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The quality of psychiatric nurses' interactions with patients: an observational study
lm J. ,X,/r, Siud.. Vol. 32. No. I, pp 49-58. IY95 Copyright s,_’ 1995 Elsevm Science Ltd Prmted m Great Britam All rights reserved om-7489,‘95 $9 so+o.oo
Pergamon 0020-7489(94)00033-d
The quality of psychiatric
nurses’
interactions with patients: an observational study G. A. TYSON Chad~~.r- Srwt
C’nirwsit~~.
Bathurst,
NS W 2795, Australia
W. G. LAMBERT L. BEATTIE Bloomfi~ld
Hospital,
Orange,
NS W 2800, Australia
Abstract-The behaviour of nursing staff in each ward of a psychiatric hospital was observed at 5-min intervals for between 7 and 10 h per day for 10 days. The nurses’ behaviour was equally divided between interacting with patients, interacting with staff, solitary task oriented behaviour and other behaviours. There was lessstaff-patient interaction in the acute ward than in the long-term and psychogeriatric wards and senior nurses interacted lesswith patients and engaged in more solitary task oriented behaviour. Of the interactions with patients, almost 25% were rated as positive and only 0.3% negative. In the long-term wards almost 47% of the interactions were positive.
Introduction
There can be little doubt that the effectiveness of a psychiatric treatment program will be determined to some extent by the attitudes and behaviour of the staff who implement it. Despite this, when programs are evaluated the behaviour of staff is frequently ignored as a variable (Robinson, 1978). One recent example of this is the Psychiatric Nursing Audit (PNA) developed by Howard and Hurst (1988) for the Central Nottinghamshire Health Authority. The manner in which the PNA quality of care measureis calculated is such that it is possible for a satisfactory standard of care to be reached largely as a result of proper administrative procedures and routine nursing activities being implemented. Hence it is possible. in terms of the PNA, for patients to be rated as receiving satisfactory care even 49
SO
G. A. TYSOiVet
al
though there may be little staff-patient interaction and the environment therapeutically sterile. Relatively little research has been done on the way in which psychiatric nurses spend their working day or on the nature of their interactions. The few observational studies that have beendone have shown fairly consistent patterns of activities, despite the useof different methodologies and subject populations (Fairbanks et al., 1977; Handy, 1991; Hodges et al., 1986; McGuire et al., 1977; Poole et al.. 1981; Sandford and Elzinga, 1990; SansonFisher et al., 1979). A relatively large amount of time, varying from 25 to over 50% was spent on administrative or task-oriented activities. On the other hand, the percentage of total time spent interacting with patients was low, ranging from 8.2 to 42.5%, with a mean of 17.6%. The figure of 42.5% reported in the study by Hodges et al. (1986) was unusually high and possibly reflects the fact that it was obtained in a chronic, closed ward with a very structured program that was designed to foster contact, whereas all the other data come mainly from short-term units. The conclusions of the above studies are based on averages across all staff, but a study of Handy (1991) shows that staff-patient interaction is highest for junior nurses while the more senior nursesspend much more time on administration. This situation has also been reported by Pines and Maslach (1978). As Handy points out, this means that the decisions about the patients tend to be taken by those staff who have the least interactions with the patients. Another disturbing finding of Handy is that only 2% of time is spent on counselling patients. Another consistent trend across the studies of nurses’ behaviour relates to their interactions with other staff. Nurses were found to interact with other staff almost twice as frequently as with patients in the studies of Fairbanks et al. (1977) McGuire et al. (1977), Sandford et al. (1990) and Sanson-Fisher et al. (I 979). These staff-staff interactions ranged from 18.7% (Fairbanks et al., 1977) to 42.9% (Sanson-Fisher et al., 1979). Only in the Hodges et al. (1986) study were the staff-staff interactions not considerably greater than the staff-patient interactions and in two wards they were less.This high level of staff-staff contact is probably related to the formal duties of the staff, but it cannot be fully explained in that way, as Sandford et ul. (1990) have shown that staff-staff contact increasesas a function of increased staffing levels. Overall, these studies suggestthat on average staff spendabout one-third of their day on administrative tasks or solitary task oriented activities and that they interact more frequently with their colleaguesthan with patients. It is commonly assumedthat staff-patient interaction enhances the therapeutic process and therefore concern has been expressedat the low level of staff-patient interaction that hasgenerally been found to occur (e.g. Sanson-Fisher et al., 1979). However, it seemslikely that it is not the amount of contact per se that is important but the quality of contact. If there is a lot of interaction but it is mainly hostile then it is lesslikely to contribute positively to the therapeutic milieu than is lesserbut more friendly contact. None of the studies on nurse-patient interactions has looked at the quality of the interactions. The present study aims to do this. Methodology
Setting The study was carried out in a rural psychiatric hospital in Australia with a catchment area of approximately two-thirds of the State of New South Wales and serving a population
QUilLIT?’
OF l.VTERACTlONS
WITH
PATIE,YTS
51
of some 300.000. The hospital was built in the mid 1920s and the accommodation available for patient care reflects an era when custody rather than therapy was a primary objective of mental health services. Facilities available within each unit were limited despite attempts to modify the structure of buildings and were characterised by dormitory-style sleeping accommodation, large dining rooms and communal living areas with no capacity to provide individual “space” to which a patient could retire when feeling stressed or in need of some privacy, The hospital is staffed predominantly by registered nurses and in common with most rural services has difficulty attracting medical and allied health staff. At the time of the study the acute admission unit was the only unit with full-time medical officers, a social worker. psychologist and a full-time equivalent psychiatrist. The remaining units were served by part time medical officers with psychiatrist and allied health input provided for assessment and treatment review on a needs basis. The hospital comprises eight units and a total of 253 beds with an average occupancy rate of 75%. All units were included in the study. For the purposes of analysis, the units were categorised into four groups---acute, long-term, psychogeriatric and medical, the latter being a 1‘-bed !ow dependency medical and post-surgical ward serving the whole hospital.
For all wards other than the Acute Admission ward, observations were conducted for 7 h per day, between the times of 08:30 and 16:30, for 10 days. The time period chosen corresponds with the therapeutic day and is the time when the greatest number of interactions is likely to occur (Sanson-Fisher et al., 1979). In the Acute Admission ward, the observational period was 10 h between the times of 08:30 and 19:30. The longer observational time period was used as the staffing levels remain high after 16:30 in that ward. The procedure used in this study was similar to that used by Sandford and his colleagues in a number of studies (Hodges et al., 1986; Positano et al., 1990; Sandford and Elzinga. 1990: Sandford et u/., 1990). The observations were made at 5-min intervals. In each interval. observation began with the first nurse encountered and continued until all nursing staff had been observed. The behaviour occurring at the moment of observation was recorded on a clipboard using predefined categories. Prior to the observations in a ward, the observers spent one and sometimes two days in the ward. This was to allow them to familiarise themselveswith the ward and personnel and to reduce their novelty value. To reduce the obtrusiveness of the observers, they participated minimally in the activities of the ward and as such occasionally talked to staff and patients.
