International Journal of the Addictions
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Ward Environment in an Inpatient Drug Dependence Treatment Unit. I. Activity Levels and Ward Atmosphere John Teasdale, Dip Psych, Sheila Greene, David Hemsley, Caryl Hitchcock, Heather Hunt & Phillip Connell To cite this article: John Teasdale, Dip Psych, Sheila Greene, David Hemsley, Caryl Hitchcock, Heather Hunt & Phillip Connell (1975) Ward Environment in an Inpatient Drug Dependence Treatment Unit. I. Activity Levels and Ward Atmosphere, International Journal of the Addictions, 10:3, 401-416, DOI: 10.3109/10826087509026724 To link to this article: http://dx.doi.org/10.3109/10826087509026724
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The International Journal of the Addictions, 10(3), 401-416, 1975
Ward Environment in an Inpatient Drug Dependence Treatment Unit. I. Activity Levels and Ward Atmosphere John Teasdale," M.A., Dip. Psych., Ph.D. Sheila Greene, B.A., M.Phil. David Hemsley, M.A., M.Phi1. Caryl Hitchcock, M.A., M.Phil. Heather Hunt, B.A., M.Phil. Phillip Connell, M.D., M.R.C.P., D.P.M., F.R.C. Psych. Drug Dependence Clinical Research and Treatment Unit Maudsley and Bethlem Royal Hospitals; Psychology Department Institute of Psychiatry University of London London, England
* Present address (to which requests for reprints should be sent): Dr. John Teasdale, University of Oxford Department of Psychiatry, The Warneford Hospital, Oxford OX3 7JX, England. 401 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
402
TEASDALE ET AL.
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INTRO D UCTION As part of the attempt to curb the spread of drug abuse in the United Kingdom, the second report of the Brain Committee, published in 1965, recommended the establishment of inpatient treatment and research units (Ministry of Health and Scottish Home and Health Department, 1965). A number of these have been set up, mainly in the London area, from 1968 onwards. In the memorandum issued by the National Health Service (1967) offering guidance on the management of such centers, it is suggested that “In order to meet the needs of young addicts, who are often of high intelligence, some intensification of the industrial or occupational therapy usually provided for adults will be necessary. It is important that young addicts should be fully occupied in a manner likely to extend their intellectual and creative abilities and to reinforce a generally weak sense of personal worth through opportunities for short-term achievement.” This suggestion stressed the importance of the ward milieu or environment as a therapeutic factor in the treatment of addicts, a suggestion endorsed by Rosenthal’s (1969) opinion that the therapeutic community was the treatment of choice in the vast majority of addicts. Taken with the frequently noted ineffectiveness of traditional individual therapy with this type of patient (e.g., Lowinson, 1971) these statements suggest that it might be profitable to investigate aspects of ward environment which might be considered therapeutic in an inpatient drug dependence treatment unit. This and a companion paper report the results of preliminary investigations of ward environment in the Drug Dependence Clinical Research and Treatment Unit, Bethlem Royal Hospital.
DESCRIPTION OF THE UNIT The establishment and running of this unit have previously been described (Connell, 1968, 1970). Briefly, it consists of two separate wards, an 1 1-bed unlocked ward for patients dependent on orally administered drugs, and a 10-bed locked ward for patients dependent on intravenously administered drugs, mainly heroin and other opiates. The latter has been the main object of the investigations reported here. Both wards were single-roomed, mixed sex, and staffed by nurses, occupational therapists, psychiatrists, a psychiatric social worker, and psychologists. To reduce contact between the intravenous drug users and other patients in the hospital, patients on the locked ward did not visit the Occupational Therapy Department of the hospital, but instead space and
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facilities were provided on the ward for a range of occupational therapy activities, including woodwork, metalwork, painting, typing, sewing, pottery, and table-tennis. It was intended that both wards should have a general “therapeutic community” orientation (Connell, 1968), but, with the exception of additional restrictions intended to reduce the risk of patients absconding, bringing in drugs, or having a harmful affect on other patients in the hospital, no specific regime of ward management different from that on other wards in the hospital was planned. It was hoped that methods of dealing with the management problems presented by addicts would be evolved over time. The nursing staff received no special training prior to the opening of the unit. In addition to “milieu therapy” received in the ward, patients in the closed ward received a number of specific therapies including individual interviews with psychiatrists and the social worker, behaviorally oriented therapy from the psychologists, opiate withdrawal via methadone over a period of 2 to 4 weeks, other medication where necessary, and (from February 1970) weekly group meetings. The investigations to be reported in this paper used two main measures of ward environment in the closed ward of the unit: activity levels and ward atmosphere.
ACTIVITY LEVELS It was thought that a useful, if somewhat crude, source of information as to what actually occurred on the ward would be a “time budget” derived from frequent, direct observation of each patient’s behavior.
