The psychiatric ward as a therapeutic space
British Journal of Psychiatry
The psychiatric ward as a therapeutic space 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 seems to be the difficulty in controlling for confounding factors such as staffing and patient characteristics. Given these observations, it
... as unfortunate that our 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 in-patient agitation and conflict on an NHS psychiatric intensive care unit (PICU). Taking advantage of a PICU moving from an old, temporary building to a new, purpose-built ward, we were able to analyse routinely collected patient data that were markers of agitation and conflict, including number of seclusion episodes, duration of close observation, number of aggressive incidents and data from the Nursing Observed Illness Intensity Scale. 3 We also had an evidence-based, objective, before-and-after measure of the ward environment: the 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 remained largely unchanged. The results showed that the key measures of agitation and conflict were reduced on the new ward, and the EAI enabled us to identify quantifiable improvements and highlight critical design elements that had been improved upon. Like many of the studies in the systematic review, ours suggested that the physical environment of the psychiatric ward had a significant effect 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 idea that improved privacy was a key environmental factor in reducing violence on psychiatric wards, and we too would make this interpretation. In the context of recent work by Ulrich et al, 5 we concluded that it might 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, Csipke E, Rose D, McKellar S, Wykes T. The psychiatric ward as a therapeutic space: systematic review. Br J Psychiatry 2014; 205: 171-6. 2 Jenkins O, Dye S, Foy C. A study of agitation, conflict and containment in association with change in ward physical environment.