The observational categories used in this study (Table I), were adapted from those used in previous studies of nurse-patient interaction (Hodges et ul., 1986; Positano et ul., 1990; Sandford and Elzinga, 1990; Sandford et al., 1990; Sanson-Fisher et al., 1979). It was felt that basing the categories on those usedin previous studies would permit comparison with the behaviour of staff at other institutions.
The observers were trained for two weeks until there was a high level of inter-rater reliability. To ensure that the observers were being consistent in their ratings throughout
52
G. A. TYSON
Table Interactive 1 Individual
behaviour verbal: 1.1 Patient
audible
1.1.1 Positive: 1.1.2 Negative: 1.1.3 Neutral:
word(s)
1. Observation
emitted
towards
categories
et al
for staff behaviour
one other person
praise, compliments, positive feedback, laughter reprimand, derogatory remark, discouragement. neither positive nor negative
negative
feedback
1.2 Staff 2 Individual
nonverbal:
staff attending to one other person and exhibiting any of the following: eye-contact, posture turned towards other, head movements, gestures, physical contact, including administering an injection, restraining patient, dressing or bathing patient
2.1 Patient
2. I. 1 Positive: 2.1.2 Negative: 2.1.3 Neutral: 2.2 Staff 3 Group
verbal:
smile, friendly gestures, positive physical contact frowns, grimaces, negative gestures, negative physical neither positive nor negative
audible word(s) a 5-s period
emitted
to more than one person
contact
with shift of gaze from person
to person within
3.1 Patient
3.1 .I Positive: 3.1.2 Negative: 3.1.3 Neutrai:
praise, compliments, positive feedback, laughter reprimand, derogatory remark, discouragement, neither positive nor negative
negative
feedback
3.2 Staff
attending
4 Group non-verbal: 4.1 Patients
4.1, I Positive: 4.1.2 Negative: 4.1.3 Neutral:
behaviours
described
above
directed
to more than one person
smile, friendly gestures, positive physical contact frowns, grimaces, negative gestures, negative physical neither positive nor negative
in a 5-s period
contact
4.2 Styff
Non-interactive
behaviour no response to patient’s behaviour despite being within opportunity to respond and deliberately ignoring it 5.1 Inappropriate patient behaviour 5.2 Appropriate patient behaviour appropriateness or inappropriateness cannot be judged 5.3 Neutral:
5 Ignoring
patient:
6 So[itarF
task-orientated:
7 Other:
includes
any on-task behaviour carried out independently talking on phone, cleaning, walking, etc.
all behaviours
which do not fall into the above
categories.
1 m of patient.
of others,
Includes
e.g. reading.
e.g. absent from
missing
writing.
ward
the course of the study, inter-rater reliability checks were performed for 1 h each day. To synchronise scanning in each 5-min interval, a verbal cue was given by one observer. The reliability of the observations was established by calculating the percentage agreement between the two observers. While this may not be the ideal measure of reliability it does have the advantage of being extremely stringent (Hartmann, 1977). Because it was thought that having the observers code the quality of interaction may reduce the reliability, percentage agreements were calculated both with and without the evaluative level of coding. Overall, the inter-observer reliability was 88.7 and this increased marginally to 90.9 when the evaluative categories were excluded.
QUALITY
OF INTERACTIONS
WITH
53
PATIENTS
Results and discussion Behaviour
pmfiles
In all, 129 nurses (46 male, 83 female) were observed in the study. Of these, 20 were Enrolled Nurses, 84 Registered Nurses, 14 Clinical Nurse Specialists and 11 were Nursing Unit Managers. As the wards were not observed concurrently, some nurseswere observed in more than one ward. It is possible that the behaviour of nurseswho were not working in their usual ward might have been different and may have biased the results. Consequently, only the observations made about a nurse in that nurse’s usual ward were included in the analysis of the behaviour profiles. In the interests of parsimony, the results of the observations were analysed in terms of broader categories. To check for differences between groups in terms of the number of times a particular category of behaviour was observed, one-way analyses of variance were performed and where these where significant, Scheffe tests (p = 0.10) were used to identify where the differences lay. The behaviour profile of the nursesin terms of the proportion of time spent on interaction with either patients or staff, solitary task oriented behaviour and other behaviour is shown in Table 2. On average, the nurses’ time was divided almost evenly between interacting with patients, interacting with staff, engaged in solitary activities and doing other things. The average amount of staff-patient interaction is higher than the proportions reported in previous studies (Fairbanks et al., 1977; McGuire et al., 1977; Poole et al., 1981; Sandford et (II., 1990; Sanson-Fisher et al., 1979)except in the caseof Hodges et al. (1986). While the proportion of staff-staff interaction is similar to that reported in the previous studies. it is notable that the ratio of staff-staff to staff-patient interaction is different. In most of the previous studies the amount of staff-staff interaction has been considerably greater than the staff-patient interaction, with several studies (Fairbanks et al., 1977; McGuire et al.. 1977; Sandford et al., 1990; Sanson-Fisher et al., 1979) reporting that nurses spend twice as much time interacting with staff than with patients. In the current study staff spent almost the sameamount of time interacting with patients as they did with staff. One possibleexplanation for the above is that most of the previous studies have obtained data from admissions wards and as the present study shows, there is less staff-patient interaction and more staff-staff interaction in such wards, Nevertheless, the amount of Table
2. Proportion
of time spent by nurses on interacting, of ward
Type of ward Acute Long-term Psychogeriatric Medical Total
(all wards
‘F(3.125) ‘F(3.125) long-term.
combined)
solitary
tasks or other
activities
Interaction ~~______~~ With patients’ With 19.3 27.1 26.3 17.7
~~~~~ Solitary stalf task’ ~~______ 2s 29.7 23.8 19.2 23.8 23 31.4 29.1
24.6
24.5
= 4.37, p < 0.01. Acute less than long-term, psychogeriatric. = 8.24. p < 0.000 I, Acute greater than long-term. psychogeriatric:
24
by type
Other 26.2 30.7 21.2 21.4 26.9
medical
greater
than
54
G. A. TYSON
el ~1.
