Discussion

A strong preference for single-occupancy patient rooms emerged in our study, with shared accommodation frequently cited as a source of dissatisfaction. Despite this, empirical data on the impact of single-occupancy patient rooms in psychiatric settings remain limited. Our findings align with studies in general hospital environments, where patients report a preference for single-occupancy patient rooms because of privacy, comfort and flexibility. ^{Reference Maben, Griffiths, Penfold, Simon, Anderson and Robert25} Evidence from intensive care units suggests single-occupancy patient rooms reduce noise disturbances and improve patient outcomes. Reflecting these benefits, architectural guidelines in the USA and several European countries now mandate single-occupancy patient rooms in new hospital designs. Studies highlight advantages such as reduced infections, fewer transfers, improved sleep and enhanced confidentiality. ^{Reference Maben, Griffiths, Penfold, Simon, Anderson and Robert25,Reference van de Glind, de Roode and Goossensen26} A systematic review further supports single-occupancy patient rooms as predominantly beneficial. ^{Reference Taylor, Card and Piatkowski27} Unsurprisingly, the private clinic, which offered only single-occupancy patient rooms, reported the highest patient satisfaction with room features. These findings suggest that public psychiatric in-patient care may also benefit from increased single-occupancy patient room availability. Conducting prospective trials on single-occupancy patient rooms in psychiatry remains challenging for financial, practical and ethical reasons. ^{Reference Ulrich, Bogren, Gardiner and Lundin28} Although some studies suggest that single-occupancy patient rooms enhance privacy, reduce stress and mitigate aggression, ^{Reference Ulrich, Bogren, Gardiner and Lundin28,Reference Stolker, Nijman and Zwanikken29} others have found no significant impact on patient satisfaction. ^{Reference Jovanović, Miglietta, Podlesek, Malekzadeh, Lasalvia and Campbell5} Privacy concerns, particularly in psychiatric care, have been emphasised because of the sensitive nature of consultations and diagnoses. Nevertheless, shared rooms may provide social support, reduce loneliness and enhance safety by allowing fellow patients to alert staff in crises. Sleep disturbances, particularly difficulties initiating and maintaining sleep, are highly prevalent among psychiatric in-patients and represent a critical yet often overlooked concern. Our findings align with existing literature, underscoring the near-ubiquitous nature of insomnia symptoms in psychiatric wards. This is particularly worrisome, given the growing recognition of sleep disturbances as a key yet underexplored factor contributing to both the symptoms and functional impairment associated with psychiatric disorders. Notably, sleep improvement has demonstrated transdiagnostic benefits in psychiatric populations, enhancing overall well-being. ^{Reference Sheaves, Isham, Bradley, Espie, Barrera and Waite30} Although empirical evidence remains surprisingly limited, ^{Reference van de Glind, de Roode and Goossensen26} expert opinion suggests that single-occupancy patient rooms may facilitate better sleep quality. Additionally, as recently demonstrated during the COVID-19 pandemic, single-occupancy patient rooms offered logistical advantages for infection control by reducing the spread of infections and simplifying isolation measures. This highlights the need to prioritise the expansion of single-occupancy patient room availability in psychiatric in-patient settings. Most existing research on single-occupancy patient rooms is based on general hospital settings, underscoring the need for qualitative as well as quantitative studies, including randomised controlled trials, to evaluate their specific impact in psychiatric care. Given the overwhelming preference for single-occupancy patient rooms observed in our cohort, single rooms should form the predominant configuration of future in-patient wards. Retaining a small, clearly designated proportion of shared or higher-observation rooms may nonetheless serve specific clinical situations; for example, patients in acute crisis who benefit from continuous observation, those at elevated risk who should not be left alone, or individuals who explicitly prefer the reassurance of company. We acknowledge that combining room types carries practical trade-offs: when a patient’s condition changes and closer observation becomes necessary, reallocating beds can necessitate relocations that, particularly at full occupancy, may disturb several patients simultaneously. A predominantly single-room design supplemented by only a limited number of purpose-designated shared rooms may therefore best reconcile the strong patient preference for privacy with these operational realities.

Although this study was conducted in general rather than forensic psychiatry, the security dimension of the physical environment remains relevant to everyday risk management on general psychiatric wards. The widely used trinity model of security distinguishes three interdependent components: environmental (or physical) security, relational security arising from therapeutic staff–patient contact and procedural security embodied in policies and routines. ^{Reference Kennedy31} Design decisions concerning single rooms, sight lines, communal areas and access to outdoor space inevitably interact with all three dimensions. Single-occupancy rooms, for example, enhance privacy and dignity, but may reduce passive observation, placing greater weight on relational and procedural safeguards; conversely, well-designed communal and green spaces can strengthen relational security by facilitating therapeutic contact. Considering the trinity model alongside patient preferences may therefore help reconcile the goals of a calming, dignity-preserving environment with the safety requirements of acute in-patient care.

Patients rated the surrounding park of our clinic as highly important, and most favoured diagnosis-specific wards that align with the track concept. These findings validate the UPK Basel’s historic pavilion layout. Grouping patients with similar diagnoses in dedicated wards, with ample green space between them, was recognised as beneficial for mental health in the 1880s and remains so today. Empirical research highlights the mental health benefits of green spaces and natural environments. ^{Reference Oeljeklaus, Schmid, Kornfeld, Hornberg, Norra and Zerbe32,Reference Bratman, Anderson, Berman, Cochran, de Vries and Flanders33} Studies show that exposure to garden-like environments reduces stress and improves emotional well-being, ^{Reference Ulrich, Bogren, Gardiner and Lundin28} with recent meta-analyses indicating that forest-based therapies contribute to mental health improvements.

