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Communication and behavior on a small psychiatric unit
Communication
and Behavior on a Small Psychiatric Unit
By CARllOLL ~/I. BRODSKY THE PROCESSING OF I N F O R M A T I O N is OVte of the major tasks required of all human beings, but in modem, densel) populated societies, it b e comes everybody's principal, business. Furthermore, within a proliferating technology such as ours, incredibly complex circuits o f communication are necessary to sustain the precision and efficiency r e q u i r e d by t h e technology. Breakdowns or distortions of communication, even very minor ones, can have far-reaching, disastrous effects. Consequently, modern research in communication faihtres manifests a strong sense .of urgency today. Since studying t h e larger systems is often prohibitive, much of this research has to be ]imited to smaller groups, where it iS lloped findings will illuminate defects or impedances w h i c h can cause breakdox~aaS in all communication systems. The present study analyzes the patterns of communication that developed on the ward of a small, l l - b e d psychiatric unit in a university general llospital, and attempts to show how distortions, rumors, and other misconceptions can enter certain message cycles and, in turn, disrupt the functions of an entire work group. Although small, this refit revealed all the vulnerability to breakdown found in larger social systems: individuals disagreed, role boundaries were breeched, and organizational rules were broken. At times, staff members seemed more bent on creating a psychotogenic tlmn a therapeutic environment." The same problems have plagued the larger psychiatric institutions and, as revealed by several important studies, failures in communication there have been shown to be the immediate cause. Stanton and Schwartz observed how distortions of communication in a private, well established mental hospital prolonged patients" illnesses, ~ Sta'auss et al. speak of' the communicative gap between nurses and resident psychiatrists in a university psychiatric hospital ,and of the despa:ir and lowered morale resulting from dais.-" I n comparison, Szurek noted the improvement of patients in a dafld-psychiatr)' t r e a t m e n t Unit when communication channels were opened to the entire staff, z. Indeed, w e a r e more and more coming t o see that failures in communication are extremely important ha the pathogenesis of mental disorders themselves. 4"6 RuesOa writesFrom ,the-evidence we have today we must assume.that ~successfad participation i n networks of communication whida involve other human b¢iffgs is necessary ff t h e indix~idual is to survive. Subjectively, t h e individual experiences failure in communication as frnstrating. If frustration is very intense, of long duration, or repeated, the individnal's thinkhag, feeling and reacting become progressively more disorgmaized m i d inappropriate. In turn, such behavior is regarded by others as abnormal. ~ CAnRO~Z, M, B~o~sg~', PH.D., M.D.: Associate Clinical Projessor of Psgmh/atry, Langley Porler Neuropsychiatric Institute and the Department of Psychiatry, Uni~ersiQl OJ Cali/onlia School of Medicine, Smz Francisco, Calif. Director, Adult Psychiatry Clinic, Universlty of California Medical Get,let, San Francisco, Calif. COMVm:~IE.X'SIVE PSVCmATnV, VoL. 9, No. 5, (September), 1988
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I n all f o r m a l o r g a n i z a t i o n s , work roles are p r i m a r i l y d e f i n e d b y t h e i r f u n c tions in the eoln+~qaanication n e t w o r k of the e n t i r e grctup. T h e s e functions, u s u a l l y expressct~ as d o u b l e - h e a d e d arrox.:s b e t w e e n the circles of the organization's c h a r t s a n d soeiograms, are u s u a l l y c o n c e i v e d as s i m p l e , b i l a t e r a l e x c h a n g e s b e t w e e n two i n d i v i d u a l s or units i n t h e social system, but, often, little a c c o u n t is t a k e n o f ' t h e m u l t i t u d e of i n t e r f e r e n c e s that o f t e n i m p a i r effective c o m m u n i c a t i o n . In p s y c h i a t r i c facilities w h e r e these are not h e e d e d , results can b e tragic, Sclawartz r notes: [Tlhe formal organization of the system of commtufication and the informal means for trat~smitting and receiving information play an important role in the patient's therapeutic progress. Defect,g in communicative organization, breakdowns, blocks, distortions, omissions in the transmission of information, the pa.ssing on of inadequate data--all may contribute to misunderstandings between and among hospital parHcipants. These misunder~andings tend to perpetuate the patient's mental illness (p. 193). Nlanv factors coalesce to p r o d u c e these r u p t u r e s a n d distortions of comm u n i c a t i o n - - s o m e p e r s o n a l ( n o t p r i m a r i l y our c o n c e r n h e r e ) a n d s o m e systemic, i.e., a r i s i n g out of defects w i t h i n t h e circuits of t h e i n s t i t u t e d systems. T h e p e r s o n a l factors i n c l u d e sensor), disabilities, p e r c e p t u a l rigidity, d i s t r a c t i v e moods, or i n t e l l e c t u a l i n a d e q u a c y . T h e s y s t e m i c factors w i t h i n h o s p i t a l settings in p a r t i c u l a r , i n c l u d e the hierarcqaieal social s t r u c t u r e of h o s p i t a l staffs, status b a r r i e r s b e t w e e n o c c u p a t i o n a l groups, p r o f e s s i o n a l codes of r e s t r a i n t a n d "objectivity," p o o r j o b satisfaction, a n d t h e like. s-~° P e r h a p s a n e v e n m o r e imp o r t a n t distortion arises w h e n w o r k roles a n d v a l u e s are a m b i g u o u s l y def i n e d a a - - t h e p r i n c i p a l c o n c e r n of this p a p e r . M a n y of t h e s e i m p e d a n c e s listed i n s t i g a t e d the conflicts a n d inefficiencies o b s e r v e d on the u n i t u n d e r study, a n d it is the a i m of this p a p e r to d e s c r i b e w h a t these i m p e d a n c e s w e r e a n d h o w t h e y w e r e r e s o l v e d w i t h i n the limits of the special c i r c u m s t a n c e s existing for s u c h a group. P a t t e r n s a n d P r o b l e m s in C o m m t t n i c a t i o n on t h e U n i t
T h i s s t u d y was u n d e r t a k e n at a t i m e w h e n there w a s c o n s i d e r a b l e intrastaff conflict over the m , ' m a g e m e n t of c e r t a i n p a t i e n t s w h o w e r e d i s t u r b e d , b u t ~not a n y m o r e so t h a n o t h e r p a t i e n t s w h o h a d b e e n m a n a g e d w i t h o u t difficultT. By the t i m e the staff's p r o b l e m s c a m e to t h e a t t e n t i o n of the superv i s i n g p s y c h i a t r i s t , h o w e v e r , t h e d e v e l o p m e n t of the p r o b l e m s w a s o b s c u r e d b y t h e tension s u r r o u n d i n g t h e m . I n r e s p o n d i n g to i n q u i r y , the staff b l a m e d p a t i e n t s a n d t h e i r p r i v a t e p s y c h i a t r i s t s , a n d o c c a s i o n a l l y e a c h other. I n a n effort to u n d e r s t a n d h o w these p r o b l e m s h a d d e v e l o p e d a n d to d i s c o v e r t h e m e a n s of r e s o l v i n g t h e m , it w a s d e c i d e d to m a k e t a p e r e c o r d i n g s of n u r s i n g reports g i v e n d u r i n g t h e c h a n g e of shifts, for it w a s e v i d e n t t h a t r u m o r s a n d misc o n c e p t i o n s w e r e b e i n g g e n e r a t e d ~ ' i t h i n t h e c o m m t m i c a t i o n cycles that h a d e v o l v e d on the unit. D a i l y , for f o u r weeks, as e a c h q u i t t i n g s h i f t r e p o r t e d to the o n c o m i o g s~hift, t h e y d i d so in the p r e s e n c e of an o p e r a t i n g t a p e recorder. T h e r e c o r d i n g s g l e a n e d f r o m t h e first w e e k of r e p o r t i n g w e r e often i n a u d i b h - a n d those .that cxmld b e h e a r d w e r e m a r k e d b y stilted l a n g u a g e or IH.r~,ous l a u g h t e r , r e l l e c t i n g the nurses' self-conscious a w a r e n e s s of the re-
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cording apparatus. However, by the end of the first week, they became quite accustomed to the recording equipment, and the reports of the succeeding 21 days were more spontaneous and of adequate clarity for analysis: At the same time, a record was kept of events on the w a r d as they were observed directly or as they were reported by the patients, file private psychiatrists, the residents, or the nursing staff. Special note was taken of requests for seclusion of patients or inquiries about prescribing tranquilizers or increasing the already-prescribed dose. All complaints of staff members and patients were carefully noted.
