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The psychiatric ward as a therapeutic space: systematic review

  • Constantina Papoulias (a1), Emese Csipke (a2), Diana Rose (a1), Susie McKellar (a1) and Til Wykes (a3)...



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


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


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.


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.


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.

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Corresponding author

Dr Emese Csipke, Institute of Psychiatry, King's College London, Henry Wellcome Building, De Crespigny Park, London SE5 8AF, UK. Email:


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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




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The psychiatric ward as a therapeutic space: systematic review

  • Constantina Papoulias (a1), Emese Csipke (a2), Diana Rose (a1), Susie McKellar (a1) and Til Wykes (a3)...
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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.


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.

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Conflict of interest: None declared

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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

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