staff-patient interaction found in this study is still relatively high. It should also be borne in mind that the base for the calculations in this study includes meal and tea breaks which were part of the “other” category, whereas in other studies this does not appear to have been the case. Thus the base, that is, the total number of observations, used in these studies would be smaller relative to the number of interactions and this would inflate the proportion of interaction in other studies. The behaviour profile according to the type of ward is also shown in Table 2. Analyses of these data showed that there was a higher staff-patient interaction in the psychogeriatric and long-term wards than in the acute ward. This is in line with the results of Hodges et al. (1986) who found that chronic patients are interacted with more than acute. The difference in the amounts of interaction in acute and chronic wards is probably due to the nature of the illness and the surroundings. The acute patients are in new and unfamiliar surroundings and their ability and desire to communicate are probably reduced by their illness and medication. Chronic patients, on the other hand, are more likely to feel at home and the staff will have become part of their family so to speak, and consequently they are more likely to initiate interactions with the staff. With regard to the higher staff-patient interaction in the psychogeriatric wards, it is obvious that their condition requires more staff-patient interaction. In the case of staff-staff interactions, there were no significant differences between the wards although there was a trend towards a higher amount in the medical ward. This would be expected because of the greater need to confer at the change over of shifts and the more frequent visits of the medical officer. With regard to solitary activities, which included activities such as answering telephones, writing reports, etc., the average of 24% of total time is less than that reported in most of the previous studies. However, the definition of solitary task oriented behaviour is not consistent across studies and therefore it is difficult to draw any definite conclusions in relation to other studies. As shown in Table 2, more time was spent on solitary tasks in the acute ward compared to the long-term and psychogeriatric wards. This would be expected given that acute nature of the patients’ illness and the rapid turnover of patients. There was also a higher level of solitary task-oriented behaviour in the medical ward compared to the long stay wards, which probably reflects a need for more frequent record keeping. The behaviour profile of the staff was also analysed in terms of the rank of the nurses and the results of this analysis are shown in Table 3. From the table it can be seen that
Table
3. Proportion
of time spent by nurses on interacting,
solitary
tasks or other
activities
by rank
Interaction ~~ Type of ward
~~ .~~ Enrolled Nurse (EN) Registered Nurse (RN) Clinical Nurse Specialist (CNS) Nursing Unit Manager (NUM) Total
(all nursing
‘F(3.125) ‘F(3,125) ‘F(3.125)
staff combined)
With patients’ ~~~ 30.8 26.3 19 8.3 24.6
Solitary task’
Other
20 24.4 28.3 2X.6
22.3 23 21 37.9
27.1 26.2 31.9 25.5
24.5
24
26.9
With
~ staff
= 15.33, p < 0.0001. NUM less than EN, RN, CNS; CNS less than EN. RN = 4.17, p < 0.01. NUM greater than EN, RN. = 9.89,~ < 0.0001. NUM greater than EN, RN, CNS.
QC’ALITY Table 4. Percentage
Acute Long-term Psychogeriatric Medical (all) wards
‘F(3.125) ‘F(3.125) ‘F(3.125) ‘F(3.125)
= = = =
WITH
of total time spent by nurses in verbal with patients by type of ward
Type of ward
Total
OFINTERACTIONS
combined
PATIENTS and nonverbal
interactions
Individual verbal’
Individual nonverbal’
Group verbal‘
6.5 IO.5 5.9 6.3
4.8 6.3 13.6 10.1
I.? 2.1 0.9 0.4
6.6 8.2 5.8 0.8
6.9
10.3
1.3
6.1
5.57, p < 0.01. Long-term greater 17.00. p < 0.0001. Psychogeriatrtc 4.17, p < 0.01. Long-term greater 2.78. p < 0.05. Long-term greater
Group nonverbal”
than acute. psychogeriatric. greater than acute, long-term than medical. psychogeriatric. than medical.
there was a trend for more junior staff to spend more time with patients and that the Nursing Unit Managers spent significantly less time interacting with patients than the other staff. This is consistent with the findings of Handy (1991) and Pines and Maslach (1978). Conversely, the Nursing Unit Managers spent significantly more time on solitary tasks than did any of the other nursing staff and more time interacting with other staff than did Enrolled Nurses and Registered Nurses. These results would be expected given that a large part of a Nursing Unit Manager’s job would consist of administrative tasks and supervision of staff. The staff interactions with patients were then analysed in terms of whether they were verbal or nonverbal and individual or group-oriented and the results are shown in Table 4. Although on average a greater amount of time was spent in nonverbal interaction with individual patients, this was largely due to the psychogeriatric ward that had a significantly higher level of nonverbal interaction as would be expected given the nature of the patients. In the long-term wards, individual verbal interaction predominated and was significantly higher than in both the psychogeriatric and acute wards. Group interaction, both verbal and nonverbal. was highest in the long-term wards (Table 4). For verbal interaction. it was significantly higher in the long-term wards than in the medical and psychogeriatric wards and for nonverbal interaction it was significantly higher than in the medical ward. These results are a little surprising as one might have expected a high level of group interaction in the psychogeriatric wards where immobile patients require lifting. bathing: etc., which would involve at least two nurses. The fact that this did not show up may be because such activities usually occurred outside the observation period. In addition. most psychogeriatric and medical patients were immobile which means that they themselves did not form groups. On the other hand the acute and long-term patients could form groups with which staff could interact. The interactions of staff with patients were also rated in terms of their quality. Percentages of the total interactions that were either positive, negative or neutral was calculated and these are shown in Table 5. The results of this analysis show that almost all the interactions with patients were either positive or neutral. Particularly encouraging is the fact that nearly half the interactions in the long-term wards were rated as positive, Although the incidence of negative behaviour was so low. it is necessary to look at it in greater detail because of its possible negative implications. In all, 32 negative behaviours were observed involving 17 staff. Of these, 29 were individual verbal interactions and there
56
G. A. TYSON Table
5. Quality
of nurses’ interactions
Type of ward
(all wards
combined)
‘F(3,125) = 36.74, geriatric, acute. ‘F(3.125) = 35.79, term, medical.
with patients
Positive’
Acute Long-term Psychogeriatric Medical Total
et al.
p
< 0.0001.
p < 0.0001.
Negative
Neutral*
22.5 46.9 15.5 42.1
0.3 0 0.4 0
71.3 53.2 84.1 57.9
24.5
0.3
75.3
Medical, Acute,
by type of ward
long-term
greater
psychogeriatric
greater
than
psycho-
than
long-
was one in each of the remaining categories, namely, individual nonverbal, group verbal and group nonverbal. In most cases, the negative behaviour was an isolated incident in the behaviour of the staff, the highest frequency being five that occurred for two staff members. In interpreting these data, it must be borne in mind that the negative categories included not only very abusive behaviour but also behaviour such as frowning or an abrupt response which are behaviours which occur in normal everyday interactions. Given this, it is remarkable that negative interactions were so low (0.29% of all interactions). While it might be suggested that this could be due to a Hawthorne effect, we do not think that played a major role as it did appear as if the staff adapted to the observers very quickly and it would be difficult to control behaviour so consistently for the length of the observational periods. Although the Nursing Unit Managers spent less time interacting with patients, the quality of their interactions was more positive as can be seen in Table 6. There are two possible explanations for this. First, it is possible that during routine activities the interactions between staff and patients tend to be more neutral and that the Nursing Unit Managers are less involved in those routine activities. Alternatively or in addition, it is possible that because they have fewer interactions with patients, it is easier for Nursing Unit Managers to be positive in their interactions. Conclusion
Overall, the results of this study provide some positive indicators for the hospital in which the study occurred. Staff-patient interaction appears to be higher than that reported in previous studies and much of the interaction was of a positive nature, especially in the Table
6. Quality
of nurse interactions
with patients
Rank
Positive’
Enrolled Nurse (EN) Registered Nurse (RN) Clinical Nurse Specialist (CNS) Nursing Unit Manager (NUM)
19 23.1 28.2 40.3
0.6 0.2 0.4 0.1
80.5 76.7 71.3 59.7
Total
24.5
0.3
75.3
(all nursing
‘F(3,125) ‘F(3,125)
staff combined)
= 3.80, p < 0.05. NUM = 3.74, p < 0.05. NUM
Negative
by level
greater than EN, RN less than EN, RN.