The Unit and Its Staff The small private psychiatric unit attached to a general hospital is becoming more common throughout the counta), in response to the trend in modern psychiatry to treat patients near their homes in the community. T h e unit offers definite advantages to private practitioners in that referrals can be conveniently admitted into the general hospital and the continuity of the psychiatrist's treatment preserved. As such, the unit is well suited to meeting momentary crises in private-patient care. Usually these units have a director who is himself a practicing psychiatrist but whose responsibilities are primarily administrative. Also, there is customarily only one head nurse on these units, and she works on the d a y shift. Often she is the only person on the unit with graduate training and experience in psychiatric nursing. H e r immediate supervisors, as well as those for all three shifts, are usually medical-surgical nurses who are responsible for a n u m b e r of wards, of which the psychiatric unit is only one. The remainder of the staff is composed of nurses who have some interest in psychiatric nursing b u t little formal training or ewperienee. The supervisory staff makes sere that hospital rules are maintained and that general nursing procedures are up to standard, but they are of little help in dealing with the psychiatric problems which arise within the unit itself. The burden of maintaining: a d e q u a t e nursing care during the 24 hours of the day rests almost entirely with the h e a d nurse ,and the chief of service. It should also be noted here that the atmosphere of informality mad closeness prevailing on such a small unit tends to diminish somewhat the authority inherent in the head nurse's role. The Unit's Program In the traditional psychiatric institution, patient care is vested in a permanent medical staff with each psychiatrist responsible for the ten or twelve patients assigned to him. Because the small psychiatric unit is primarily a private referral service, there can be as many psychiatrists involved with the unit as there are beds. Designing a single therapeutic program is, thus, quite diflleult. Each psychiatrist has his own treatment approach, his own reasons for referring his patient to the unit, and his own perceptions of the hospital's role in his therapy for the patient. Specifically, one psychiatrist might perceive die lmit where his patient can be temporarily protected from sensory bombard-
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ment, while another might perceive it as a place for socialization and stimulation by an i1~erea.s'e of sensory input. In contrast with the older institution where h u n d r e d s of patients are cared for in a large cultural complex, the unit, o p e r a t i n g primarily as a custodial facility, has little o p p o r t u n i t y to develop s t a n d a r d operating procedures. The larger institutions have evolved philosoplfies of p a t i e n t care a n d t h e r a p e u t i c t e c h n i q u e out of it tong history of meeting and resolving crises. In addition, nurses a~ad supervisorg there have b e c o m e highly skilled in spotting problerns early and resolving them t h r o u g h a u t h o r i t y a n d experience. Although this kind of p r o g r a m m i g h t tend to i n , ibit innovations, it has the virtues of efficieuev a n d effectiveness.
Bole Insecurity T h e psychiatric nurse on the small unit does not work widfin such a wells t r u c t u r e d set o f expectations and duties. T h e ambiguities of h e r role cause her to question her t r e a t m e n t a p p r o a c h and to vacillate in the t h e r a p e u t i c values she intends to uphold. A resultant anxiety can easily be projected onto patients, who, ~ in tur~a, b e c o m e tense, precipitating m a n a g e m e n t crises between nurses and director a n d his private-practice colleague. U n s h a k e a b l e "positions" are assumed and u n b r e a k a b l e stalemates ensue. Such struggles arc readily rellected in the communications the nurses exchange a m o n g themselves.
Types of Nursing Colnlnunieation.s F o r m a ! communications b e t w e e n nurses are both w r i t t e n and oral, while informal c o m m u n i c a t i o n s are entirely oral. E v e n with a small staff of fourteen. one can i m m e d i a t e l y see that s t u d y i n g the entire eommunicatiort network. including social exchanges b e t w e e n staff m e m b e r s , would be impossible. One message cycle, however, built into the routine of the unit's w o r k - d a y is a m e n a b l e 1o analysis: the nursing reports t r a n s m i t t e d b e t w e e n shifts. These reports, mostly oral, can be easily s t r u c t u r e d for adequate, d a t a - g a t h e r i n g purposes and analysis. As is c u s t o m a r y on all hospital units, the shift completing its work reports to the shift arriving. T h r e e shifts, d a y (7:30-4:00), evening (3:30--12:00). and night (11:45--7:45), exchange information on n e w and old patients, t r e a t m e n t changes, and n e w information or orders from the referring psych/atrists. T h e informal n a t u r e of these communications also permits the relating of interpersonal experienees with patients. On the present unit, n e i t h e r nursing supervisors nor psyehiatrists w e r e present at these e x d m n g e s d u r i n g the study period. F o r these four weeks of stud)', few personnel changes occurred and shifts r e m a i n e d stable, except for days o i l T h e head nurse worked during the d a y shift b u t r e m a i n e d nominally in charge for file evening a n d n i g h t shifts. One psychiatric technician, usually a male college student: was on d u t y during each shift.
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,,D~aly,s'is el the Taped Bel)orts In general, three types of c o m m u n i q u 6 forms a p p e a r e d in the taped reports: (1) narrative, (:29) therapeutic, a n d ( 3 ) g o s s i p y . Tile narrative c o n l m u n i e a t i o n was objective and used p r i m a r i l y for routine matters. T h e therapeutic reports were concerned with the m a n a g e m e n t of p a r t i c u l a r p a t i e n t s ~ a n d partidularly the t r o u b l e s o m e ones. In these statements, there was a f r e q u e n t complim e n t i n g o f ' e a c h other a n d eonsensual griping; p r a i s e was m e t e d out to staff m e m b e r s who h a d h a n d l e d a difficult situation b e y o n d the call of duty, o r c o m p l a i n t s w e r e raised, u s u a l l y a g a i n s t specific patients or genei'alized circumstances p r e v a i l i n g on the ward. T h e gossipy report wa s m a r k e d b y i n f o r m a l candor, laughter, a n d drama, either a m u s i n g or shocking. Caudill, analyzirJg similar inter-staff c o m m u n i c a t i o n patterns, ma ke s a just disthaction b e t w e e n eogna~ve a n d affect:ve messages. ~z At times, one or the other type of message is r e p r e s s e d or favored, i n d i c a t i n g some interference in the fuIl transmission of information, as in the pr e se nt s t u d y w h e n a nurse felt t h a t h e r attitude or b e h a v i o r towa r d a certain p a t i e n t h a d not m e t w i t h the approwtl of the other nurses. To: protect herself, she suppr e sse d all affect, w i t h d r e w into p u r e l y narrative reporting, a nd r e f u s e d to "'discuss the m a t t e r further." In times of crisis, the reverse could be observed: the p r i m a c y of affect over cognitive communications.
Setting the Expectations of the Next Shift T h e p r i n cipal goal of the present research was to spot a n d trace the course of i n d i v i d u a l perceptions which, once entering a c o m m u n i c a t i o n cycle, e,-m b e c o m e p e rpetuated, affecting all the perceptions of the i n t e r e h a n g e r s a l o n g the circuit. Easiest to p i n p o i n t were i n f o r m a l l y expressed attitudes toward certain patients which, once easamlly d r o p p e d into the me ssa ge cycle, colored the perceptions of the other two shifts. Statements a b o u t a n y patient, suc h as, "'I feel very u n e a s y in the s a m e room with him; .... I'm c e r t a i n l y glad I'm off tomorrow, I don' t think I could take h i m a nothe r day; .... I h o p e they increase his drugs soon" i m m e d i a t e l y suggest experience vdth an u n m m a a g e a b l e p a t i e n t w h i c h odaers will b e b o u n d to have. Put on edge b y suc h "hints," e a c h shift "mcorporate~ the projected anxiety a n d then proceeds to p e r p e t u a t e it in its report to the next shift. By the time of hall circle, one e,-m observe the same report b e i n g transmitted to its originator, d o u b l y confirming its validity for her, x,Vith the u n f a v o r a b l e perception n o w "'ringing him'7*about, so to speak,-the p a t i e n t picks u p the "'bad" cues a n d amplifies the m x(,ith m o r e of the s a m e behavior that h a d instigated t h e m in the first place. ~Arith certMn cases of d i s t u r b e d behavior, this vicious circle can b e e o m e so a g g r a v a t e d that comm u n i c a t i o n on the unit breaks d o w n entirely. T h e resulting stalemate isolates all those w ho transmit or receive information a long the circuit. E a c h staff mena~ier, now m o r e concerned with his i n d i v i d u a l integrity, withdravts from his responsibilities to clearly transmit all information he h a d g l e m m d from others a n d observed for himself. T h e recalcitrant p a t i e n t is "locked into" a socially-shared perception w h i c h n e i t h e r he nor his psychiatrist can alter. ~'~ Even w h e n the b e h a v i o r a l difficulties instigating the me ssa ge cycle h a d cleared
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and the "bad" patient was discharged in an improved condition, the members of the message %vele still remained angry and unrec°ncilecl- E(,en, as in certain cases, where a post-discharge discussion of these patients was possible , the issues could not be resolved beyond a lingering guilt and dissatisfaction.
