Behaviour patterns within a general hospital psychiatric unit: an observational study.

Employing a reliable and objective ‘behavioural mapping’ procedure, information was obtained by three independent observers, on what, where and when staff and patients engaged in various categories of behaviour, within a general hospital psychiatric unit. Observations were undertaken during two separate 6-day periods, using a seven category behaviour rating scale. Staff and patient behaviour profiles were found to be stable across the two rating periods, despite an almost complete change in the patient population from the first to the second set of observations. Results also indicated that staff spend a majority of their time engaged in interaction with their peers, or engaged in solitary task activity, with little of their time being spent in interaction with patients. Patients spent approximately half of their time in solitary behaviour, and when they were observed to be interacting it was found to be primarily with their peers. A significant negative correlation was obtained between those areas of the unit most frequently occupied by staff and patients, suggesting a territorial separation of the two groups. Analysis, of interaction rates by time, further indicated that the vast majority of interaction was observed to occur during the period 9.00a.m. to 5.00p.m. Monday to Friday. Some implications of the observed findings are discussed and it is concluded that the data suggest that the therapeutic potential of the observed unit is under-utilized.     

Behavioural analysis of ward rounds within a general hospital psychiatric unit.

A naturalistic observational procedure was used to examine the content of staff verbal interaction during the ward rounds of two inpatient teams in a general hospital psychiatric unit. Observers reliably rated staff discussion of 10 neurotic and 10 psychotic inpatients, using a nine category behavioural scale. The major focus of this scale was the extent to which three broad orientations, viz the medical, psychotherapeutic and sociotherapeutic models, were utilized by the staff. It was found that an eclectic approach was used by staff in their discussion of patients' aetiology, treatment and prognosis. However, the medical model was primarily utilized to formulate patient care, with the sociotherapeutic approach being employed for approximately one-third of the time. The psychotherapeutic orientation was only used 2.9% of the total time that patients were discussed. This pattern of use of the three orientations was consistent across the psychotic and neurotic patient groups. The behavioural data were found to be at variance with the degree to which staff believed the models should be applied. Analysis of the amount of time during which each professional group spoke in the ward rounds, and the rate at which they were found to make denned ‘authority statements’, indicated that a hierarchical model of management operated in the unit. These findings are related to the concept of shared power and responsibility within the therapeutic team.     

The aggression-coercion cycle: Use of seclusion and restraint in a child psychiatric hospital

The widespread use of seclusion and restraint in child psychiatric hospitals to manage aggression and noncompliance is based on the assumption that coercive consequences reduce the frequency of undesirable behaviors exhibited by the patients. We report a study of the use of seclusion and restraint in a public child psychiatric hospital during a 3-year period. Twenty-eight percent of the patients had been secluded or restrained a total of 1670 times. About 25% of these patients had been secluded more than five times during their hospitalization, and 32% had been placed in restraints more than once. Behaviors that typically resulted in repeated seclusion included physical aggression toward staff, verbal aggression toward peers, non-compliant or oppositional behavior, and self-harm. Variables that predicted patients most at risk for repeated seclusion included age, gender, and psychiatric diagnosis. The predictor variables for those most at risk for repeated restraint included age, property destruction, and self-harm. The high rates of use of seclusion and restraint suggest that these methods for controlling the behavior of children and adolescents in this child psychiatric hospital may not have been therapeutic. We suggest that staff in such hospitals engage in a pattern of behavior characterized by an aggression-coercion cycle, in which increasingly aggressive and coercive behaviors are exhibited by both patients and staff.     

Symptomatology of adopted and nonadopted adolescents in a psychiatric hospital

This study compared the symptomatology and diagnoses of adopted and nonadopted adolescents in a psychiatric hospital. Data were gathered from the hospital charts of adolescents who already had been discharged from the hospital. Contrary to expectations, adoptees were no more likely than nonadoptees to have received personality disorder diagnoses, nor were they more likely to be hospitalized as the result of antisocial behavior. However, in comparison with nonadopted adolescents, the adopted adolescents were younger upon admission to the hospital, significantly less often diagnosed psychotic, and significantly more often diagnosed adjustment reaction. It was suggested that adopted adolescents may be less likely than nonadopted adolescents to require severe or prolonged pathology in order to be admitted to a psychiatric hospital. It was also suggested that the antisocial symptomatology so frequently observed in adopted children in mental health settings does not account for the hospitalizations of those receiving inpatient treatment.     

