janssen (a2) and E. O. Noorthoorn (a2)...



The physical environment is presumed to have an effect on aggression and also on the use of seclusion on psychiatric wards. Multicentre studies that include a broad variety of design features found on psychiatric wards and that control for patient, staff and general ward characteristics are scarce.


To explore the effect of design features on the risk of being secluded, the number of seclusion incidents and the time in seclusion, for patients admitted to locked wards for intensive psychiatric care.


Data on the building quality and safety of psychiatric as well as forensic wards (n = 199) were combined with data on the frequency and type of coercive measures per admission (n = 23 868 admissions of n = 14 834 patients) on these wards, over a 12-month period. We used non-linear principal components analysis (CATPCA) to reduce the observed design features into a smaller number of uncorrelated principal components. Two-level multilevel (logistic) regression analyses were used to explore the relationship with seclusion. Admission was the first level in the analyses and ward was the second level.


Overall, 14 design features had a significant effect on the risk of being secluded during admission. The ‘presence of an outdoor space’, 'special safety measures' and a large ‘number of patients in the building’ increased the risk of being secluded. Design features such as more ‘total private space per patient’, a higher ‘level of comfort’ and greater ‘visibility on the ward’, decreased the risk of being secluded.


A number of design features had an effect on the use of seclusion and restraint. The study highlighted the need for a greater focus on the impact of the physical environment on patients, as, along with other interventions, this can reduce the need for seclusion and restraint.

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Corresponding author

P. S. van der Schaaf, TNO, Dutch Centre for Health Assets/DuCHA Kampweg 5, 3769 DE Soesterberg, The Netherlands. Email:


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Impact of the physical environment of psychiatric wards on the use of seclusion

  • P. S. van der Schaaf (a1), E. Dusseldorp (a1), F. M. Keuning (a1), W. A. Janssen (a2) and E. O. Noorthoorn (a2)...


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Impact of the physical environment of psychiatric wards on the use of seclusion

  • P. S. van der Schaaf (a1), E. Dusseldorp (a1), F. M. Keuning (a1), W. A. Janssen (a2) and E. O. Noorthoorn (a2)...
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Influence of the physical environment of psychiatric inpatient facilities on the staff and coercive measures

K.A.L.A. Kuruppuarachchi, Professor of Psychiatry
01 July 2013

The article on Impact of the physical environment of psychiatric wards on the use of seclusion ( van der Schaaf et al 2013) has been readwith much concern as it has a global relevance including psychiatric practice in low- and middle-income countries.

The reasons for seclusion and coercive measures are intricately linked and one may find it difficult to distinguish/disentangle the impactof individual factors such as poor quality of the environment, patients characteristics and the staff characteristics. It has been repeatedly highlighted the reasons for seclusion and ways of minimizing the deleterious consequences of seclusion. Even more recent articles addressedthe contribution of inadequate resources and facilities to the quality of care leading to adverse outcomes. Majority of the psychiatric inpatient facilities were considered as disgusting and disrespectful by the families, patients and the nursing staff. It appears that the nursing carein acute inpatient units has become mainly a custodial task, and a wide range of problems encountered in nursing care in such wards and also possible remedies have been highlighted( Allen & Jones 2002).

On the other hand overcrowding in psychiatric inpatient units is a common occurrence all over the world. A recent longitudinal study has shown an association between patient overcrowding in the wards and elevated risk of physical assaults by patients (Virtanen et al. 2011). This also highlights the importance of managing psychiatric patients in less overcrowded , safe , less stressful and a more conducive environment.Introduction of psychiatric intensive care units(PICU) in certain areas inNew Zealand contributed to decline in episodes of seclusion. A study done in New Zealand has shown that psychotic illnesses particularly schizophrenia, schizo- affective disorder and mania are the main reasons for seclusion and the majority of patients were secluded as a result of disturbed behavior, involving threats of assaults to the patients, staff and property whereas the actual physical attack has taken place in one fifth of the episodes(Tyrer et al. 2012).

Coercive measures have been viewed as having both negative and positive aspects, and there is a tendency to integrate them into the life stories of the people who had such experiences differently and diversely. Coercion may be considered as deleterious as well as unnecessary and the need for improvements of its implementation has been addressed(Sibitz et al. 2011 ).

The other important area needs to be highlighted is the influence of the physical environment on the stress levels and behavior of the staff members and other care givers. This can act as a compounding variable which is inadequately addressed in many research work/ articles.It has been shown the importance of a healthy work place including organizational aspects in psychiatric practice as those factors will facilitate to mitigate some work related negative consequences on psychiatrists(Thomsen et al. 1998).

The coping abilities, stress levels and overall behaviour of the staff members can also be improved by modifying the environment of the psychiatric facilities. This area has a more relevance to our part of the world. For instance in countries such as Sri Lanka still the mentally ill patients are managed in overcrowded poorly staffed inpatient facilities with minimum resources. Many psychiatric inpatient units are poorly designed and located in unsuitable areas. Stigmatizing attitudes towards the mentally ill and the discipline appear to be contributing to this. On the other hand unattractive, dilapidated units tend to reinforce and maintain the negative attitudes towards psychiatry. Some units encourage the family members to visit and help the patients which relieve the burden at least to some extent on already overworked staff members, which could also be regarded as a "community model"( Kuruppuarachchi & Rajakaruna 1999 ). It has been highlighted that a soothing, calm environment such as a spacious temple garden and engaging in religious activities /rituals help to reduce the disturbance in elderly dementing patients which could be utilized in the management(Kuruppuarachchi & Lawrence 2006).The issue of the influence of the design and facilities of the inpatient units on the staff members/cares and the transmission of their emotions towards the patients need to be addressed. The reciprocal nature of this area should be acknowledged. It is note- worthy that an attractive environment will help to reduce the stigma as well. Obviously we need to do more research work related to this area including addressing the influence of the environment on the staff members as this will help to understand this problem further.


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. British Journal of Psychiatry 2013 ; 202: 142-149.

Allen C, Jones J. Acute wards: problems and solutions. Psychiatric Bulletin 2002 ; 26: 458-459.

Virtanen M, Vahtera J, Batty GD, Tuisku K, Pentti J et al. Overcrowding in psychiatric wards and physical assaults on staff: data-linked longitudinal study. British Journal of Psychiatry 2011 ; 198: 149-155.

Tyrer S, Beckley J, Goel D, Dennis B, Martin B. Factors affecting thepractice of seclusion in an acute mental health service in Southland, New Zealand. The Psychiatrist 2012 ; 36: 214-218.

Sibitz I, Scheutz A, Lakeman R, Schrank B, Schaffer M, Amering M. Impact of coercive measures on life stories: qualitative study. British Journal of Psychiatry 2011 ; 199: 239-244.

Thomsen S, Dallender J, Soares J, Nolan P, Arnetz B. Predictors of a healthy workplace for Swedish and English Psychiatristrs. British Journal of Psychiatry 1998 ; 173: 80 -84.

Kuruppuarachchi KALA, Rajakaruna RR. Psychiatry in Sri Lanka. Psychiatric Bulletin 1999 ; 23: 686- 688.

Kuruppuarachchi KALA, LawrenceTS. Incorporating spiritual and religious beliefs in taking care of the elderly with psychiatric problems - Some personal experiences. Indian Journal of Geriatric Mental Health 2006 ; 2(1): 51-54.

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