Patients' and Staff's Perceptions of the Psychiatric Ward Environment

PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ July 2004 Vol. 55 No. 7779988

Although patients who have psy-choses are treated primarily inthe community, inpatient

units play an important role in thetreatment of patients who have severepsychotic disorders and suicidality(1,2). Several studies have demon-strated the importance of the treat-ment environment for inpatients withpsychoses (3–8). The Ward Atmos-phere Scale (WAS) is the most widelyused instrument for capturing aspectsof the treatment environment (9).

The ward atmosphere may be expe-rienced differently by differentgroups, giving the impression that pa-tients and staff live in “differentworlds,” even though they share the

same physical and social environment(10–14). These differences in percep-tion are important, because they di-rectly challenge the common viewsthat staff’s perceptions of the ward at-mosphere reflect those of inpatients(15,16) and that patients’ and staff’sWAS scores can be pooled (17,18).

Studies of differences between pa-tient’s and staff’s perceptions of thetreatment environment have had in-consistent results (19–22), probablybecause the studies have used indi-vidual WAS scores, whose reliabilityis unsatisfactory for most subscales(23). In contrast, mean WAS scoreshave satisfactory reliability. However,to our knowledge, only two studies

have examined differences betweenpatient’s and staff’s scores at the wardlevel. Moos (10) found that staff’sscores were higher on all the WASsubscales except for the order and or-ganization subscale, on which staffand patients had equal scores, and thestaff control subscale, on which staffhad lower scores. Friis (24) replicatedthese findings, except that staff’sscores were lower on the order andorganization subscale in that study.

To better understand the differentperspectives of patients and staff, it isimportant also to examine other as-pects of the treatment climate, suchas patient and staff satisfaction, andthe work environment as perceivedby staff. Patient satisfaction is consid-ered to be a critical health care indi-cators (25). The potentially stressfulnature of a poor work environment isassociated with reduced job satisfac-tion, absenteeism, somatic com-plaints, burnout, and depressionamong staff (26–30).

However, only two studies have ex-amined various aspects of staff’sworking conditions and patient satis-faction. Garman and colleagues (31)found a significant positive relation-ship between staff burnout and pa-tient satisfaction. Corrigan and asso-ciates (32) found a strong relationshipbetween different styles of team lead-ership and consumer satisfaction. Toour knowledge, no previous studieshave explicitly examined the relation-ship between the core dimensions ofthe working environment and patientsatisfaction. We undertook such aninvestigation by including a short anduser-friendly working-environmentquestionnaire comprising ten items—the Working Environment Scale–10(WES-10). The WES-10 has been

Patients’ and Staff’s Perceptions of the Psychiatric Ward EnvironmentJJaann IIvvaarr RRoossssbbeerrgg,, MM..DD..SSvveeiinn FFrriiiiss,, MM..DD..,, PPhh..DD..

The authors are affiliated with the division of psychiatry of Ulleval University Hospital,N-0407 Oslo, Norway (e-mail, [email protected]).

Objective: This study examined the extent to which patients’ and staff’sperceptions of the psychiatric ward atmosphere and the working con-ditions of staff influence patient and staff satisfaction. Methods: A totalof 640 staff members on 42 wards completed the Ward AtmosphereScale (WAS) and the Working Environment Scale–10 (WES-10). A totalof 424 patients on the same wards completed the WAS. Both patientsand staff members answered three questions about their general satis-faction with the ward. The ward means were used as the unit of analy-sis. Results: The staff members had significantly higher scores than thepatients on nine of the 11 WAS subscales. Patients’ and staff’s WASscores were moderately correlated. No significant correlation wasfound between patients’ and staff’s scores on the three satisfactionitems. Patient satisfaction was strongly correlated with patients’ WASscores and was moderately correlated with staff’s WAS scores but wasnot significantly correlated with staff’s WES-10 scores. Staff satisfactionwas moderately correlated with staff’s WAS and WES-10 scores but wasnot correlated with patients’ WAS scores. Conclusions: Different aspectsof the treatment climate seem to be important for patient and staff sat-isfaction. The ward atmosphere seems to be more important for patientsatisfaction than for staff satisfaction. The working environment isstrongly related to staff satisfaction but seems to be unrelated to patientsatisfaction. (Psychiatric Services 55:798–803, 2004)

shown to measure the core dimen-sions of the work environment (33).