Patients expressed a desire for access to various therapy resources (e.g. relaxation areas, fitness rooms, art studios, kitchens, group therapy rooms) in addition to garden spaces. This demand aligns with treatment guidelines emphasising the importance and transdiagnostic efficacy of physical exercise, occupational therapy, nature-based therapies and lifestyle interventions in quality psychiatric care. ^{Reference Firth, Solmi, Wootton, Vancampfort, Schuch and Hoare34} Given the reduced lifespan observed in individuals with mental disorders, partly because of associated unhealthy lifestyles, a Lancet Commission has recommended incorporating lifestyle interventions into mental health services. Barriers to implementation include limited access to therapeutic facilities, insufficient supervision and lack of proximity to wards. Our respondents’ needs are consistent with findings from other studies, where patients identified boredom, limited activities ^{Reference Staniszewska, Mockford, Chadburn, Fenton, Bhui and Larkin35} and inadequate physical exercise opportunities as significant challenges in in-patient care. Patients have also reported that inactivity negatively affected their care. ^{Reference Staniszewska, Mockford, Chadburn, Fenton, Bhui and Larkin35} The importance of addressing these issues is underscored by a study showing that most patients (87.5%) experienced significant passivity because of the traditionally inactive role in psychiatric settings. As such, providing an enabling physical and social environment is crucial for patient well-being, as highlighted in a systematic review. ^{Reference Staniszewska, Mockford, Chadburn, Fenton, Bhui and Larkin35}

An interesting finding was the preference of patients for age-inclusive, integrative care models over dedicated geriatric departments. The limited availability of high-quality studies on the effectiveness of old-age psychiatry services means that providers and policy makers must rely on lower-quality evidence when designing care models. ^{Reference Cations, Wilton-Harding, Laver, Brodaty, Low and Collins36} In Switzerland, geriatric psychiatry is a specialised field requiring additional training following general psychiatry residency. The ageing population in Switzerland, along with the complex needs of elderly care, highlights the necessity for an interdisciplinary approach that combines medical, geriatric and geronto-psychiatric concepts and interventions. Although geriatric psychiatry subspecialty care seems to offer distinct benefits in assessment and treatment, spatial separation may not always be required. Future research in this area will be valuable.

Since the 1970s, the ‘out-patient before in-patient’ paradigm has gained increasing importance in psychiatric care in German-speaking countries, a trend that continues today. As part of the reform processes, the de-hospitalisation of psychiatric care – i.e. reducing in-patient treatment capacities – was prioritised for many years. At the same time, out-patient treatment capacities were expanded, and new alternative care models were implemented. Day hospitals and home-based treatment provide non-in-patient care settings offering crisis intervention, acute treatment and medium- and long-term regular care. ^{Reference Salize37} Despite the efforts and rationale behind them, our data indicate that respondents still show a strong preference for inpatient treatment. These preferences should be considered in the context of the ongoing transition of in-patient psychiatric care from restrictive environments to more open and welcoming spaces. Despite growing evidence supporting the effectiveness of innovative psychiatric care models, including home treatment, telemedicine/telepsychiatry and night clinics, ^{Reference Sharma and Devan38} our survey reveals more cautious findings, showing limited patient acceptance among former in-patients. This highlights the need for ongoing improvements in these services, as well as increased psychoeducation and public relations efforts to foster broader interest and acceptance. A limitation of our survey is the relatively low response rate, which is partly offset by the sample’s representativeness of the overall patient population. However, more vulnerable groups, such as individuals with current psychosis, cognitive impairments, homelessness or language barriers, may be underrepresented. To address this, healthcare providers must implement alternative methods to capture the perspectives of these patients. ^{Reference Nepal, Keniston, Indovina, Frank, Stella and Quinzanos-Alonso6} Furthermore, since we selected for in-patient experiences, the preferences expressed in regard to out-patient services should be interpreted with caution. Relatedly, the marked preference for in-patient care over more innovative or community-based treatment models is perhaps unsurprising given that all respondents were themselves former in-patients, whose familiarity with this setting is likely to shape their expectations; this preference should therefore not be interpreted as evidence against alternative models of care. In addition to patient perspectives, it would be valuable to explore hospital staff views on the design and environment of the psychiatric clinic. The study’s strengths include its stratified random sample, which ensured broad patient representation, and the comprehensive questionnaire covering multiple domains. The involvement of former patients and peers in designing the questionnaire further strengthens its relevance and accuracy. The fully anonymous survey design is a further strength, as it reduced social-desirability bias and encouraged candid responses; by design, however, it precluded linking individual characteristics – such as age, gender or diagnosis – to specific answers.

In conclusion, respondents expressed clear preferences for single-occupancy rooms, access to outdoor spaces and various complementary therapy resources. They also favoured diagnosis-specific wards and age-inclusive care models. Structural requirements in psychiatry are underexplored, and future research, including randomised controlled trials on how structure affects outcomes, is highly desirable. Such trials could be pragmatic in nature, evaluating the effectiveness of interventions in real-world, everyday clinical settings.