Reports and Differences in Nursing Shifts Ideal nursing procedure would dictate that the head nurse assume full responsibility for these breakdox~ms in w a r d communication between nursing shifts, but, in the present instance, she was excluded from the conflict either as participant or arbiter. The smallness o f the unit created a role ambiguity which the head nurse could not properly-resolve. Although her admh~istrative authori W was acknowledged, other nurses considered her a peer in experiene.e in psychiatric nursing. In practice, her suggestions were often either ignored or rejected. The tapes show a repeated phenomenon. Since the head n u r s e did not preside at the exchange bet~veen afternoon and night shifts (occurring usually at 1t:45 p.m.), these p a r t i c i p a n t s w e r e prone to transmit the affective, gossipy, and rumor-ridden reports over the objective or narrative-type messages which had been fed earlier into the cycle. Between these two shifts, there was a good deal of "'mutual consoling," a sharing of mutually-experielmed isolation and anxiety, and an intereh~mge of m u t u a l support. No one present was criticized, implicitly or explicitly. In fact, the night shift showed the least disagreement among themselves in their reporting. However, the head nurse and he r policies were discussed often, subtly or directly, more at this reporting time than at any other. D u r i n g this nightly encounter, w a r d conflicts were polarized. The interchange was particularly informal, mustering a different set of loyalties than w h a t was evident in the other two reporting-points. W h a t e v e r affect had entered the message cycle was intensified here. Since patients were supposed to be merely "maintained" at night, the night shift did not consider themselves playing a particularly important role in therapeutic program s set up for indi,~5dual patients. The shift was generally Uninterested in patient histories or clinical assessments of progress. Accordingly, a patient who presented night problems~insisting, for example, on sitting up in the dayroom in full v i e w of the nurses instead of retiring t o his own room, was considered a "%peeial problem.'" Disruptive night behavior, even when quiet ,and not disturbing to other patients, always seemed to elieit the d e m a n d that '-something be d o n e about this patient." Appeals would be expressed in the reports to p u t more controls on the p a t i e n t in his treatment. This low level of tolerance for aberrant behavior on the part of the night nursing staff was, at firs:t difl~eutt to lmderstand. Interviews with the nurses, however, showed that the), not only felt isolated and distant from the unit's therapeutic regimens but from the hospital's nighttime administration as well. Nurses at night werd reluct,'mt to call in the house physician because they felt very strong justifications would be necessary and that, if called, the house
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physician w o u l d be reluctant to intea~'ene in any crucial w a y in a psychiatric case. U n d e r the circumstances, they felt v e r y m u c h "on their own.'" Curiously, the n i g h t shift's subjective contributions to the unit's message cycle were short-circuited directly to the afternoon shift at the 1i:45 p.m. reporting. In r e p o r t i n g to the head nurse in the monaing, however, the shift would narrate the events of the previous night objectively. This seIa, ed to delay supervisor~; action which could have n i p p e d in the b u d the :;tatFs d~stress when the), discovered that they were faced with a full-fledged "'problem.'" Unable to relieve t h e tension, f_he h e a d nurse t u r n e d to the psychiatrist in charge of the ward. H o w e v e r , the hierarchical relationship she h a d with h i m forced her to translate the p r o b l e m a s due solely to the p a t i e n t a n d not to her nursing staff. It was the patient's behavior which was creating difficulties in m a n a g e m e n t and taking u p too m u c h nursing time. As the night shift had suggested, she would now agree t h a t some intervention was necessary: either m o r e drugs or a talk with the patient's psychiatrist. W h e n e v e r t h e unit h e a d w o u l d suggest that the root of the p r o b l e m p e r h a p s lay with the nursing staff, the h e a d nurse would usually t a k e the defensive, r e p e a t i n g all that t h e nurses h a d told her, even though she herself h a d d e b a t e d these matters with her staff.' It was not until the commuI,ieation p a t t e r n which h a d evolved on the unit was studied, as described ha d a i s p a p e r , that a constructive effort to ease intrastaff conflict was possible.
Resolution of Conflicts A preliminary effort to solve the problem b y instigating t r e a ~ n e n t - r e v i e w meetings at which ,all present could discuss the patients ,and make suggestions for their care was singularly uI~successful. Such conferences merely concluded with f u r t h e r d e m a n d s for more drugs or for the forceful intervention of the referring psychiatrist. At t h e s e meetings, the night shift was not present, and the day-evening nursing reports which followed the meetings were general])" gossipy b u t polite. T h e r e were, momentarily, a few m i n o r shifts in position, but, by the time of the next report ( b e t w e e n evening and n i g h t shifts), participants h a d r e t u r n e d to the positions held before t r e a t m e n t re,dew. Another tack was tried, finally with some success, b u t n o t before a few false starts were overcome. This a p p r o a c h involved a m e e t i n g of the psychiatrist in charge of the troublesome case with the nursing staff. These meetings, however, were not successful w h e n t h e psychiatrist a t t e m p t e d flaerapy with the nurses b y directly inquiring a b o u t their problems ~vith the patient mad b y interpreting their difficulties as resulting from either some personality deficit of t h e i r own or of the patient. T h e nurses l e f t such meetings m o r e frustrated than w h e n they entered, a n d ~patient care Was in no w a y enhanced. Nursing reports following such meetings often mentioned the p s y c h i a t r i s t in unfavorable terms, a n d "the o p i n i o n was frequently expressed that if a n o t h e r psychiatrist, in w h o m t i e staff .had confidence, were treating the patient, the patient would do better. T h e s e conferences were considerably improved when the private psychiatrist did not approach the difficulty as being the p r o b a b l e r e s u h of the nurses' lack
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of knowledge or technique. Instead, rather titan asking any direct questions about his patient's behavior, he presented a ease histoD- of flae patient nmch as he would to a group of his own colleagues. A specific example illustrates the procedure: Dr. XV. ol)lained hospital admission for N'Ir. E. R., a 32-year-old schizophrenic who, during his first 24 htmrs on the ward, set nursing staff and patients into a turmoil. Dr. ~V. p r e s c r i b e d no drugs except a mild sedative, w h i c h h a d b e e n definitely i n a d e q u a t e to control Mr. E. li.'s behavior. Fortunately, at the time of adrnission, Dr. ~V. had expressed his intention to confer with the nursing staff on the following day. W h e n he w a l k e d into the conference, Dr. ~V. m e t a vel~, angry stall. H o w e v e r , despite his awareness of his patient's tnmulhm~s behavior, he b e g a n relating his patient's backgn'ound, h o w h e had appeared at the first interview, and w h a t he, ,as the doctor, h a d learned of his patient's relatives. I t e then p r o c e e d e d to describe Mr. E. R . ' s history in the minute.~t details, delving into his patient's interpersonal problems, his p a t t e r n of handling communications, relationships, and stress, a n d his o w n interpretations of the genesis of Mr. E. It.'s presently a b e r r a n t behavior. H e then turned to his i m m e d i a t e goMs for his patient's hospitalization a n d described specifically w h a t he hoped the nursing staff, the o c c u p a tional therapist, and the unit director w o u l d do to benefit his p a t i e n t most. At the conclusion of the conference, he asked for questions and suggestions. T h e nurses proffered no suggestions b n t asked m a n y questions.
The nursing report following this conference sixty minutes later revealed a marked shift in the nurses" attitudes. They discussed h o w to allot their time so that they could carry out some of the approaches that had beefl suggested during the treatment review. They closed ranks to carry out a cooperative.effort to ¢~olve a problem rather than to bemoan their fate at having to care for an obnoxious patient. The problem of the isolated night shift was handled in two ways, once the problem was recognized t h r o u g h the study of the tape-recorded reports. A special effort was made to include at least one member of this shift at the colfferences with the referring psychiatrists. Also, the unit director deliberately inter~,ened into the message cycle by appeari0g on the ward either at the beginning or at the end of the Shift. At this time, he listened to the reports and counselled staff members when particular problems with patients arose. In this fashion, the night shift was finally incorporated into a well integrated therapeutic program. In rare instances, a dramatic change of events can alter the seemingly inexorable course of deterioration in these crises "~sdthout the benefit of the direct interventions. E v e r y psychiatric facility has in its records accounts of episodes where, quite suddenly, the Gordian Knot of a particular impasse was cut through b y some untoward event. The therapeutic power of these episodes can be tremendous, as the following ease illustrates: Mr. ~¢V. S., a 38-year-old man diagnosed as paranoid-schizophrenic, was causing more problems on the w a r d than a n y other p a t i e n t u p to his time. H e w a s negativistic t o w a r d the nursing staff and, on occasion, violent, t i e had even assaulted his o~na psychiatrist. T h e mlrsing staff ,,'.'as afraid of him, a n d ' h e was d e a r l y quite angry with them. D u r i n g an evening shift, while one o f the nurses was out to dinner and only one regular ps3,ehiatrie nurse w~e; in attendance, Miss L. B., another very distalrbed patient, pried open a w i n d o w and m a d e her w a y out onto a w i n d o w ledge five stories a b o v e the