Environmental risk factors in hospital suicide

Suicide of hospitalized patients is the most common sentinel event reviewed by The Joint Commission on Accreditation of Healthcare Organizations. Shorter lengths of stay, sicker patients, and higher patient to staff ratios challenge the ability of the hospital to maintain safety. Risk factors associated with the physical environment of the inpatient psychiatric unit, cited as the most common root cause of inpatient suicide, may be neglected because evaluation of these factors is generally not included in medical education and training. Minimization of fixtures that can facilitate strangulation and other high risk aspects within the hospital environment is an important element in the prevention of suicide on psychiatric units.     

A Cluster of Suicides at a London Psychiatric Unit

In an epidemiologically based study, a spate of 14 suicides among current patients of a London psychiatric unit was investigated. Statistical analysis showed it to be a discrete cluster of suicides, rather than a chance occurrence. There was no evidence of direct linkage or “contagion” between the suicides. Thirteen of the patients suffered from severe, chronic mental illness and all but 2 had been known to the psychiatric unit for at least a year. Twelve used violent methods, in 8 cases jumping from a high place. Although no definite cause for the cluster could be established, it coincided with a period of uncertainty concerning the future of the hospital and with changes in and absenteeism of senior medical staff.     

Predicting treatment outcome and recidivism among patients in a maximum security token economy

The relationship between program performance and outcome for patients in maximum security token economy programs has not been previously studied. We examined variables related to success in a token economy program and to postrelease failure for 92 men in a maximum security psychiatric hospital. Point earnings later in the program were best predicted by earlier point earnings. Variables that best predicted postrelease failure, defined in various ways, were similar to those found in other studies; youthfulness, having spent more time in institutions, a diagnosis of personality disorder or retardation rather than psychosis, not having been found not guilty by reason of insanity or unfit to stand trial, and having been referred from another psychiatric hospital. That program variables were generally unrelated to later outcome suggests that treatment programs for patients in maximum security settings must emphasize skills that are relevant to postrelease success.     

The predictive validity and practical utility of structured schemes used to assess risk for aggression in psychiatric inpatient settings

There has been increased interest in structured schemes for the assessment of risk for aggression within inpatient psychiatric settings. The most commonly utilized schemes are those previously developed to assess risk for prisoners being considered for release on parole and for forensic psychiatric patients being considered for discharge from the hospital to the community. Few structured schemes have been developed with the explicit aim of assessing risk for aggression in the inpatient setting. Recent research utilising a variety of risk assessment schemes has revealed reasonable predictive validity. This narrative review summarizes and appraises this expanding literature within the context of risk assessment decision making tasks typically undertaken by psychiatric unit staff. It is concluded that a number of structured risk assessments schemes do have acceptable predictive validity. Unfortunately, many of the schemes tested are compromised by a lack of practical utility, and only a few are capable of contributing to the entire range of risk assessment decision making tasks required. Options for the application of structured risk assessment schemes are raised.     

Clinical pastoral training in an emergency psychiatric service

Summary This paper reports the utilization of an emergency psychiatric service as a new factor in the clinical pastoral training experience. The usual pattern of clinical setting for these students is the hospital ward, where the patient has already been admitted and is making some adjustment to hospital routine and treatment. In such a setting the student misses the opportunity to see the patient at the crisis point of the illness and does not see the large numbers of individuals troubled enough to require psychiatric help but not sick enough to be hospitalized. The latter group constitute the largest portion seen by the parish minister even before psychiatric referral is arranged. During a twelve-week clinical pastoral training program, each student spent a major portion of his time for two of the weeks working on an emergency psychiatric service with a psychiatrist and social worker and seeing a large variety of patients, most of whom were not hospitalized. The experience provided an opportunity to develop evaluative skills and knowledge of appropriate community resources, and offered some experience in brief counseling under supervision. The clinical pastoral training student and the personnel of the emergency service all felt that this was an experience of mutual value and that it should be for a longer period. It is suggested that other clinical pastoral training programs would find it of value to utilize emergency psychiatric clinic settings where available.     