Our main aim was to further exam-ine the different perspectives of pa-tients and staff. First, we wanted toexamine whether we would obtainthe same findings as those of Moos(10) and Friis (24), which showed thatpatients and staff perceive the wardatmosphere differently. Becausemany aspects of inpatient treatmenthave changed since the 1970s—forexample, inpatient stays are shorter,and a higher percentage of patientshave psychoses—these earlier find-ings need to be replicated in the cur-rent inpatient setting. Second, wewanted to examine the relationshipbetween patient and staff satisfactionand the extent to which patient andstaff satisfaction are related to WASand WES-10 scores. We hypothe-sized that patient and staff satisfac-tion would be significantly correlatedand that the working environment asperceived by staff would be signifi-cantly correlated with patient satis-faction. Furthermore, we hypothe-sized that WAS scores would be moststrongly correlated with patient satis-faction and that WES-10 scoreswould be most strongly correlatedwith staff satisfaction.

MethodsDuring the period 1990 through 2000a total of 640 staff members on 42wards for psychotic patients complet-ed the WAS and the WES-10. A totalof 424 inpatients on the same wardscompleted the WAS during the sameperiod. All data were collected withinfive days on each ward, and each wardwas rated only once. All the psychi-atric wards were part of the commu-nity hospital system in Norway. Thechairman of the regional ethical com-mittee approved the study.

Most of the wards were short-termwards (36 wards), but six intermedi-ate and long-term wards were also in-cluded. We included wards only whenmore than two-thirds of the patientshad diagnoses within the psychoticrange. So that reliable means wouldbe obtained for each ward, at leastfive patients had to complete theWAS. If fewer than five patients on award completed the questionnaires,that ward was excluded from the

study. All staff members—physicians,psychologists, nurses, and aides—were included in the study. Nightstaff were excluded, however, be-cause of difficulties in obtaining anacceptable number of completedquestionnaires from the night staff.Each staff member was asked abouthis or her duration of employment onthe psychiatric ward. Ninety-six staffmembers (15 percent) had been em-ployed for less than six months, 141(22 percent) between six months and18 months, 128 (20 percent) between18 months and three years, and 275(43 percent) for more than threeyears.

Staff and patients participated inthe study on a voluntary basis. Partic-ipants were asked to complete a mod-ified version of the WAS for the wardas they experienced it, or a “realward” WAS (WAS-R). The WAS-R isa self-report questionnaire containing100 statements about the ward, eachrequiring a true or false answer. Weused a revised version of the WAS-Rcomprising 80 items, as describedpreviously (23,34). In addition, wemodified the true-or-false format to a4-point scale ranging from 0, totallydisagree, to 3, totally agree.

The revised WAS comprised 11subscales: involvement (a measure of

how active and energetic patients arein the program), support (a measureof how much patients help and sup-port each other and how supportivethe staff are toward patients), spon-taneous behavior (a measure of thelevel of open expression of feelingsby patients and staff), autonomy (ameasure of how self-sufficient andindependent patients are in makingtheir own decisions), practical orien-tation (a measure of the extent towhich patients learn practical skillsand are prepared for release fromthe program), personal problem ori-entation (a measure of the extent towhich patients seek to understandtheir feelings and personal prob-lems), angry and aggressive behavior(a measure of how much patients ar-gue with other patients and staff, be-come openly angry, and display oth-er aggressive behavior), order andorganization (a measure of how im-portant order and organization are inthe program), program clarity (ameasure of the extent to which pa-tients know what to expect in theirday-to-day routine and the explicit-ness of program rules and proce-dures), staff control (a measure ofthe extent to which the staff use pro-cedures to keep patients under nec-essary controls), and staff’s attitudetoward expressed feelings (a meas-ure of the extent to which staff en-courage patients to express theirfeelings openly).