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street. The nurse in charge was thrown somewhat into a panic, but Mr. ~V. S. reached out over the sill, held on to Miss L. B. on the ledge, and talked her back in through the window. ,Xlr, \V. S. immediately became the hero of the ward and the nursing staff began to tuke a different view of him. From this time on, he made startling proK~ress toward recovery. D~scuss~ox T w o d i l f e r e n t c o m n m n i c a t i o n m o d e l s exist oll the small p s y c h i a t r i c unit. O n e , p y r a m i d a l in f o r m , d e p i c t s t h e line c o m m u n i c a t i o n p a t t e r n b e t w e e n the d i r e c t o r of the u n i t a n d his statf; t h e other, c i r c u l a r in f o r m , results f r o m t h e i n t e r s t a f f r e p o r t i n g b e t w e e n shifts. This l a t t e r m o d e l c a n f u n c t i o n so a u t o n o m o u s l y t h a t a r u m o r a n u r s e on the d a y shift m i g h t t r a n s m i t to the evening shift c a n b e r e t u r n e d to h e r as fact w h e n she c o m e s to w o r k o n t h e following day. T h e s e d i s t o r t i o n s c a n u l t i m a t e l y affect the nurses" r e l a t i o n s h i p s w i t h p a t i e n t s a n d o t h e r staff m e m b e r s , r e s u l t i n g in serious d i s r u p t i o n s of the t h e r a p e u t i c p r o g r a m s of the unit. W h e n t h e object of discussion is a difficult p a t i e n t , t h e effect c a n 1)e especially serious. T h e n u r s e s b e c o m e f r u s t r a t e d b e c a u s e t h e y a r e u n a b l e to h e l p the p a t i e n t ; t h e y t h e n b e c o m e g u i l t y b e c a u s e of their a n g e r a t h i m a n d his p s y c h i a t r i s t ; a n d , finally, t h e y m o b i l i z e a d e f e n s iveness w h i c h as " reltected in t h e i r t r a n s m i t t i n g f u r t h e r distortions into t h e w a r d ' s m e s s a g e cycles. Unless the crisis is relieved b y d i r e c t i n t e r v e n t i o n s ( o r b y the o f f e n d i n g p a t i e n t ' s i m p r o v e m e n t or t r a n s f e r ) , t h e s e n e g a t i v e p e r c e p tions c a n b e c o m e p r o g r e s s i v e l y intensified as t h e y are t r a n s m i t t e d t h r o u g h e a c h successive c y c l e of n u r s i n g r e p o r t s . T h e small p s y c h i a t r i c u n i t is p a r t i c u l a r l y v u l n e r a b l e to this k i n d of d i s t o r t i n g of c o m m u n i c a t i o n . It is g e n e r a l l y a d m i n i s t e r e d b y a p a r t - t i m e s u p e r v i s o r w h o is i n e x p e r i e n c e d . F r e q u e n t l y , h e is a r e s i d e n t or in his first p o s t - r e s i d e n c y position. P a t i e n t s on the unit a r e u n d e r t h e c a r e of p r i v a t e p s y c h i a t r i s t s w h o a r e senior to t h e w a r d supervisor. N u r s i n g s u p e r v i s o r s a r e . u n t r a i n e d in p s y c h i a t D, a n d o v e r s e e m e d i c a l a n d surgical w a r d s as well as the p s y c h i a t r k unit. T h e h e a d nurse, thus, h a s no p s y c h i a t r i c n u r s i n g s u p p o r t o u t s i d e of the unit. F i n a l l y , the a d m i n i s t r a t i v e s t r u c t u r e e n c o u r a g e s the division of t h e nursi n g staff into t h r e e d i s c r e t e units w h o i d e n t i f y themselves b y shift. A c c o r d i n g l y , t h e unit's n u r s i n g staff s h o u l d b e seen, n o t as a single b o d y , b u t as t h r e e s e p a r a t e g r o u p s of n u r s i n g p e r s o n n e l , e a c h w i t h its special p r o b l e m s . E a c h shift s h o u l d b e k e p t i n f o r m e d of the r e f e r r i n g p s y c h i a t r i s t ' s t h e r a p e u t i c goals a n d r e g u l a r l y c o u n s e l l e d b y t h e w a r d a d m i n i s t r a t o r as p r o b l e m s of patient m a n a g e m e n t arise. W h e n e v e r a n y shift c o m e s to feel itself isolated. t h e m a n a g e m e n t ,)f p a t i e n t s suffers. B e c a u s e the u l t i m a t e a u t h o r i t y a n d r e s p o n s i b i l i t y for t h e p a t i e n t ' s c a r e on t h e unit rests w i t h his p r i v a t e psychiatrist, it is he w h o m u s t take the r e s p o n s i b i l i t y for m a k i n g d i r e c t c o n t a c t w i t h e a c h of the shifts, a n d h e m u s t also b e e s p e c i a l l y a l e r t to the d e v e l o p m e n t of crises in relation to his p a t i e n t . T h e m o s t effective m e a n s of d e a l i n g w i t h s u c h a crisis, o n c e it develops, is not to a p p r o a c h t h e n u r s e s as p s y c h i a t r i c "'patients," a t t e m p t i n g to h e l p t h e m w o r k t h r o u g h t h e i r o w n i n t c r p s y c h i c a n d interp e r s o n a l p r o M e m s , b u t r a t h e r to s h a r e w i t h all staff m e m b e r s w h a t the p s y c h i a t r i s t k n o w s a n d thinks a b o u t his p a t i e n t , w l m t his t h e r a p e u t i c goals are
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in this case, and w h a t he w o u l d suggest as the most beneficial care. If such direct communication is not built into the unit's s t a n d a r d otSerating procedures, p.'ltic,nts suffer b y having t o exist in four different t r e a t m e n t worlds: withha three separate nursing shifts as well as within the f r a m e w o r k of the treatanent provided b y their psychiatrists. SU~I2~IAtlY
Psychiatric institutions are social units and, as such, are subject to all of the interpersonal disturbances o f other social systems. W h a t e v e r i m m u n i t y to conflict ,and m i s u n d e r s t a n d i n g m i g h t b e conferred by psychological sophistication is eroded by the uncertahaty a n d anxiety resulting from work with psychiatric patients. Administrators of larger institutions have established safeguards w h i c h tend to p r e v e n t the b u i l d - u p of tension. "Well-trained, experienced supervisors participate in all aspects of the larger hospital's operations. The), sense the beginnings of dif[iculty a m o n g staft m e m b e r s or b e t w e e n staff a n d patients. T h e y act to abort the d e v e l o p m e n t of serious problems. T h e small private psychiatric unit has neither the medical nor the nursing supervisory staff to fulfill this function. W h e n explosions do occur on a small unit, t h e y are less spectacular because fewer patients a n d nurses are involvect. F o r this vei-y reason, less attention is p a i d to t h e m a n d they can easily result in the d e v e l o p m e n t of an anti-therapeutic attitude and low staff morale. In this report, one area of nursing communications, n a m e l y the report to the succeeding shift, was shox~Tn to be one in w h i c h u n f a v o r a b l e attitudes are likely to be t r a n s m i t t e d a n d prejudices created. A circular communications p a t t e r n enhances the d a n g e r of intensification of these attitudes. It is i n c u m b e n t on the private psychiatrist w h o has patients in the small private psychiatric unit to consider the relationship of each shift of nurses to himself a n d to his patient. F u r t h e r , he m u s t give the m e m b e r s of each shift of nurses the o p p o r t u n i t y to inform him of their special problems in dealing with his patients and, in turn, to tell them of his oxwn problems in treating his patients and of his t h e r a p e u t i c p r o g r a m and its rationale. REFERENCES 1. Stanton, A. H., a n d Sehwart.z, M. S.: 5. Hoch, P. H., a n d Z u b i n , J.: PsychoT h e M e n t a l Itospital: A Shady of Institalp a t h o l o g y of C o m m u n i c a t i o n . N e w York, tion,-d Participation in P ~ ' e h i a t r i e IHness a n d (:tame & Stratton, 1958. T r e a t m e n t . N e w York, Basic Books~ 1954. 6. ~Vatzlawick, P., Bea,dn, J. H., a n d Jack2. Strauss, A., Sehatzman, L., Bueher, R. son, D. D.: Pragnmtics of H u m a n C o m m u n Ehrlieh, D . , a n d Sabshin, M.: Psyehiatrle ication: A S t u d y of Interactional Patterns, Ideologies a n d Institutions. N e w York, T h e Pathologies, a n d Paradoxes. N e w York, NorFree Press of Glencoe, 1964. ton a n d C o m p a n y , 1967. 3. Szurek, S. A.: D waamies of staff inter7. Schwartz, S.: Social research i n the action in hospital psychiatric t r e a t m e n t of mental hospital. I n Rose, A. M. (Ed.): Mental Health anti M e n t a l Disorder: A Sociochildren. Amer. J. Orthopsychiat. 17:652-f~B4, 1947. logical A p p r o a c h . N e w York, N o r t o n a n d C o m p a n y , 1955, pp, 190--202. 4. Ruesch, J.: Disturbt, d C o m m u n i c a tion: "]['he Clinical Assessment of N o r m a l 8. Croog, It.: Interpersonal relations in medical settings. In F r e e m a n , If, E., Levine, a n d Pathological Commu]ficative Behavior. N e w York, N o r t o n anti C o m p a n y , 1957. S., a n d Reeder, L. G. (Eds.): H a n d b o o k of
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Medical Sociology. Englewood Cliffs, N. J., Prentice-Hall, 1963, pp. 2A1-271. 9. Christman, L. ~P.: Nurse-physician communications in tl~c)hospital. J.A.M.A. 194:539-544, 1965. 10. Quint, J. C.: Communications problems affecting patient care in hospitals. J.A.M,A. 195;36--37, 1966. 11. Kahn, R: L., V~rolfe, D. M., Quinn, R. P. Shock, J. D., and RosenthM, R. A.:
535 Organizational Stress: Studies in Role Conflict and Ambiguity. Nexv York, John Wiley and Soils, 1964. 12. CaudiU, W.: The Psychiatric Iiospital ~ts a Small Society. Cambridge, Mass., Harvard University Press, 1958. I3. Tudor, G. E.: A sociopsychiatric nursing approach to intervention in a problena of mutual withdrawal on a mental hospital ward. Psychiatry 15:193-217, 1952.