Adult oligophrenia in the large psychiatric hospital

Adult patients with mental retardation are a large group in big psychiatric hospitals. In the last years they were not enough heeded in regard of social psychiatric efforts and rehabilitation. The study shows the problems of misplacement for a big part of that group as in-patients in psychiatric hospitals, points out the necessary integration and continuous social and rehabilitative-pedagogical care. The analysis is based upon some point prevalence studies in the psychiatric hospital BFKH Rodewisch. Finally there are given statements about the future organization of process of caring for adult patients with mental retardation.     

Aggressive encounters between patients and general hospital staff: Staff perceptions of the context and assailants' levels of cognitive processing

A considerable body of research has accumulated regarding aggression toward health care staff, yet little is known about the contextual factors involved. The present study examined the context within which aggressive incidents occurred and the dynamics of the interaction between staff and patients. Two aspects in particular were investigated; firstly, whether incidents were preceded by some anxiety provoking stimulus and secondly, the assailants' levels of cognitive processing apparent at the time of the incident. A prospective study collected data concerning incidents of physical assault and threatening behaviour in a general hospital. Staff were interviewed soon after the incident occurred. A content analysis determined that 82.8% of incidents involved experiences delivered by the staff victims likely to have provoked anxiety in the assailant. Most commonly, incidents involved staff intervening in the patient's intended behaviour. In addition, in 64% of cases, assailants were actually displaying some impairment in cognitive processing at the time of the incident Data suggest that many patients may not have been fully aware of their situation and might have experienced some difficulty in comprehending the staff member's actions. Patients who do not appear to understand what is happening may require additional time and effort to ensure they comprehend fully and accept what the staff member is intending to do, particularly if patients are experiencing an event likely to increase anxiety levels. Aggr. Behav. 30:534–543, 2004. © 2004 Wiley‐Liss, Inc.     

Bullying among mentally‐ill patients detained in a high‐secure hospital: an exploratory study of the perceptions of staff and patients into how bullying is defined

The present study is the first to explore patient‐to‐patient bullying within a secure psychiatric hospital housing mentally‐ill patients. Its main aim was to provide an outline of the perceptions held by both patients and staff with regards to patient‐to‐patient bullying as opposed to providing an objective study of bullying. The total sample comprised 104 participants, 44 patients and 60 staff. These were sampled from wards housing male patients and wards housing female patients. All participants took part in a semi‐structured interview based on that developed by Ireland and Ireland [2003] and Ireland [2005, 2004]. One quarter of participants stated they had seen a patient being bullied in the previous week, with staff perceiving a higher extent of bullying than patients. Differences between wards were minimal. It was predicted that theft‐related bullying would be reported most frequently, that staff would identify a wider range of bullying behaviours than patients and that direct forms of aggression would be identified more readily as bullying than indirect forms. All predictions were supported. Problems in attempting to obtain a definition of bullying were also identified, with participants operating broader definitions than those found in the school‐based literature. For example, bullying was not generally considered a repeated form of aggression, the severity of the aggression or provocative behaviour of the victim were not defining features, and it was felt bullying could be accidental. In summary, the current study highlights how patient‐to‐patient bullying does occur in services housing mentally‐ill patients and that researching the behaviour may require the adoption of broader hospital‐specific definitions of bullying. Aggr. Behav. 32:1–13, 2006. © 2006 Wiley‐Liss, Inc.     

Concurrent group and individual psychotherapy in a psychiatric day hospital for depressed elderly

Concurrent psychotherapy is used in various settings for patients of different diagnoses and ages. The concurrent group and individual psychotherapy of older adults with depressive disorders in a psychiatric day hospital is described, emphasizing phases of treatment and transference and countertransference themes uniquely relevant to working with depressed elderly patients in a day hospital. Case examples are offered to illustrate these issues. The special technical considerations that need to be utilized when multiple therapists and settings are present are described. The model employs the use of an integrative, interactive group therapy, along with various other group treatments and antidepressant medication, with individual therapy serving a subordinate but organizing role.     