The WES-10 is also a self-reportquestionnaire. The staff rated theitems on a 5-point scale ranging from1, totally disagree, to 5, totally agree.The WES-10 measures four clinicallymeaningful subscales and has beenexamined in a previous study (33).The four subscales are self-realization(a measure of the extent to which thestaff members feel supported andwhether they feel that they are able touse their knowledge working on theward), workload (a measure of thenumber of tasks imposed on the staffmembers and the extent to whichthey feel that they should have beenin several places at the same time),conflict (a measure of the extent towhich the staff members experienceconflicts and loyalty problems), andnervousness (a measure of the extentto which staff are worried about going

PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ July 2004 Vol. 55 No. 7 779999

The

ward

atmosphere may

be experienced differently

by different groups, giving

the impression that

patients and staff

live in “different

worlds.”

to work and the extent to which theyfeel nervous or tense on the ward).The mean±SD scores for the foursubscales were 3.64±.22 for self-real-ization, 3.42±.36 for workload, 2.06±.28 for conflict, and 1.99± .21 fornervousness.

Both patients and staff respondedto three questions developed byMoos (35) to capture general satisfac-tion: How satisfied are you with thisward?; How much do you like the pa-tients on this ward?; and How muchdo you like the staff on this ward? Thequestions were rated on a 5-pointscale ranging from 1, very unsatisfied,to 5, very satisfied. The staff mem-bers’ mean±SD scores on these threequestions were 4.03±.33 for question1; 4.20±.20 for question 2; and4.43±.21 for question 3. The patients’

respective scores on the same ques-tions were 3.74±.46, 3.82±.31, and4.05±.43.

In a previous study (23), we foundthat even if the internal consistencyof the WAS subscales was doubtful atan individual level, it was satisfactoryat the ward level. This finding is inaccordance with the literature, whichsuggests that a Cronbach’s alphagreater than .7 is satisfactory for indi-vidual comparisons and that a Cron-bach’s alpha greater than .5 is satis-factory for group comparisons(36,37). Consequently, the wardmeans were used in all the statisticalanalyses of the WAS subscales, theWES-10 subscales, and the threegeneral satisfaction items. Becausewe had changed the original true-or-false rating scale (0 or 1) to a 4-point

scale ranging from 0 to 3, we dividedthe sum of the item scores by 3. Be-cause of the reduced number ofitems, we divided the sum score bythe total number of items includedand multiplied the resultant value by10. This approach allowed us to com-pare the mean values obtained in thisstudy with the mean values obtainedin previous studies that used the orig-inal ten-item, 2-point scale. Conse-quently, the mean WAS subscalescores reported here range from 0(low) to 10 (high).

Nonpaired t tests were used to ana-lyze the differences between patients’and staff members’ perceptions of theward atmosphere. Correlations be-tween the WAS subscales, WES-10subscales, and general satisfactionitems were calculated as Pearsonproduct-moment coefficients. Datawere analyzed by using the StatisticalPackage for the Social Sciences (ver-sion 11.0).

ResultsAs can be seen from Table 1, themean scores for staff were significant-ly higher than those for patients onnine of the 11 WAS subscales. No sig-nificant difference between groupswas found on the order and organiza-tion subscale, whereas the staffscored significantly lower than the pa-tients on the staff control subscale.

The subscale scores for patientsand staff were moderately correlated.The strongest correlation was be-tween autonomy scores (r=.58), andthe weakest correlation was betweenspontaneous behavior scores (r=.27).The median intercorrelation coeffi-cient was .41. No significant correla-tions were found between patientsand staff on the three satisfactionitems.