and Behavior on a Small Psychiatric Unit
By CARllOLL ~/I. BRODSKY THE PROCESSING OF I N F O R M A T I O N is OVte of the major tasks required of all human beings, but in modem, densel) populated societies, it b e comes everybody's principal, business. Furthermore, within a proliferating technology such as ours, incredibly complex circuits o f communication are necessary to sustain the precision and efficiency r e q u i r e d by t h e technology. Breakdowns or distortions of communication, even very minor ones, can have far-reaching, disastrous effects. Consequently, modern research in communication faihtres manifests a strong sense .of urgency today. Since studying t h e larger systems is often prohibitive, much of this research has to be ]imited to smaller groups, where it iS lloped findings will illuminate defects or impedances w h i c h can cause breakdox~aaS in all communication systems. The present study analyzes the patterns of communication that developed on the ward of a small, l l - b e d psychiatric unit in a university general llospital, and attempts to show how distortions, rumors, and other misconceptions can enter certain message cycles and, in turn, disrupt the functions of an entire work group. Although small, this refit revealed all the vulnerability to breakdown found in larger social systems: individuals disagreed, role boundaries were breeched, and organizational rules were broken. At times, staff members seemed more bent on creating a psychotogenic tlmn a therapeutic environment." The same problems have plagued the larger psychiatric institutions and, as revealed by several important studies, failures in communication there have been shown to be the immediate cause. Stanton and Schwartz observed how distortions of communication in a private, well established mental hospital prolonged patients" illnesses, ~ Sta'auss et al. speak of' the communicative gap between nurses and resident psychiatrists in a university psychiatric hospital ,and of the despa:ir and lowered morale resulting from dais.-" I n comparison, Szurek noted the improvement of patients in a dafld-psychiatr)' t r e a t m e n t Unit when communication channels were opened to the entire staff, z. Indeed, w e a r e more and more coming t o see that failures in communication are extremely important ha the pathogenesis of mental disorders themselves. 4"6 RuesOa writesFrom ,the-evidence we have today we must assume.that ~successfad participation i n networks of communication whida involve other human b¢iffgs is necessary ff t h e indix~idual is to survive. Subjectively, t h e individual experiences failure in communication as frnstrating. If frustration is very intense, of long duration, or repeated, the individnal's thinkhag, feeling and reacting become progressively more disorgmaized m i d inappropriate. In turn, such behavior is regarded by others as abnormal. ~ CAnRO~Z, M, B~o~sg~', PH.D., M.D.: Associate Clinical Projessor of Psgmh/atry, Langley Porler Neuropsychiatric Institute and the Department of Psychiatry, Uni~ersiQl OJ Cali/onlia School of Medicine, Smz Francisco, Calif. Director, Adult Psychiatry Clinic, Universlty of California Medical Get,let, San Francisco, Calif. COMVm:~IE.X'SIVE PSVCmATnV, VoL. 9, No. 5, (September), 1988
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I n all f o r m a l o r g a n i z a t i o n s , work roles are p r i m a r i l y d e f i n e d b y t h e i r f u n c tions in the eoln+~qaanication n e t w o r k of the e n t i r e grctup. T h e s e functions, u s u a l l y expressct~ as d o u b l e - h e a d e d arrox.:s b e t w e e n the circles of the organization's c h a r t s a n d soeiograms, are u s u a l l y c o n c e i v e d as s i m p l e , b i l a t e r a l e x c h a n g e s b e t w e e n two i n d i v i d u a l s or units i n t h e social system, but, often, little a c c o u n t is t a k e n o f ' t h e m u l t i t u d e of i n t e r f e r e n c e s that o f t e n i m p a i r effective c o m m u n i c a t i o n . In p s y c h i a t r i c facilities w h e r e these are not h e e d e d , results can b e tragic, Sclawartz r notes: [Tlhe formal organization of the system of commtufication and the informal means for trat~smitting and receiving information play an important role in the patient's therapeutic progress. Defect,g in communicative organization, breakdowns, blocks, distortions, omissions in the transmission of information, the pa.ssing on of inadequate data--all may contribute to misunderstandings between and among hospital parHcipants. These misunder~andings tend to perpetuate the patient's mental illness (p. 193). Nlanv factors coalesce to p r o d u c e these r u p t u r e s a n d distortions of comm u n i c a t i o n - - s o m e p e r s o n a l ( n o t p r i m a r i l y our c o n c e r n h e r e ) a n d s o m e systemic, i.e., a r i s i n g out of defects w i t h i n t h e circuits of t h e i n s t i t u t e d systems. T h e p e r s o n a l factors i n c l u d e sensor), disabilities, p e r c e p t u a l rigidity, d i s t r a c t i v e moods, or i n t e l l e c t u a l i n a d e q u a c y . T h e s y s t e m i c factors w i t h i n h o s p i t a l settings in p a r t i c u l a r , i n c l u d e the hierarcqaieal social s t r u c t u r e of h o s p i t a l staffs, status b a r r i e r s b e t w e e n o c c u p a t i o n a l groups, p r o f e s s i o n a l codes of r e s t r a i n t a n d "objectivity," p o o r j o b satisfaction, a n d t h e like. s-~° P e r h a p s a n e v e n m o r e imp o r t a n t distortion arises w h e n w o r k roles a n d v a l u e s are a m b i g u o u s l y def i n e d a a - - t h e p r i n c i p a l c o n c e r n of this p a p e r . M a n y of t h e s e i m p e d a n c e s listed i n s t i g a t e d the conflicts a n d inefficiencies o b s e r v e d on the u n i t u n d e r study, a n d it is the a i m of this p a p e r to d e s c r i b e w h a t these i m p e d a n c e s w e r e a n d h o w t h e y w e r e r e s o l v e d w i t h i n the limits of the special c i r c u m s t a n c e s existing for s u c h a group. P a t t e r n s a n d P r o b l e m s in C o m m t t n i c a t i o n on t h e U n i t
T h i s s t u d y was u n d e r t a k e n at a t i m e w h e n there w a s c o n s i d e r a b l e intrastaff conflict over the m , ' m a g e m e n t of c e r t a i n p a t i e n t s w h o w e r e d i s t u r b e d , b u t ~not a n y m o r e so t h a n o t h e r p a t i e n t s w h o h a d b e e n m a n a g e d w i t h o u t difficultT. By the t i m e the staff's p r o b l e m s c a m e to t h e a t t e n t i o n of the superv i s i n g p s y c h i a t r i s t , h o w e v e r , t h e d e v e l o p m e n t of the p r o b l e m s w a s o b s c u r e d b y t h e tension s u r r o u n d i n g t h e m . I n r e s p o n d i n g to i n q u i r y , the staff b l a m e d p a t i e n t s a n d t h e i r p r i v a t e p s y c h i a t r i s t s , a n d o c c a s i o n a l l y e a c h other. I n a n effort to u n d e r s t a n d h o w these p r o b l e m s h a d d e v e l o p e d a n d to d i s c o v e r t h e m e a n s of r e s o l v i n g t h e m , it w a s d e c i d e d to m a k e t a p e r e c o r d i n g s of n u r s i n g reports g i v e n d u r i n g t h e c h a n g e of shifts, for it w a s e v i d e n t t h a t r u m o r s a n d misc o n c e p t i o n s w e r e b e i n g g e n e r a t e d ~ ' i t h i n t h e c o m m t m i c a t i o n cycles that h a d e v o l v e d on the unit. D a i l y , for f o u r weeks, as e a c h q u i t t i n g s h i f t r e p o r t e d to the o n c o m i o g s~hift, t h e y d i d so in the p r e s e n c e of an o p e r a t i n g t a p e recorder. T h e r e c o r d i n g s g l e a n e d f r o m t h e first w e e k of r e p o r t i n g w e r e often i n a u d i b h - a n d those .that cxmld b e h e a r d w e r e m a r k e d b y stilted l a n g u a g e or IH.r~,ous l a u g h t e r , r e l l e c t i n g the nurses' self-conscious a w a r e n e s s of the re-
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cording apparatus. However, by the end of the first week, they became quite accustomed to the recording equipment, and the reports of the succeeding 21 days were more spontaneous and of adequate clarity for analysis: At the same time, a record was kept of events on the w a r d as they were observed directly or as they were reported by the patients, file private psychiatrists, the residents, or the nursing staff. Special note was taken of requests for seclusion of patients or inquiries about prescribing tranquilizers or increasing the already-prescribed dose. All complaints of staff members and patients were carefully noted.