Neutral’
QUALITY
OFINTERACTIONS
WITH
PATIENTS
57
long stay wards. Conversely there appears to be very little interaction that could be classified as negative. A possible explanation for the results is the Hawthorne effect, although this seems unlikely for the reasons given previously. Even if it were operating, however, it would not necessarily invalidate the results as it would have also been operating in the other observational studies done in the past. There is no reason why it should have operated more strongly in the current study and therefore the differences in the data between this study and previous ones are still meaningful. Regarding the qualitative aspect, it is possible that staff may have tried especially hard to be on their best behaviour, but given that on average several hundred instances of behaviour were observed for each staff member, it seems unlikely that the observed behaviours were that unrepresentative of normal behaviour. While the results suggest that a friendly atmosphere prevailed, they do not tell us all that much about the therapeutic atmosphere. There was no analysis of the content of the interactions nor the context in which they occurred. Furthermore the duration of the interactions was not recorded. Hence it is possible and even likely that most of the interactions occurred during routine activities rather than in a therapeutic type interaction. Handy (199 1) found that only 2% of admission ward nurses’ time was spent on counselling patients compared with 19% for practical care and 7% for meal breaks. In this regard one of the interviewer’s comments is significant. After the study she stated that the patients were very accepting of her and really seemed to appreciate the opportunity to speak to someone about their problems. All this suggests that further studies on the nature of the interactions would be beneficial. A noticeable feature of the results and those of other studies is that relatively little time was spent interacting with patients-less than 20% in the acute ward in this study. This raises the question of the need to develop structured programs which increase meaningful staff--patient interaction. The Australian National Mental Health policy developed jointly by the Federal, States’ and Territories’ governments has adopted a strong consumer orientation. The Mental Health Statement of Rights and Responsibilities adopted by the Australian Health Ministers Conference (1991) states inter alia the consumers rights to “interact with health care providers, particularly in decision making regarding treatment, care and rehabilitation” (p. 1). It would therefore be appropriate to develop local protocols which include the patient actively in the clinical decision-making process. This could be accomplished, for example, by mandating that the patient must be consulted when their nursing care plan is being developed or changed. In addition, the development of structured group programs aimed at improving the patients’ knowledge of their illness, the effects of their medication. or which address specific issues such as discharge planning could also be considered. Another way of possibly increasing stall-patient interaction may be by reducing the amount of clerical work that staff are required to do. Overall, almost a quarter of nurses’ time was spent on such tasks. This seems high and suggests that a review of this area would be appropriate. It may well be that routine paperwork could be reduced by the greater use of information technologies. Whether or not this freeing up of time would lead to greater staffpatient interaction is a moot point, however, given that Sandford et ~1. (1990) found that increased levels of staffing increased staff-staff interaction but did not affect staff patient interaction. Although it seems obvious that we should be concerned about the relatively low amount of staff--patient interaction and should seek ways to increase it, a note of caution should be
58
G. A. TYSONat
ul
sounded. Such concern is based on the assumption that lots of staff-patient contact is good for the patient. This assumption is untested and it may well be that at least for some patients less contact is desirable, especially if it is routine rather than specific therapeutic contact. Thus the primary focus of programs relating to staff-patient interaction should be on the quality of the interaction rather than quantity per se. Acknowl~u’y~~en/s-This study was funded by the New South Wales Health Department. The authors would like to thank Ann Hall, Dierdrie Leslie, Cathy Walker, Tracy Brown, Bert Prusiak and Kim Stevens for their assistance in designing and implementing the study.
References Australian Health Ministers’ Conference (1991). Mental hralth statement ofrights and rrsponsibi~ities. Australian Government Publishing Service, Canberra. Fairbanks, S., McGuire, M. T., Cole, R.. Sbordone, F.. Silvers, M., Richards, M. and Akers, J. (1977). The ethological study of four psychiatric wards: patient, staff and system behaviors. J. Psych. Res. 13, 193-210. Handy, J. A. (I 99 1). The social context of occupational stress in a caring profession. Social Sci. Med. 32(7), 8 l9830. Hartmann, D. P. (1977). Considerations in the choices of interobserver reliability estimates. J. Appl. Behar. Awl. 10, 103-l 16. Hodges. V., Sandford, D. and Elzinga, R. (1986). The role of ward structure on nursing staff behaviours: an observational study of three psychiatric wards. Actu P.rJrhiutr. Stand. 73, 6-l I. Howard, D.J. and Hurst, K. (1988) Psychiutric nursing uudit. Central Nottinghamshire Health Authority. McGuire, M.. Fairbanks, S., Cole, R., Sbordone, F., Stlvers, M., Richards. M. and Akers, J (1977). Theethological study of four psychiatric wards: behavioural changes associated with new staff and new patients. J. Psych. Rex. 13,2 1 l-224. Pines, A. and Maslach, C. (1978). Characteristics of staff burnout in mental health settings. Hospitul c‘owmmit~ PsJch. 29,233-237. Poole, D. A.. Sanson-Fisher. R. W. and Thompson V. (1981). Observations on the behaviour of patients in a state mental hospital and genera1 hospital psychiatric unit: a comparative study. Brhar. Rrs. Therapy 19, 125 134. Positano, S., Sandford, D. A., Elzinga, R. H. and James, J. E. (1990). Virtue rewarded: reinforcement and punishment in an acute psychiatric ward. J. Be/ma. Therup~~ E.yp. Pq~ch. 21, 257-262. Robinson, V. M. J. (1978). The behavior of staff: an ignored variable in programme evaluation. Social Sci. Med. 12, 175-I 82. Sandford. D. A. and Elzinga. R. H. (1990). Patient interactions in four psychiatric wards. Ac,tcr Pswhiatr. Stand. 82, 125.. 125. Sandford, D. A., Elringa, R. H. and Iversen. R. (1990). A quantitative study of nursing staff interactions in psychiatric wards. Acta Psj,chiatr. Stand .81, 46651. Sanson-Fisher, R.. Poole. A. D. and Thompson, V. (1979). Behavioural patterns within a general hospital psychiatric unit: an observational study. Behar. Rps. Therapy 17, 317--332. (Rcceiced
7 June 1993; accepted
fbr publication
28 April
1994)
Pergamon 0020-7489(94)00033-d
The quality of psychiatric
nurses’
interactions with patients: an observational study G. A. TYSON Chad~~.r- Srwt
C’nirwsit~~.