As can be seen from Table 2, pa-tients’ WAS scores were stronglycorrelated with the three patientsatisfaction items but not with thethree staff satisfaction items. Table 3shows that the staff WAS scoreswere fairly strongly correlated withthe three staff satisfaction items.The staff perceptions of involve-ment, personal problem orientation,and angry and aggressive behaviorwere also significantly correlatedwith the patients’ general liking for


TTaabbllee 11

Differences between patients’ and staff’s scores on the 11 subscales of the WardAtmosphere Scale (WAS) (N=640 staff and 424 patients)

WAS subscalea Mean SD t df Two-tailed p

Involvement –5 80 <.001Patients 5.08 .9Staff 6 .78

Support –3.7 79 <.001Patients 5.35 .83Staff 5.97 .69

Spontaneous behavior –8.41 69 <.001Patients 4.37 .78Staff 5.56 .49

Autonomy –5.08 75 <.001Patients 4.7 1.06Staff 5.73 .78

Practical orientation –6.35 82 <.001Patients 5.2 .9Staff 6.49 .97

Personal problem orientation –9.57 73 <.001Patients 4.99 .87Staff 6.56 .6

Angry and aggressive behavior –6.53 79 <.001Patients 3.96 .82Staff 5.03 .68

Order and organization 1.29 82 .203Patients 6.3 1.01Staff 6.02 .99

Program clarity –6.83 78 <.001Patients 5.56 .9Staff 6.77 .71

Staff control 9.63 71 <.001Patients 4.84 .78Staff 3.45 .52

Staff attitude toward expressedfeelings –7.16 77 <.001

Patients 5.1 1.23Staff 6.81 .94

a Possible scores range from 0 to 10, with higher scores indicating a high level of the characteristicmeasured by that subscale on the psychiatric ward.

the ward. Tables 2 and 3 indicatethat satisfaction was more stronglylinked to perceived ward atmos-phere for patients than for staff,probably because staff satisfaction isalso strongly dependent on the workenvironment.

As can be seen from Table 4, thework environment scores were strong-ly correlated with staff members’ gen-eral liking of the ward, liking of pa-tients, and liking of staff. In contrast,no significant relationship was foundbetween the three patient satisfactionitems and the work environment asperceived by staff.

Discussion and conclusionsOur finding that WAS scores weresignificantly higher among staff thanamong patients on nearly all WASsubscales is consistent with the find-ings of Moos (10) and Friis (24). Bothour data and data from those studiessuggest that staff tend to view thetreatment environment more favor-ably than do patients. As pointed outby Main and colleagues (38), staff’sperceptions are expected to be higheron dimensions that represent positiveaspects of their roles and lower in ar-eas that could have negative implica-tions. This expectation is consistent

with our results, with the exception ofthe angry and aggressive behaviorsubscale scores. A low level of angryand aggressive behavior has been as-sociated with a better treatment out-come and a higher level of patient sat-isfaction (7,39–41).

Our study showed no significantcorrelation between patient and staffsatisfaction and no significant rela-tionship between patient satisfactionand the work environment as per-ceived by staff. The main reason forthe lack of correlation between pa-tient and staff satisfaction may be thatdifferent aspects of the treatment en-


TTaabbllee 22

Correlations between patients’ scores on subscales of the Ward Atmosphere Scale (WAS) and patients’ and staff’s general lik-ing of the ward, general liking of patients, and general liking of staff

General satisfactionwith the ward General liking of patients General liking of staff

WAS subscale Patients Staff Patients Staff Patients Staff

Involvement .72∗∗ .03 .5∗∗ .09 .46∗∗ .11Support .61∗∗ .08 .38∗ .24 .5∗∗ .07Spontaneous behavior .42∗∗ –.05 .18 .15 .39∗ .16Autonomy .51∗∗ .08 .13 .31∗ .45∗∗ .17Practical orientation .59∗∗ .09 .3 .13 .41∗∗ .05Personal problem orientation .4∗∗ –.03 .32∗ .11 .36∗ –.05Angry and aggressive behavior –.4∗∗ –.02 –.36∗ –.02 –.31 –.08Order and organization .65∗∗ .1 .45∗∗ .16 .51∗∗ .14Program clarity .39∗ .04 .44∗∗ .26 .44∗∗ .05Staff control –.7∗∗ –.12 –.41∗∗ –.12 –.5∗∗ –.13Staff attitude to expressed feelings .31 .04 .39∗ .04 .12 .03

∗p<.05, two-tailed test∗∗p<.01, two-tailed test

TTaabbllee 33

Correlations between staff’s scores on subscales of the Ward Atmosphere Scale (WAS) and patients’ and staff’s general likingof the ward, general liking of patients, and general liking of staff