The Unit and Its Staff The small private psychiatric unit attached to a general hospital is becoming more common throughout the counta), in response to the trend in modern psychiatry to treat patients near their homes in the community. T h e unit offers definite advantages to private practitioners in that referrals can be conveniently admitted into the general hospital and the continuity of the psychiatrist's treatment preserved. As such, the unit is well suited to meeting momentary crises in private-patient care. Usually these units have a director who is himself a practicing psychiatrist but whose responsibilities are primarily administrative. Also, there is customarily only one head nurse on these units, and she works on the d a y shift. Often she is the only person on the unit with graduate training and experience in psychiatric nursing. H e r immediate supervisors, as well as those for all three shifts, are usually medical-surgical nurses who are responsible for a n u m b e r of wards, of which the psychiatric unit is only one. The remainder of the staff is composed of nurses who have some interest in psychiatric nursing b u t little formal training or ewperienee. The supervisory staff makes sere that hospital rules are maintained and that general nursing procedures are up to standard, but they are of little help in dealing with the psychiatric problems which arise within the unit itself. The burden of maintaining: a d e q u a t e nursing care during the 24 hours of the day rests almost entirely with the h e a d nurse ,and the chief of service. It should also be noted here that the atmosphere of informality mad closeness prevailing on such a small unit tends to diminish somewhat the authority inherent in the head nurse's role. The Unit's Program In the traditional psychiatric institution, patient care is vested in a permanent medical staff with each psychiatrist responsible for the ten or twelve patients assigned to him. Because the small psychiatric unit is primarily a private referral service, there can be as many psychiatrists involved with the unit as there are beds. Designing a single therapeutic program is, thus, quite diflleult. Each psychiatrist has his own treatment approach, his own reasons for referring his patient to the unit, and his own perceptions of the hospital's role in his therapy for the patient. Specifically, one psychiatrist might perceive die lmit where his patient can be temporarily protected from sensory bombard-
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ment, while another might perceive it as a place for socialization and stimulation by an i1~erea.s'e of sensory input. In contrast with the older institution where h u n d r e d s of patients are cared for in a large cultural complex, the unit, o p e r a t i n g primarily as a custodial facility, has little o p p o r t u n i t y to develop s t a n d a r d operating procedures. The larger institutions have evolved philosoplfies of p a t i e n t care a n d t h e r a p e u t i c t e c h n i q u e out of it tong history of meeting and resolving crises. In addition, nurses a~ad supervisorg there have b e c o m e highly skilled in spotting problerns early and resolving them t h r o u g h a u t h o r i t y a n d experience. Although this kind of p r o g r a m m i g h t tend to i n , ibit innovations, it has the virtues of efficieuev a n d effectiveness.
Bole Insecurity T h e psychiatric nurse on the small unit does not work widfin such a wells t r u c t u r e d set o f expectations and duties. T h e ambiguities of h e r role cause her to question her t r e a t m e n t a p p r o a c h and to vacillate in the t h e r a p e u t i c values she intends to uphold. A resultant anxiety can easily be projected onto patients, who, ~ in tur~a, b e c o m e tense, precipitating m a n a g e m e n t crises between nurses and director a n d his private-practice colleague. U n s h a k e a b l e "positions" are assumed and u n b r e a k a b l e stalemates ensue. Such struggles arc readily rellected in the communications the nurses exchange a m o n g themselves.
Types of Nursing Colnlnunieation.s F o r m a ! communications b e t w e e n nurses are both w r i t t e n and oral, while informal c o m m u n i c a t i o n s are entirely oral. E v e n with a small staff of fourteen. one can i m m e d i a t e l y see that s t u d y i n g the entire eommunicatiort network. including social exchanges b e t w e e n staff m e m b e r s , would be impossible. One message cycle, however, built into the routine of the unit's w o r k - d a y is a m e n a b l e 1o analysis: the nursing reports t r a n s m i t t e d b e t w e e n shifts. These reports, mostly oral, can be easily s t r u c t u r e d for adequate, d a t a - g a t h e r i n g purposes and analysis. As is c u s t o m a r y on all hospital units, the shift completing its work reports to the shift arriving. T h r e e shifts, d a y (7:30-4:00), evening (3:30--12:00). and night (11:45--7:45), exchange information on n e w and old patients, t r e a t m e n t changes, and n e w information or orders from the referring psych/atrists. T h e informal n a t u r e of these communications also permits the relating of interpersonal experienees with patients. On the present unit, n e i t h e r nursing supervisors nor psyehiatrists w e r e present at these e x d m n g e s d u r i n g the study period. F o r these four weeks of stud)', few personnel changes occurred and shifts r e m a i n e d stable, except for days o i l T h e head nurse worked during the d a y shift b u t r e m a i n e d nominally in charge for file evening a n d n i g h t shifts. One psychiatric technician, usually a male college student: was on d u t y during each shift.
SSIALL
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,,D~aly,s'is el the Taped Bel)orts In general, three types of c o m m u n i q u 6 forms a p p e a r e d in the taped reports: (1) narrative, (:29) therapeutic, a n d ( 3 ) g o s s i p y . Tile narrative c o n l m u n i e a t i o n was objective and used p r i m a r i l y for routine matters. T h e therapeutic reports were concerned with the m a n a g e m e n t of p a r t i c u l a r p a t i e n t s ~ a n d partidularly the t r o u b l e s o m e ones. In these statements, there was a f r e q u e n t complim e n t i n g o f ' e a c h other a n d eonsensual griping; p r a i s e was m e t e d out to staff m e m b e r s who h a d h a n d l e d a difficult situation b e y o n d the call of duty, o r c o m p l a i n t s w e r e raised, u s u a l l y a g a i n s t specific patients or genei'alized circumstances p r e v a i l i n g on the ward. T h e gossipy report wa s m a r k e d b y i n f o r m a l candor, laughter, a n d drama, either a m u s i n g or shocking. Caudill, analyzirJg similar inter-staff c o m m u n i c a t i o n patterns, ma ke s a just disthaction b e t w e e n eogna~ve a n d affect:ve messages. ~z At times, one or the other type of message is r e p r e s s e d or favored, i n d i c a t i n g some interference in the fuIl transmission of information, as in the pr e se nt s t u d y w h e n a nurse felt t h a t h e r attitude or b e h a v i o r towa r d a certain p a t i e n t h a d not m e t w i t h the approwtl of the other nurses. To: protect herself, she suppr e sse d all affect, w i t h d r e w into p u r e l y narrative reporting, a nd r e f u s e d to "'discuss the m a t t e r further." In times of crisis, the reverse could be observed: the p r i m a c y of affect over cognitive communications.
Setting the Expectations of the Next Shift T h e p r i n cipal goal of the present research was to spot a n d trace the course of i n d i v i d u a l perceptions which, once entering a c o m m u n i c a t i o n cycle, e,-m b e c o m e p e rpetuated, affecting all the perceptions of the i n t e r e h a n g e r s a l o n g the circuit. Easiest to p i n p o i n t were i n f o r m a l l y expressed attitudes toward certain patients which, once easamlly d r o p p e d into the me ssa ge cycle, colored the perceptions of the other two shifts. Statements a b o u t a n y patient, suc h as, "'I feel very u n e a s y in the s a m e room with him; .... I'm c e r t a i n l y glad I'm off tomorrow, I don' t think I could take h i m a nothe r day; .... I h o p e they increase his drugs soon" i m m e d i a t e l y suggest experience vdth an u n m m a a g e a b l e p a t i e n t w h i c h odaers will b e b o u n d to have. Put on edge b y suc h "hints," e a c h shift "mcorporate~ the projected anxiety a n d then proceeds to p e r p e t u a t e it in its report to the next shift. By the time of hall circle, one e,-m observe the same report b e i n g transmitted to its originator, d o u b l y confirming its validity for her, x,Vith the u n f a v o r a b l e perception n o w "'ringing him'7*about, so to speak,-the p a t i e n t picks u p the "'bad" cues a n d amplifies the m x(,ith m o r e of the s a m e behavior that h a d instigated t h e m in the first place. ~Arith certMn cases of d i s t u r b e d behavior, this vicious circle can b e e o m e so a g g r a v a t e d that comm u n i c a t i o n on the unit breaks d o w n entirely. T h e resulting stalemate isolates all those w ho transmit or receive information a long the circuit. E a c h staff mena~ier, now m o r e concerned with his i n d i v i d u a l integrity, withdravts from his responsibilities to clearly transmit all information he h a d g l e m m d from others a n d observed for himself. T h e recalcitrant p a t i e n t is "locked into" a socially-shared perception w h i c h n e i t h e r he nor his psychiatrist can alter. ~'~ Even w h e n the b e h a v i o r a l difficulties instigating the me ssa ge cycle h a d cleared
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and the "bad" patient was discharged in an improved condition, the members of the message %vele still remained angry and unrec°ncilecl- E(,en, as in certain cases, where a post-discharge discussion of these patients was possible , the issues could not be resolved beyond a lingering guilt and dissatisfaction.