Bathurst,
NS W 2795, Australia
W. G. LAMBERT L. BEATTIE Bloomfi~ld
Hospital,
Orange,
NS W 2800, Australia
Abstract-The behaviour of nursing staff in each ward of a psychiatric hospital was observed at 5-min intervals for between 7 and 10 h per day for 10 days. The nurses’ behaviour was equally divided between interacting with patients, interacting with staff, solitary task oriented behaviour and other behaviours. There was lessstaff-patient interaction in the acute ward than in the long-term and psychogeriatric wards and senior nurses interacted lesswith patients and engaged in more solitary task oriented behaviour. Of the interactions with patients, almost 25% were rated as positive and only 0.3% negative. In the long-term wards almost 47% of the interactions were positive.
Introduction
There can be little doubt that the effectiveness of a psychiatric treatment program will be determined to some extent by the attitudes and behaviour of the staff who implement it. Despite this, when programs are evaluated the behaviour of staff is frequently ignored as a variable (Robinson, 1978). One recent example of this is the Psychiatric Nursing Audit (PNA) developed by Howard and Hurst (1988) for the Central Nottinghamshire Health Authority. The manner in which the PNA quality of care measureis calculated is such that it is possible for a satisfactory standard of care to be reached largely as a result of proper administrative procedures and routine nursing activities being implemented. Hence it is possible. in terms of the PNA, for patients to be rated as receiving satisfactory care even 49
SO
G. A. TYSOiVet
al
though there may be little staff-patient interaction and the environment therapeutically sterile. Relatively little research has been done on the way in which psychiatric nurses spend their working day or on the nature of their interactions. The few observational studies that have beendone have shown fairly consistent patterns of activities, despite the useof different methodologies and subject populations (Fairbanks et al., 1977; Handy, 1991; Hodges et al., 1986; McGuire et al., 1977; Poole et al.. 1981; Sandford and Elzinga, 1990; SansonFisher et al., 1979). A relatively large amount of time, varying from 25 to over 50% was spent on administrative or task-oriented activities. On the other hand, the percentage of total time spent interacting with patients was low, ranging from 8.2 to 42.5%, with a mean of 17.6%. The figure of 42.5% reported in the study by Hodges et al. (1986) was unusually high and possibly reflects the fact that it was obtained in a chronic, closed ward with a very structured program that was designed to foster contact, whereas all the other data come mainly from short-term units. The conclusions of the above studies are based on averages across all staff, but a study of Handy (1991) shows that staff-patient interaction is highest for junior nurses while the more senior nursesspend much more time on administration. This situation has also been reported by Pines and Maslach (1978). As Handy points out, this means that the decisions about the patients tend to be taken by those staff who have the least interactions with the patients. Another disturbing finding of Handy is that only 2% of time is spent on counselling patients. Another consistent trend across the studies of nurses’ behaviour relates to their interactions with other staff. Nurses were found to interact with other staff almost twice as frequently as with patients in the studies of Fairbanks et al. (1977) McGuire et al. (1977), Sandford et al. (1990) and Sanson-Fisher et al. (I 979). These staff-staff interactions ranged from 18.7% (Fairbanks et al., 1977) to 42.9% (Sanson-Fisher et al., 1979). Only in the Hodges et al. (1986) study were the staff-staff interactions not considerably greater than the staff-patient interactions and in two wards they were less.This high level of staff-staff contact is probably related to the formal duties of the staff, but it cannot be fully explained in that way, as Sandford et ul. (1990) have shown that staff-staff contact increasesas a function of increased staffing levels. Overall, these studies suggestthat on average staff spendabout one-third of their day on administrative tasks or solitary task oriented activities and that they interact more frequently with their colleaguesthan with patients. It is commonly assumedthat staff-patient interaction enhances the therapeutic process and therefore concern has been expressedat the low level of staff-patient interaction that hasgenerally been found to occur (e.g. Sanson-Fisher et al., 1979). However, it seemslikely that it is not the amount of contact per se that is important but the quality of contact. If there is a lot of interaction but it is mainly hostile then it is lesslikely to contribute positively to the therapeutic milieu than is lesserbut more friendly contact. None of the studies on nurse-patient interactions has looked at the quality of the interactions. The present study aims to do this. Methodology
Setting The study was carried out in a rural psychiatric hospital in Australia with a catchment area of approximately two-thirds of the State of New South Wales and serving a population
QUilLIT?’
OF l.VTERACTlONS
WITH
PATIE,YTS
51
of some 300.000. The hospital was built in the mid 1920s and the accommodation available for patient care reflects an era when custody rather than therapy was a primary objective of mental health services. Facilities available within each unit were limited despite attempts to modify the structure of buildings and were characterised by dormitory-style sleeping accommodation, large dining rooms and communal living areas with no capacity to provide individual “space” to which a patient could retire when feeling stressed or in need of some privacy, The hospital is staffed predominantly by registered nurses and in common with most rural services has difficulty attracting medical and allied health staff. At the time of the study the acute admission unit was the only unit with full-time medical officers, a social worker. psychologist and a full-time equivalent psychiatrist. The remaining units were served by part time medical officers with psychiatrist and allied health input provided for assessment and treatment review on a needs basis. The hospital comprises eight units and a total of 253 beds with an average occupancy rate of 75%. All units were included in the study. For the purposes of analysis, the units were categorised into four groups---acute, long-term, psychogeriatric and medical, the latter being a 1‘-bed !ow dependency medical and post-surgical ward serving the whole hospital.
For all wards other than the Acute Admission ward, observations were conducted for 7 h per day, between the times of 08:30 and 16:30, for 10 days. The time period chosen corresponds with the therapeutic day and is the time when the greatest number of interactions is likely to occur (Sanson-Fisher et al., 1979). In the Acute Admission ward, the observational period was 10 h between the times of 08:30 and 19:30. The longer observational time period was used as the staffing levels remain high after 16:30 in that ward. The procedure used in this study was similar to that used by Sandford and his colleagues in a number of studies (Hodges et al., 1986; Positano et al., 1990; Sandford and Elzinga. 1990: Sandford et u/., 1990). The observations were made at 5-min intervals. In each interval. observation began with the first nurse encountered and continued until all nursing staff had been observed. The behaviour occurring at the moment of observation was recorded on a clipboard using predefined categories. Prior to the observations in a ward, the observers spent one and sometimes two days in the ward. This was to allow them to familiarise themselveswith the ward and personnel and to reduce their novelty value. To reduce the obtrusiveness of the observers, they participated minimally in the activities of the ward and as such occasionally talked to staff and patients.