Parental Communication Deviance as a Predictor of Competence in Children at Risk for Adult Psychiatric Disorder

Measures of communication deviance derived from three different Rorschach situations were obtained from parents of 62 children vulnerable to future psychiatric disturbance. The families were maritally intact, with one parent having a history of previous psychiatric hospitalization and a male index child, 7 or 10 years of age. Amount of parental communication deviance in one situation was not significantly related to amount of communication deviance observed in another setting. However, mothers who exhibited high levels of communication deviance in both the Individual and Family Consensus situations tended to have offspring who were judged as low functioning in multiple settings, based on teacher ratings, peer ratings, and parental report. Conversely, children judged as high functioning in multiple settings had mothers who were free of high levels of communication deviance in both Rorschach situations.     

Relationships between patients' perceived improvement and their evaluations of treatment components in a behaviorally-oriented psychiatric inpatient unit

Patients on a behaviorally-oriented inpatient psychiatric unit were asked to rate their perceptions of treatment outcome and the value of 16 program components in producing that outcome. Significant correlations were found between perceived outcome and positive evaluations of the overall behavioral treatment plan, individual meetings with nursing staff, individual meetings with team psychologists, assertion group training, and daily group therapy. Patients perceived individual meetings with the nursing staff to be the single most valuable program component among those related to favorable outcome. Implications for the increased utilization of nursing staff during a time of dwindling resources for mental health are discussed.     

Gender,sexual harassment,workplace violence,and risk assessment:: Convergence around psychiatric staff's perceptions of personal safety

This paper reviews literature in sexual harassment, workplace violence, and risk assessment as it relates to staff in psychiatric and forensic work environments. These three areas of research overlap in their applicability to psychiatric staff in that each addresses the understanding and management of types of violence to which many staff, particularly women, are likely to be exposed while working. Employee well-being, encompassing mental and physical health, job satisfaction, and morale, has been shown to be closely tied to organizational productivity and cost. In addition, gender has been shown to be an important factor in perceptions and decision-making, and prior work has suggested that female staff often have qualitatively different experiences in traditional male workplaces such as inpatient and forensic settings. Despite these findings, research to date on psychiatric staff has typically focused only on number of assaults by patients. It has not addressed how staff's gender may impact their perceptions of personal safety and judgments of risk from patients, nor have any empirical studies been performed in naturalistic settings to investigate this issue. Given the high correlation between organizational productivity and employee well-being, it is mutually beneficial to both employers and staff to examine current understanding of how certain staff variables such as gender may influence their feelings of safety and judgments of risk from patients.     

Can anybody hear me? Reacting to pressures from psychotic states of mind

In this paper material is presented from supervision groups run for nurses and other mental health professionals. The patients presented to the group all came from different mental health settings and suffered from psychotic states of mind. In this paper I will argue that the psychodynamic model can help nurses and other front‐line mental health professionals in their understanding of psychotic process. Nursing staff, in particular, are with their patients over long periods of time and see them in different settings. The psychodynamic model can be helpful in giving mental health professionals a language for describing their experiences of, and interaction with, their patients. The psychodynamic model can also provide a dynamic picture of the patient's problems over time. This type of assessment and thinking, which includes an understanding of the dynamic process involved in psychosis, can then stand alongside the medical model.     

Item-by-Item Versus End-of-Test Feedback in a Computer-Based PSI Course

This study examined the effects of three different types of computer feedback on the following variables in a Personalized System of Instruction (PSI) course: unit quiz and final exam performance, the amount of time tutors and other teaching staff spent answering student questions, and students' preference for each type of feedback. The feedback conditions were the following: (a) end-of-test, (b) item-by-item with the option to skip questions during the test, and (c) item-by-item without the option to skip questions during the test. Students who received item-by-item feedback with the skip option performed the same as students who received end-of-test feedback on the unit quizzes and final exam. However, the teaching staff spent significantly less time answering questions when students received item-by-item feedback with the skip option than when they received end-of-test feedback. Finally, 65% of the students preferred item-by-item feedback with the skip option. The authors concluded that this type of item-by-item feedback decreases the workload on teaching staff in a PSI course without sacrificing performance, and students like it more than the other types of feedback.