Involvement .51∗∗ .51∗∗ .18 .39∗ .17 –.08Support .23 .48∗∗ .09 .38∗ .03 .07Spontaneous behavior .19 .32∗ –.26 .32∗ .14 –.04Autonomy .18 .32∗ .12 .51∗∗ .04 .13Practical orientation .23 .36∗ .14 .5∗∗ .08 .15Personal problem orientation .55∗∗ .17 .13 .15 .3 .03Angry and aggressive behavior –.42∗∗ –.29 –.17 –.35∗ –.2 .02Order and organization .27 .52∗∗ .31 .43∗∗ –.06 –.02Program clarity .19 .37∗ .3 .29 .04 .06Staff control –.3 –.32∗ .11 –.31∗ –.19 –.07Staff attitude to expressed feelings .05 .18 .36∗ .3 .09 .22

∗p<.05, two-tailed test∗∗p<.01, two-tailed test

vironment are related to patient andstaff satisfaction. Patient satisfactionwas strongly correlated with patients’WAS scores and was moderately cor-related with staff’s WAS scores butwas not correlated with WES-10scores. In contrast, staff satisfactionwas moderately correlated with staff’sWAS and WES-10 scores but not withpatients’ WAS scores.

Consequently, it appears that theward atmosphere is more importantfor patient satisfaction than for staffsatisfaction. It is important to consid-er the different roles and viewpointsof patients and staff, each of whomare on the ward for different reasons.Most notable is that, unlike most ofthe patients, staff members can leavethe ward after their shifts and maywithdraw from the ward milieu if theyexperience it as too stressful. Thusthe ward atmosphere is likely to bemore important for patient satisfac-tion than for staff satisfaction.

Several studies have shown a signif-icant relationship between the workenvironment and burnout amongmental health workers (26–30). Gar-man and associates (31) found a sig-nificant relationship between burn-out and patient satisfaction in inpa-tient and community programs thatused psychosocial rehabilitation ap-proaches. On the basis of the resultsof these studies, we expected to find asignificant correlation between pa-tient and staff satisfaction. The mainreason for the contrary results in ourstudy may be that we examined pri-marily short-term units. A shorter in-patient stay may give patients less ac-cess to different aspects of the treat-ment environment and may strength-

en the impression that patients andstaff live in “different worlds.” Thisexplanation is supported to some ex-tent by the stronger correlation be-tween patients’ and staff’s WAS scoresin a sample from the 1970s (42),when patients were admitted for alonger time than in our study. The av-erage correlations between patients’and staff’s WAS scores were .61 in the1970s (24) and .41 in our study.

It is possible that our study wouldhave had different results if all pa-tients and staff members had com-pleted the questionnaires. We did notcollect information about patientswho did not complete the question-naires. It is possible that the patientswho refused or were unable to com-plete the questionnaires were themore severely disturbed patients.However, in a previous study (8), per-ceptions of the ward atmosphere didnot differ between the more severelydisturbed patients and other patients.Moreover, an average of ten patientscompleted the questionnaires oneach ward, which should have mini-mized any possible selection bias.

We used three questions to capturegeneral satisfaction with the treat-ment climate. It could be argued thata more sophisticated instrumentwould have yielded different results.The reliability of these three itemshas not been examined. However, theuse of ward means instead of individ-ual scores increases the reliability ofthe satisfaction scores (43).

Our study provides new informa-tion about the different perspectivesof patients and staff on the treatmentenvironment. The ward atmosphereseems to be most important for pa-

tient satisfaction, and staff tend toview the treatment environmentmore favorably than do patients. Ourdata suggest that patients’ and staff’sscores should be analyzed separatelyand not pooled to provide one singlemeasurement of the treatment envi-ronment. Furthermore, our data sug-gest that the commonly held view thatthe working conditions of staff influ-ence patient satisfaction and theirperceptions of the treatment environ-ment needs to be moderated. ♦

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TTaabbllee 44

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EElleeccttrroonniicc TTaabbllee ooff CCoonntteennttss SSeerrvviiccee

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Patients' and Staff's Perceptions of the Psychiatric Ward Environment