The observational categories used in this study (Table I), were adapted from those used in previous studies of nurse-patient interaction (Hodges et ul., 1986; Positano et ul., 1990; Sandford and Elzinga, 1990; Sandford et al., 1990; Sanson-Fisher et al., 1979). It was felt that basing the categories on those usedin previous studies would permit comparison with the behaviour of staff at other institutions.
The observers were trained for two weeks until there was a high level of inter-rater reliability. To ensure that the observers were being consistent in their ratings throughout
52
G. A. TYSON
Table Interactive 1 Individual
behaviour verbal: 1.1 Patient
audible
1.1.1 Positive: 1.1.2 Negative: 1.1.3 Neutral:
word(s)
1. Observation
emitted
towards
categories
et al
for staff behaviour
one other person
praise, compliments, positive feedback, laughter reprimand, derogatory remark, discouragement. neither positive nor negative
negative
feedback
1.2 Staff 2 Individual
nonverbal:
staff attending to one other person and exhibiting any of the following: eye-contact, posture turned towards other, head movements, gestures, physical contact, including administering an injection, restraining patient, dressing or bathing patient
2.1 Patient
2. I. 1 Positive: 2.1.2 Negative: 2.1.3 Neutral: 2.2 Staff 3 Group
verbal:
smile, friendly gestures, positive physical contact frowns, grimaces, negative gestures, negative physical neither positive nor negative
audible word(s) a 5-s period
emitted
to more than one person
contact
with shift of gaze from person
to person within
3.1 Patient
3.1 .I Positive: 3.1.2 Negative: 3.1.3 Neutrai:
praise, compliments, positive feedback, laughter reprimand, derogatory remark, discouragement, neither positive nor negative
negative
feedback
3.2 Staff
attending
4 Group non-verbal: 4.1 Patients
4.1, I Positive: 4.1.2 Negative: 4.1.3 Neutral:
behaviours
described
above
directed
to more than one person
smile, friendly gestures, positive physical contact frowns, grimaces, negative gestures, negative physical neither positive nor negative
in a 5-s period
contact
4.2 Styff
Non-interactive
behaviour no response to patient’s behaviour despite being within opportunity to respond and deliberately ignoring it 5.1 Inappropriate patient behaviour 5.2 Appropriate patient behaviour appropriateness or inappropriateness cannot be judged 5.3 Neutral:
5 Ignoring
patient:
6 So[itarF
task-orientated:
7 Other:
includes
any on-task behaviour carried out independently talking on phone, cleaning, walking, etc.
all behaviours
which do not fall into the above
categories.
1 m of patient.
of others,
Includes
e.g. reading.
e.g. absent from
missing
writing.
ward
the course of the study, inter-rater reliability checks were performed for 1 h each day. To synchronise scanning in each 5-min interval, a verbal cue was given by one observer. The reliability of the observations was established by calculating the percentage agreement between the two observers. While this may not be the ideal measure of reliability it does have the advantage of being extremely stringent (Hartmann, 1977). Because it was thought that having the observers code the quality of interaction may reduce the reliability, percentage agreements were calculated both with and without the evaluative level of coding. Overall, the inter-observer reliability was 88.7 and this increased marginally to 90.9 when the evaluative categories were excluded.
QUALITY
OF INTERACTIONS
WITH
53
PATIENTS
Results and discussion Behaviour
pmfiles
In all, 129 nurses (46 male, 83 female) were observed in the study. Of these, 20 were Enrolled Nurses, 84 Registered Nurses, 14 Clinical Nurse Specialists and 11 were Nursing Unit Managers. As the wards were not observed concurrently, some nurseswere observed in more than one ward. It is possible that the behaviour of nurseswho were not working in their usual ward might have been different and may have biased the results. Consequently, only the observations made about a nurse in that nurse’s usual ward were included in the analysis of the behaviour profiles. In the interests of parsimony, the results of the observations were analysed in terms of broader categories. To check for differences between groups in terms of the number of times a particular category of behaviour was observed, one-way analyses of variance were performed and where these where significant, Scheffe tests (p = 0.10) were used to identify where the differences lay. The behaviour profile of the nursesin terms of the proportion of time spent on interaction with either patients or staff, solitary task oriented behaviour and other behaviour is shown in Table 2. On average, the nurses’ time was divided almost evenly between interacting with patients, interacting with staff, engaged in solitary activities and doing other things. The average amount of staff-patient interaction is higher than the proportions reported in previous studies (Fairbanks et al., 1977; McGuire et al., 1977; Poole et al., 1981; Sandford et (II., 1990; Sanson-Fisher et al., 1979)except in the caseof Hodges et al. (1986). While the proportion of staff-staff interaction is similar to that reported in the previous studies. it is notable that the ratio of staff-staff to staff-patient interaction is different. In most of the previous studies the amount of staff-staff interaction has been considerably greater than the staff-patient interaction, with several studies (Fairbanks et al., 1977; McGuire et al.. 1977; Sandford et al., 1990; Sanson-Fisher et al., 1979) reporting that nurses spend twice as much time interacting with staff than with patients. In the current study staff spent almost the sameamount of time interacting with patients as they did with staff. One possibleexplanation for the above is that most of the previous studies have obtained data from admissions wards and as the present study shows, there is less staff-patient interaction and more staff-staff interaction in such wards, Nevertheless, the amount of Table
2. Proportion
of time spent by nurses on interacting, of ward
Type of ward Acute Long-term Psychogeriatric Medical Total
(all wards
‘F(3.125) ‘F(3.125) long-term.
combined)
solitary
tasks or other
activities
Interaction ~~______~~ With patients’ With 19.3 27.1 26.3 17.7
~~~~~ Solitary stalf task’ ~~______ 2s 29.7 23.8 19.2 23.8 23 31.4 29.1
24.6
24.5
= 4.37, p < 0.01. Acute less than long-term, psychogeriatric. = 8.24. p < 0.000 I, Acute greater than long-term. psychogeriatric:
24
by type
Other 26.2 30.7 21.2 21.4 26.9
medical
greater
than
54
G. A. TYSON
el ~1.