Reports and Differences in Nursing Shifts Ideal nursing procedure would dictate that the head nurse assume full responsibility for these breakdox~ms in w a r d communication between nursing shifts, but, in the present instance, she was excluded from the conflict either as participant or arbiter. The smallness o f the unit created a role ambiguity which the head nurse could not properly-resolve. Although her admh~istrative authori W was acknowledged, other nurses considered her a peer in experiene.e in psychiatric nursing. In practice, her suggestions were often either ignored or rejected. The tapes show a repeated phenomenon. Since the head n u r s e did not preside at the exchange bet~veen afternoon and night shifts (occurring usually at 1t:45 p.m.), these p a r t i c i p a n t s w e r e prone to transmit the affective, gossipy, and rumor-ridden reports over the objective or narrative-type messages which had been fed earlier into the cycle. Between these two shifts, there was a good deal of "'mutual consoling," a sharing of mutually-experielmed isolation and anxiety, and an intereh~mge of m u t u a l support. No one present was criticized, implicitly or explicitly. In fact, the night shift showed the least disagreement among themselves in their reporting. However, the head nurse and he r policies were discussed often, subtly or directly, more at this reporting time than at any other. D u r i n g this nightly encounter, w a r d conflicts were polarized. The interchange was particularly informal, mustering a different set of loyalties than w h a t was evident in the other two reporting-points. W h a t e v e r affect had entered the message cycle was intensified here. Since patients were supposed to be merely "maintained" at night, the night shift did not consider themselves playing a particularly important role in therapeutic program s set up for indi,~5dual patients. The shift was generally Uninterested in patient histories or clinical assessments of progress. Accordingly, a patient who presented night problems~insisting, for example, on sitting up in the dayroom in full v i e w of the nurses instead of retiring t o his own room, was considered a "%peeial problem.'" Disruptive night behavior, even when quiet ,and not disturbing to other patients, always seemed to elieit the d e m a n d that '-something be d o n e about this patient." Appeals would be expressed in the reports to p u t more controls on the p a t i e n t in his treatment. This low level of tolerance for aberrant behavior on the part of the night nursing staff was, at firs:t difl~eutt to lmderstand. Interviews with the nurses, however, showed that the), not only felt isolated and distant from the unit's therapeutic regimens but from the hospital's nighttime administration as well. Nurses at night werd reluct,'mt to call in the house physician because they felt very strong justifications would be necessary and that, if called, the house
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physician w o u l d be reluctant to intea~'ene in any crucial w a y in a psychiatric case. U n d e r the circumstances, they felt v e r y m u c h "on their own.'" Curiously, the n i g h t shift's subjective contributions to the unit's message cycle were short-circuited directly to the afternoon shift at the 1i:45 p.m. reporting. In r e p o r t i n g to the head nurse in the monaing, however, the shift would narrate the events of the previous night objectively. This seIa, ed to delay supervisor~; action which could have n i p p e d in the b u d the :;tatFs d~stress when the), discovered that they were faced with a full-fledged "'problem.'" Unable to relieve t h e tension, f_he h e a d nurse t u r n e d to the psychiatrist in charge of the ward. H o w e v e r , the hierarchical relationship she h a d with h i m forced her to translate the p r o b l e m a s due solely to the p a t i e n t a n d not to her nursing staff. It was the patient's behavior which was creating difficulties in m a n a g e m e n t and taking u p too m u c h nursing time. As the night shift had suggested, she would now agree t h a t some intervention was necessary: either m o r e drugs or a talk with the patient's psychiatrist. W h e n e v e r t h e unit h e a d w o u l d suggest that the root of the p r o b l e m p e r h a p s lay with the nursing staff, the h e a d nurse would usually t a k e the defensive, r e p e a t i n g all that t h e nurses h a d told her, even though she herself h a d d e b a t e d these matters with her staff.' It was not until the commuI,ieation p a t t e r n which h a d evolved on the unit was studied, as described ha d a i s p a p e r , that a constructive effort to ease intrastaff conflict was possible.
Resolution of Conflicts A preliminary effort to solve the problem b y instigating t r e a ~ n e n t - r e v i e w meetings at which ,all present could discuss the patients ,and make suggestions for their care was singularly uI~successful. Such conferences merely concluded with f u r t h e r d e m a n d s for more drugs or for the forceful intervention of the referring psychiatrist. At t h e s e meetings, the night shift was not present, and the day-evening nursing reports which followed the meetings were general])" gossipy b u t polite. T h e r e were, momentarily, a few m i n o r shifts in position, but, by the time of the next report ( b e t w e e n evening and n i g h t shifts), participants h a d r e t u r n e d to the positions held before t r e a t m e n t re,dew. Another tack was tried, finally with some success, b u t n o t before a few false starts were overcome. This a p p r o a c h involved a m e e t i n g of the psychiatrist in charge of the troublesome case with the nursing staff. These meetings, however, were not successful w h e n t h e psychiatrist a t t e m p t e d flaerapy with the nurses b y directly inquiring a b o u t their problems ~vith the patient mad b y interpreting their difficulties as resulting from either some personality deficit of t h e i r own or of the patient. T h e nurses l e f t such meetings m o r e frustrated than w h e n they entered, a n d ~patient care Was in no w a y enhanced. Nursing reports following such meetings often mentioned the p s y c h i a t r i s t in unfavorable terms, a n d "the o p i n i o n was frequently expressed that if a n o t h e r psychiatrist, in w h o m t i e staff .had confidence, were treating the patient, the patient would do better. T h e s e conferences were considerably improved when the private psychiatrist did not approach the difficulty as being the p r o b a b l e r e s u h of the nurses' lack
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of knowledge or technique. Instead, rather titan asking any direct questions about his patient's behavior, he presented a ease histoD- of flae patient nmch as he would to a group of his own colleagues. A specific example illustrates the procedure: Dr. XV. ol)lained hospital admission for N'Ir. E. R., a 32-year-old schizophrenic who, during his first 24 htmrs on the ward, set nursing staff and patients into a turmoil. Dr. ~V. p r e s c r i b e d no drugs except a mild sedative, w h i c h h a d b e e n definitely i n a d e q u a t e to control Mr. E. li.'s behavior. Fortunately, at the time of adrnission, Dr. ~V. had expressed his intention to confer with the nursing staff on the following day. W h e n he w a l k e d into the conference, Dr. ~V. m e t a vel~, angry stall. H o w e v e r , despite his awareness of his patient's tnmulhm~s behavior, he b e g a n relating his patient's backgn'ound, h o w h e had appeared at the first interview, and w h a t he, ,as the doctor, h a d learned of his patient's relatives. I t e then p r o c e e d e d to describe Mr. E. R . ' s history in the minute.~t details, delving into his patient's interpersonal problems, his p a t t e r n of handling communications, relationships, and stress, a n d his o w n interpretations of the genesis of Mr. E. It.'s presently a b e r r a n t behavior. H e then turned to his i m m e d i a t e goMs for his patient's hospitalization a n d described specifically w h a t he hoped the nursing staff, the o c c u p a tional therapist, and the unit director w o u l d do to benefit his p a t i e n t most. At the conclusion of the conference, he asked for questions and suggestions. T h e nurses proffered no suggestions b n t asked m a n y questions.
The nursing report following this conference sixty minutes later revealed a marked shift in the nurses" attitudes. They discussed h o w to allot their time so that they could carry out some of the approaches that had beefl suggested during the treatment review. They closed ranks to carry out a cooperative.effort to ¢~olve a problem rather than to bemoan their fate at having to care for an obnoxious patient. The problem of the isolated night shift was handled in two ways, once the problem was recognized t h r o u g h the study of the tape-recorded reports. A special effort was made to include at least one member of this shift at the colfferences with the referring psychiatrists. Also, the unit director deliberately inter~,ened into the message cycle by appeari0g on the ward either at the beginning or at the end of the Shift. At this time, he listened to the reports and counselled staff members when particular problems with patients arose. In this fashion, the night shift was finally incorporated into a well integrated therapeutic program. In rare instances, a dramatic change of events can alter the seemingly inexorable course of deterioration in these crises "~sdthout the benefit of the direct interventions. E v e r y psychiatric facility has in its records accounts of episodes where, quite suddenly, the Gordian Knot of a particular impasse was cut through b y some untoward event. The therapeutic power of these episodes can be tremendous, as the following ease illustrates: Mr. ~¢V. S., a 38-year-old man diagnosed as paranoid-schizophrenic, was causing more problems on the w a r d than a n y other p a t i e n t u p to his time. H e w a s negativistic t o w a r d the nursing staff and, on occasion, violent, t i e had even assaulted his o~na psychiatrist. T h e mlrsing staff ,,'.'as afraid of him, a n d ' h e was d e a r l y quite angry with them. D u r i n g an evening shift, while one o f the nurses was out to dinner and only one regular ps3,ehiatrie nurse w~e; in attendance, Miss L. B., another very distalrbed patient, pried open a w i n d o w and m a d e her w a y out onto a w i n d o w ledge five stories a b o v e the