staff-patient interaction found in this study is still relatively high. It should also be borne in mind that the base for the calculations in this study includes meal and tea breaks which were part of the “other” category, whereas in other studies this does not appear to have been the case. Thus the base, that is, the total number of observations, used in these studies would be smaller relative to the number of interactions and this would inflate the proportion of interaction in other studies. The behaviour profile according to the type of ward is also shown in Table 2. Analyses of these data showed that there was a higher staff-patient interaction in the psychogeriatric and long-term wards than in the acute ward. This is in line with the results of Hodges et al. (1986) who found that chronic patients are interacted with more than acute. The difference in the amounts of interaction in acute and chronic wards is probably due to the nature of the illness and the surroundings. The acute patients are in new and unfamiliar surroundings and their ability and desire to communicate are probably reduced by their illness and medication. Chronic patients, on the other hand, are more likely to feel at home and the staff will have become part of their family so to speak, and consequently they are more likely to initiate interactions with the staff. With regard to the higher staff-patient interaction in the psychogeriatric wards, it is obvious that their condition requires more staff-patient interaction. In the case of staff-staff interactions, there were no significant differences between the wards although there was a trend towards a higher amount in the medical ward. This would be expected because of the greater need to confer at the change over of shifts and the more frequent visits of the medical officer. With regard to solitary activities, which included activities such as answering telephones, writing reports, etc., the average of 24% of total time is less than that reported in most of the previous studies. However, the definition of solitary task oriented behaviour is not consistent across studies and therefore it is difficult to draw any definite conclusions in relation to other studies. As shown in Table 2, more time was spent on solitary tasks in the acute ward compared to the long-term and psychogeriatric wards. This would be expected given that acute nature of the patients’ illness and the rapid turnover of patients. There was also a higher level of solitary task-oriented behaviour in the medical ward compared to the long stay wards, which probably reflects a need for more frequent record keeping. The behaviour profile of the staff was also analysed in terms of the rank of the nurses and the results of this analysis are shown in Table 3. From the table it can be seen that
Table
3. Proportion
of time spent by nurses on interacting,
solitary
tasks or other
activities
by rank
Interaction ~~ Type of ward
~~ .~~ Enrolled Nurse (EN) Registered Nurse (RN) Clinical Nurse Specialist (CNS) Nursing Unit Manager (NUM) Total
(all nursing
‘F(3.125) ‘F(3,125) ‘F(3.125)
staff combined)
With patients’ ~~~ 30.8 26.3 19 8.3 24.6
Solitary task’
Other
20 24.4 28.3 2X.6
22.3 23 21 37.9
27.1 26.2 31.9 25.5
24.5
24
26.9
With
~ staff
= 15.33, p < 0.0001. NUM less than EN, RN, CNS; CNS less than EN. RN = 4.17, p < 0.01. NUM greater than EN, RN. = 9.89,~ < 0.0001. NUM greater than EN, RN, CNS.
QC’ALITY Table 4. Percentage
Acute Long-term Psychogeriatric Medical (all) wards
‘F(3.125) ‘F(3.125) ‘F(3.125) ‘F(3.125)
= = = =
WITH
of total time spent by nurses in verbal with patients by type of ward
Type of ward
Total
OFINTERACTIONS
combined
PATIENTS and nonverbal
interactions
Individual verbal’
Individual nonverbal’
Group verbal‘
6.5 IO.5 5.9 6.3
4.8 6.3 13.6 10.1
I.? 2.1 0.9 0.4
6.6 8.2 5.8 0.8
6.9
10.3
1.3
6.1
5.57, p < 0.01. Long-term greater 17.00. p < 0.0001. Psychogeriatrtc 4.17, p < 0.01. Long-term greater 2.78. p < 0.05. Long-term greater
Group nonverbal”
than acute. psychogeriatric. greater than acute, long-term than medical. psychogeriatric. than medical.
there was a trend for more junior staff to spend more time with patients and that the Nursing Unit Managers spent significantly less time interacting with patients than the other staff. This is consistent with the findings of Handy (1991) and Pines and Maslach (1978). Conversely, the Nursing Unit Managers spent significantly more time on solitary tasks than did any of the other nursing staff and more time interacting with other staff than did Enrolled Nurses and Registered Nurses. These results would be expected given that a large part of a Nursing Unit Manager’s job would consist of administrative tasks and supervision of staff. The staff interactions with patients were then analysed in terms of whether they were verbal or nonverbal and individual or group-oriented and the results are shown in Table 4. Although on average a greater amount of time was spent in nonverbal interaction with individual patients, this was largely due to the psychogeriatric ward that had a significantly higher level of nonverbal interaction as would be expected given the nature of the patients. In the long-term wards, individual verbal interaction predominated and was significantly higher than in both the psychogeriatric and acute wards. Group interaction, both verbal and nonverbal. was highest in the long-term wards (Table 4). For verbal interaction. it was significantly higher in the long-term wards than in the medical and psychogeriatric wards and for nonverbal interaction it was significantly higher than in the medical ward. These results are a little surprising as one might have expected a high level of group interaction in the psychogeriatric wards where immobile patients require lifting. bathing: etc., which would involve at least two nurses. The fact that this did not show up may be because such activities usually occurred outside the observation period. In addition. most psychogeriatric and medical patients were immobile which means that they themselves did not form groups. On the other hand the acute and long-term patients could form groups with which staff could interact. The interactions of staff with patients were also rated in terms of their quality. Percentages of the total interactions that were either positive, negative or neutral was calculated and these are shown in Table 5. The results of this analysis show that almost all the interactions with patients were either positive or neutral. Particularly encouraging is the fact that nearly half the interactions in the long-term wards were rated as positive, Although the incidence of negative behaviour was so low. it is necessary to look at it in greater detail because of its possible negative implications. In all, 32 negative behaviours were observed involving 17 staff. Of these, 29 were individual verbal interactions and there
56
G. A. TYSON Table
5. Quality
of nurses’ interactions
Type of ward
(all wards
combined)
‘F(3,125) = 36.74, geriatric, acute. ‘F(3.125) = 35.79, term, medical.
with patients
Positive’
Acute Long-term Psychogeriatric Medical Total
et al.
p
< 0.0001.
p < 0.0001.
Negative
Neutral*
22.5 46.9 15.5 42.1
0.3 0 0.4 0
71.3 53.2 84.1 57.9
24.5
0.3
75.3
Medical, Acute,
by type of ward
long-term
greater
psychogeriatric
greater
than
psycho-
than
long-
was one in each of the remaining categories, namely, individual nonverbal, group verbal and group nonverbal. In most cases, the negative behaviour was an isolated incident in the behaviour of the staff, the highest frequency being five that occurred for two staff members. In interpreting these data, it must be borne in mind that the negative categories included not only very abusive behaviour but also behaviour such as frowning or an abrupt response which are behaviours which occur in normal everyday interactions. Given this, it is remarkable that negative interactions were so low (0.29% of all interactions). While it might be suggested that this could be due to a Hawthorne effect, we do not think that played a major role as it did appear as if the staff adapted to the observers very quickly and it would be difficult to control behaviour so consistently for the length of the observational periods. Although the Nursing Unit Managers spent less time interacting with patients, the quality of their interactions was more positive as can be seen in Table 6. There are two possible explanations for this. First, it is possible that during routine activities the interactions between staff and patients tend to be more neutral and that the Nursing Unit Managers are less involved in those routine activities. Alternatively or in addition, it is possible that because they have fewer interactions with patients, it is easier for Nursing Unit Managers to be positive in their interactions. Conclusion
Overall, the results of this study provide some positive indicators for the hospital in which the study occurred. Staff-patient interaction appears to be higher than that reported in previous studies and much of the interaction was of a positive nature, especially in the Table
6. Quality
of nurse interactions
with patients
Rank
Positive’
Enrolled Nurse (EN) Registered Nurse (RN) Clinical Nurse Specialist (CNS) Nursing Unit Manager (NUM)
19 23.1 28.2 40.3
0.6 0.2 0.4 0.1
80.5 76.7 71.3 59.7
Total
24.5
0.3
75.3
(all nursing
‘F(3,125) ‘F(3,125)
staff combined)
= 3.80, p < 0.05. NUM = 3.74, p < 0.05. NUM
Negative
by level
greater than EN, RN less than EN, RN.
Neutral’
QUALITY
OFINTERACTIONS
WITH
PATIENTS
57
long stay wards. Conversely there appears to be very little interaction that could be classified as negative. A possible explanation for the results is the Hawthorne effect, although this seems unlikely for the reasons given previously. Even if it were operating, however, it would not necessarily invalidate the results as it would have also been operating in the other observational studies done in the past. There is no reason why it should have operated more strongly in the current study and therefore the differences in the data between this study and previous ones are still meaningful. Regarding the qualitative aspect, it is possible that staff may have tried especially hard to be on their best behaviour, but given that on average several hundred instances of behaviour were observed for each staff member, it seems unlikely that the observed behaviours were that unrepresentative of normal behaviour. While the results suggest that a friendly atmosphere prevailed, they do not tell us all that much about the therapeutic atmosphere. There was no analysis of the content of the interactions nor the context in which they occurred. Furthermore the duration of the interactions was not recorded. Hence it is possible and even likely that most of the interactions occurred during routine activities rather than in a therapeutic type interaction. Handy (199 1) found that only 2% of admission ward nurses’ time was spent on counselling patients compared with 19% for practical care and 7% for meal breaks. In this regard one of the interviewer’s comments is significant. After the study she stated that the patients were very accepting of her and really seemed to appreciate the opportunity to speak to someone about their problems. All this suggests that further studies on the nature of the interactions would be beneficial. A noticeable feature of the results and those of other studies is that relatively little time was spent interacting with patients-less than 20% in the acute ward in this study. This raises the question of the need to develop structured programs which increase meaningful staff--patient interaction. The Australian National Mental Health policy developed jointly by the Federal, States’ and Territories’ governments has adopted a strong consumer orientation. The Mental Health Statement of Rights and Responsibilities adopted by the Australian Health Ministers Conference (1991) states inter alia the consumers rights to “interact with health care providers, particularly in decision making regarding treatment, care and rehabilitation” (p. 1). It would therefore be appropriate to develop local protocols which include the patient actively in the clinical decision-making process. This could be accomplished, for example, by mandating that the patient must be consulted when their nursing care plan is being developed or changed. In addition, the development of structured group programs aimed at improving the patients’ knowledge of their illness, the effects of their medication. or which address specific issues such as discharge planning could also be considered. Another way of possibly increasing stall-patient interaction may be by reducing the amount of clerical work that staff are required to do. Overall, almost a quarter of nurses’ time was spent on such tasks. This seems high and suggests that a review of this area would be appropriate. It may well be that routine paperwork could be reduced by the greater use of information technologies. Whether or not this freeing up of time would lead to greater staffpatient interaction is a moot point, however, given that Sandford et ~1. (1990) found that increased levels of staffing increased staff-staff interaction but did not affect staff patient interaction. Although it seems obvious that we should be concerned about the relatively low amount of staff--patient interaction and should seek ways to increase it, a note of caution should be
58
G. A. TYSONat
ul
sounded. Such concern is based on the assumption that lots of staff-patient contact is good for the patient. This assumption is untested and it may well be that at least for some patients less contact is desirable, especially if it is routine rather than specific therapeutic contact. Thus the primary focus of programs relating to staff-patient interaction should be on the quality of the interaction rather than quantity per se. Acknowl~u’y~~en/s-This study was funded by the New South Wales Health Department. The authors would like to thank Ann Hall, Dierdrie Leslie, Cathy Walker, Tracy Brown, Bert Prusiak and Kim Stevens for their assistance in designing and implementing the study.
References Australian Health Ministers’ Conference (1991). Mental hralth statement ofrights and rrsponsibi~ities. Australian Government Publishing Service, Canberra. Fairbanks, S., McGuire, M. T., Cole, R.. Sbordone, F.. Silvers, M., Richards, M. and Akers, J. (1977). The ethological study of four psychiatric wards: patient, staff and system behaviors. J. Psych. Res. 13, 193-210. Handy, J. A. (I 99 1). The social context of occupational stress in a caring profession. Social Sci. Med. 32(7), 8 l9830. Hartmann, D. P. (1977). Considerations in the choices of interobserver reliability estimates. J. Appl. Behar. Awl. 10, 103-l 16. Hodges. V., Sandford, D. and Elzinga, R. (1986). The role of ward structure on nursing staff behaviours: an observational study of three psychiatric wards. Actu P.rJrhiutr. Stand. 73, 6-l I. Howard, D.J. and Hurst, K. (1988) Psychiutric nursing uudit. Central Nottinghamshire Health Authority. McGuire, M.. Fairbanks, S., Cole, R., Sbordone, F., Stlvers, M., Richards. M. and Akers, J (1977). Theethological study of four psychiatric wards: behavioural changes associated with new staff and new patients. J. Psych. Rex. 13,2 1 l-224. Pines, A. and Maslach, C. (1978). Characteristics of staff burnout in mental health settings. Hospitul c‘owmmit~ PsJch. 29,233-237. Poole, D. A.. Sanson-Fisher. R. W. and Thompson V. (1981). Observations on the behaviour of patients in a state mental hospital and genera1 hospital psychiatric unit: a comparative study. Brhar. Rrs. Therapy 19, 125 134. Positano, S., Sandford, D. A., Elzinga, R. H. and James, J. E. (1990). Virtue rewarded: reinforcement and punishment in an acute psychiatric ward. J. Be/ma. Therup~~ E.yp. Pq~ch. 21, 257-262. Robinson, V. M. J. (1978). The behavior of staff: an ignored variable in programme evaluation. Social Sci. Med. 12, 175-I 82. Sandford. D. A. and Elzinga. R. H. (1990). Patient interactions in four psychiatric wards. Ac,tcr Pswhiatr. Stand. 82, 125.. 125. Sandford, D. A., Elringa, R. H. and Iversen. R. (1990). A quantitative study of nursing staff interactions in psychiatric wards. Acta Psj,chiatr. Stand .81, 46651. Sanson-Fisher, R.. Poole. A. D. and Thompson, V. (1979). Behavioural patterns within a general hospital psychiatric unit: an observational study. Behar. Rps. Therapy 17, 317--332. (Rcceiced
7 June 1993; accepted
fbr publication
28 April
1994)