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street. The nurse in charge was thrown somewhat into a panic, but Mr. ~V. S. reached out over the sill, held on to Miss L. B. on the ledge, and talked her back in through the window. ,Xlr, \V. S. immediately became the hero of the ward and the nursing staff began to tuke a different view of him. From this time on, he made startling proK~ress toward recovery. D~scuss~ox T w o d i l f e r e n t c o m n m n i c a t i o n m o d e l s exist oll the small p s y c h i a t r i c unit. O n e , p y r a m i d a l in f o r m , d e p i c t s t h e line c o m m u n i c a t i o n p a t t e r n b e t w e e n the d i r e c t o r of the u n i t a n d his statf; t h e other, c i r c u l a r in f o r m , results f r o m t h e i n t e r s t a f f r e p o r t i n g b e t w e e n shifts. This l a t t e r m o d e l c a n f u n c t i o n so a u t o n o m o u s l y t h a t a r u m o r a n u r s e on the d a y shift m i g h t t r a n s m i t to the evening shift c a n b e r e t u r n e d to h e r as fact w h e n she c o m e s to w o r k o n t h e following day. T h e s e d i s t o r t i o n s c a n u l t i m a t e l y affect the nurses" r e l a t i o n s h i p s w i t h p a t i e n t s a n d o t h e r staff m e m b e r s , r e s u l t i n g in serious d i s r u p t i o n s of the t h e r a p e u t i c p r o g r a m s of the unit. W h e n t h e object of discussion is a difficult p a t i e n t , t h e effect c a n 1)e especially serious. T h e n u r s e s b e c o m e f r u s t r a t e d b e c a u s e t h e y a r e u n a b l e to h e l p the p a t i e n t ; t h e y t h e n b e c o m e g u i l t y b e c a u s e of their a n g e r a t h i m a n d his p s y c h i a t r i s t ; a n d , finally, t h e y m o b i l i z e a d e f e n s iveness w h i c h as " reltected in t h e i r t r a n s m i t t i n g f u r t h e r distortions into t h e w a r d ' s m e s s a g e cycles. Unless the crisis is relieved b y d i r e c t i n t e r v e n t i o n s ( o r b y the o f f e n d i n g p a t i e n t ' s i m p r o v e m e n t or t r a n s f e r ) , t h e s e n e g a t i v e p e r c e p tions c a n b e c o m e p r o g r e s s i v e l y intensified as t h e y are t r a n s m i t t e d t h r o u g h e a c h successive c y c l e of n u r s i n g r e p o r t s . T h e small p s y c h i a t r i c u n i t is p a r t i c u l a r l y v u l n e r a b l e to this k i n d of d i s t o r t i n g of c o m m u n i c a t i o n . It is g e n e r a l l y a d m i n i s t e r e d b y a p a r t - t i m e s u p e r v i s o r w h o is i n e x p e r i e n c e d . F r e q u e n t l y , h e is a r e s i d e n t or in his first p o s t - r e s i d e n c y position. P a t i e n t s on the unit a r e u n d e r t h e c a r e of p r i v a t e p s y c h i a t r i s t s w h o a r e senior to t h e w a r d supervisor. N u r s i n g s u p e r v i s o r s a r e . u n t r a i n e d in p s y c h i a t D, a n d o v e r s e e m e d i c a l a n d surgical w a r d s as well as the p s y c h i a t r k unit. T h e h e a d nurse, thus, h a s no p s y c h i a t r i c n u r s i n g s u p p o r t o u t s i d e of the unit. F i n a l l y , the a d m i n i s t r a t i v e s t r u c t u r e e n c o u r a g e s the division of t h e nursi n g staff into t h r e e d i s c r e t e units w h o i d e n t i f y themselves b y shift. A c c o r d i n g l y , t h e unit's n u r s i n g staff s h o u l d b e seen, n o t as a single b o d y , b u t as t h r e e s e p a r a t e g r o u p s of n u r s i n g p e r s o n n e l , e a c h w i t h its special p r o b l e m s . E a c h shift s h o u l d b e k e p t i n f o r m e d of the r e f e r r i n g p s y c h i a t r i s t ' s t h e r a p e u t i c goals a n d r e g u l a r l y c o u n s e l l e d b y t h e w a r d a d m i n i s t r a t o r as p r o b l e m s of patient m a n a g e m e n t arise. W h e n e v e r a n y shift c o m e s to feel itself isolated. t h e m a n a g e m e n t ,)f p a t i e n t s suffers. B e c a u s e the u l t i m a t e a u t h o r i t y a n d r e s p o n s i b i l i t y for t h e p a t i e n t ' s c a r e on t h e unit rests w i t h his p r i v a t e psychiatrist, it is he w h o m u s t take the r e s p o n s i b i l i t y for m a k i n g d i r e c t c o n t a c t w i t h e a c h of the shifts, a n d h e m u s t also b e e s p e c i a l l y a l e r t to the d e v e l o p m e n t of crises in relation to his p a t i e n t . T h e m o s t effective m e a n s of d e a l i n g w i t h s u c h a crisis, o n c e it develops, is not to a p p r o a c h t h e n u r s e s as p s y c h i a t r i c "'patients," a t t e m p t i n g to h e l p t h e m w o r k t h r o u g h t h e i r o w n i n t c r p s y c h i c a n d interp e r s o n a l p r o M e m s , b u t r a t h e r to s h a r e w i t h all staff m e m b e r s w h a t the p s y c h i a t r i s t k n o w s a n d thinks a b o u t his p a t i e n t , w l m t his t h e r a p e u t i c goals are
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t~liOI)SKY
in this case, and w h a t he w o u l d suggest as the most beneficial care. If such direct communication is not built into the unit's s t a n d a r d otSerating procedures, p.'ltic,nts suffer b y having t o exist in four different t r e a t m e n t worlds: withha three separate nursing shifts as well as within the f r a m e w o r k of the treatanent provided b y their psychiatrists. SU~I2~IAtlY
Psychiatric institutions are social units and, as such, are subject to all of the interpersonal disturbances o f other social systems. W h a t e v e r i m m u n i t y to conflict ,and m i s u n d e r s t a n d i n g m i g h t b e conferred by psychological sophistication is eroded by the uncertahaty a n d anxiety resulting from work with psychiatric patients. Administrators of larger institutions have established safeguards w h i c h tend to p r e v e n t the b u i l d - u p of tension. "Well-trained, experienced supervisors participate in all aspects of the larger hospital's operations. The), sense the beginnings of dif[iculty a m o n g staft m e m b e r s or b e t w e e n staff a n d patients. T h e y act to abort the d e v e l o p m e n t of serious problems. T h e small private psychiatric unit has neither the medical nor the nursing supervisory staff to fulfill this function. W h e n explosions do occur on a small unit, t h e y are less spectacular because fewer patients a n d nurses are involvect. F o r this vei-y reason, less attention is p a i d to t h e m a n d they can easily result in the d e v e l o p m e n t of an anti-therapeutic attitude and low staff morale. In this report, one area of nursing communications, n a m e l y the report to the succeeding shift, was shox~Tn to be one in w h i c h u n f a v o r a b l e attitudes are likely to be t r a n s m i t t e d a n d prejudices created. A circular communications p a t t e r n enhances the d a n g e r of intensification of these attitudes. It is i n c u m b e n t on the private psychiatrist w h o has patients in the small private psychiatric unit to consider the relationship of each shift of nurses to himself a n d to his patient. F u r t h e r , he m u s t give the m e m b e r s of each shift of nurses the o p p o r t u n i t y to inform him of their special problems in dealing with his patients and, in turn, to tell them of his oxwn problems in treating his patients and of his t h e r a p e u t i c p r o g r a m and its rationale. REFERENCES 1. Stanton, A. H., a n d Sehwart.z, M. S.: 5. Hoch, P. H., a n d Z u b i n , J.: PsychoT h e M e n t a l Itospital: A Shady of Institalp a t h o l o g y of C o m m u n i c a t i o n . N e w York, tion,-d Participation in P ~ ' e h i a t r i e IHness a n d (:tame & Stratton, 1958. T r e a t m e n t . N e w York, Basic Books~ 1954. 6. ~Vatzlawick, P., Bea,dn, J. H., a n d Jack2. Strauss, A., Sehatzman, L., Bueher, R. son, D. D.: Pragnmtics of H u m a n C o m m u n Ehrlieh, D . , a n d Sabshin, M.: Psyehiatrle ication: A S t u d y of Interactional Patterns, Ideologies a n d Institutions. N e w York, T h e Pathologies, a n d Paradoxes. N e w York, NorFree Press of Glencoe, 1964. ton a n d C o m p a n y , 1967. 3. Szurek, S. A.: D waamies of staff inter7. Schwartz, S.: Social research i n the action in hospital psychiatric t r e a t m e n t of mental hospital. I n Rose, A. M. (Ed.): Mental Health anti M e n t a l Disorder: A Sociochildren. Amer. J. Orthopsychiat. 17:652-f~B4, 1947. logical A p p r o a c h . N e w York, N o r t o n a n d C o m p a n y , 1955, pp, 190--202. 4. Ruesch, J.: Disturbt, d C o m m u n i c a tion: "]['he Clinical Assessment of N o r m a l 8. Croog, It.: Interpersonal relations in medical settings. In F r e e m a n , If, E., Levine, a n d Pathological Commu]ficative Behavior. N e w York, N o r t o n anti C o m p a n y , 1957. S., a n d Reeder, L. G. (Eds.): H a n d b o o k of
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Medical Sociology. Englewood Cliffs, N. J., Prentice-Hall, 1963, pp. 2A1-271. 9. Christman, L. ~P.: Nurse-physician communications in tl~c)hospital. J.A.M.A. 194:539-544, 1965. 10. Quint, J. C.: Communications problems affecting patient care in hospitals. J.A.M,A. 195;36--37, 1966. 11. Kahn, R: L., V~rolfe, D. M., Quinn, R. P. Shock, J. D., and RosenthM, R. A.:
535 Organizational Stress: Studies in Role Conflict and Ambiguity. Nexv York, John Wiley and Soils, 1964. 12. CaudiU, W.: The Psychiatric Iiospital ~ts a Small Society. Cambridge, Mass., Harvard University Press, 1958. I3. Tudor, G. E.: A sociopsychiatric nursing approach to intervention in a problena of mutual withdrawal on a mental hospital ward. Psychiatry 15:193-217, 1952.