METHOD The period in which observations were scheduled was 9.30A.M. to 5.00 P . M . on the first four days of each week of observation, and 9.30 A.M. to l.OOP.M. on the fifth day. This represented the period in which the largest number of medical, nursing, psychological, and occupational therapy staff were present in the unit. Observations were made at intervals varying randomly about a mean of 30 min. The observers were the staff psychologist working on the unit and the assistant psychologists working under his supervision. The technique of observation was as follows: The observer walked to the ward and through the lounge and dining area, noticing what each
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patient was doing at the time he was first seen. These observations were noted down, and the rest of the ward was covered until every patient had been observed or accounted for, if off the ward. The observers attempted to remain as inconspicuous as possible, and the strong impression obtained was that patients rapidly habituated to being observed in this way, and that the process of observation had very little effect on the behavior being observed. The method of observation employed is obviously somewhat imprecise. Measures of inter rater agreement were obtained between the staff psychologist and each assistant psychologist participating in the observation. In terms of agreement between two raters making observations at the same time, agreement in the behavior category to which a patient’s behavior was assigned was obtained for at least 85% of observations (minimum sample size, 36) on each occasion. This suggests that the method of measurement, while crude, could give replicable results.
RESULTS Observations were made over a total period of 11 weeks, from October 1969 to March 1971. The percentage of observations falling in each category of behavior for each period of observation is shown in Table 1. The behavior categories directly relevant to the National Health Service Memorandum’s suggestions that “some intensification of the industrial or occupational therapy usually provided for adults will be necessary. It is most important that young addicts should be fully occupied in a manner likely to extend their intellectual and creative abilities . . .” would be J and K. Together these account for between 6 and 11% of the total number of observations on each occasion. If we can directly transform this into the average time the average patient spent on such activities in the period 9.30 A.M. to 5.00 P.M. each day, we arrive at a figure of between 26 and 50min. Category B included some occasions when the patients were off the ward as a result of playing squash, swimming, etc. in another part of the hospital. These occasions were only noted separately from other occasions when patients were off the ward for the last period of observation, when they amounted to 2% of the total number of observations. If this level can be assumed to be that existing on the other occasions of observation, and if such activities are considered “occupational therapy,” then the average time spent on “constructive activities” in the period 9.30 A.M. to 5.00 P.M. is from 35 to 59 min. In contrast to this small amount of time spent on “constructive activities,” the total percentage of occurrence of apparently inactive and
z
P
a
Total
Sitting doing nothingllying down doing nothing Out of ward (patients off the ward for the whole day excluded) Asleep Talking with another patient or staff member Reading other than academic study Playing cards/chess/scrabble Walking from one part of the ward to another Eatingldrinking Seeing doctor/psychologist/PSW/having EEG Cooking and preparing meals/snacks “Constructive” activities other than J (washing up, cleaning, tidying, setting out meals, drawing, mending, making models, woodwork, studying, writing, pottery, table tennis, singing, playing ball, painting, knitting, sewing, etc.) Standing, doing nothing else Toilet/washing/personal care Watching TV Other
Due to rounding off of percentages.
N 0
M
L
H I J K
G
C D E F
A B
Behavior Category
2 100 __ 100
0 1
2 2
4
1
100
4
5
2 3
7
2 3 5 3
11
~
99”
0 0
2 4
3
9 1 5 3
10 11 10
7
15
1
4
6 4
10
10 10
8 20
11 25
18 12 8 8 7 3 4 5
14 14
12
8
14
14
26/1/10 to 30/1/10
Occurrence, %
5/1/10 to 9/1/10
24/11/69 to 12/12/69
20/10/69 to 14/11/69
Table 1 Time Budget for Closed Ward on Six Occasions
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10 32 14
9 34 6 7
101”
2 3
2 4 3 7 -
100
5
1
4
5
1
4 2 2 3
0 4 4 4 5
8
10
23/3/71 to 26/3/11
7
1/2/71 to 5/2/71
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inert behavior (A + C + L) varies from 28 to 44%. If these can be translated into the average time spent in this way by the average patient in the period 9.30 A.M. to 5.00 P.M. each day, a figure varying from 2 hr 6 min to 3 hr 18 min is obtained. The proportion of this time accounted for by the patients being asleep appears to increase from the earlier periods of observation to the later. By February and March 1971 approximately a third of all observations fell in Category C.
DISCUSSION The results obtained suggest that the ward environment could not be described as one in which the patients were “fully occupied in a manner likely to extend their intellectual and creative abilities and t o reinforce a generally weak sense of personal worth.” On the contrary, it appears that with the exception of the routine functions of life (eating, drinking, washing, etc.) and of seeing individual members of the professional team, the patients spent most of their time asleep, off the ward, talking, reading, playing games, or doing nothing in particular. From the data of the present study it is impossible to assess the therapeutic value of the talking that was observed. The impression obtained was that most of the reading material was either newspapers or comics. Playing games such as cards or Scrabble, while a feature of earlier periods of observation, appeared to have disappeared from the ward culture by the two latest periods of observation. The first period of observation occurred after the ward had been open for 16 months; the last after the ward had been open for 2 years 9 months. In terms of the behavior observations made, there seems to be no consistent trend for the behavior in the ward to become more constructive in the later periods of observation than in the earlier periods. If anything, judged by the percentage of observations on which patients were asleep, the ward appears to be deteriorating in this respect. Most of the observations in which patients were asleep were the result of their late hour of rising. It might be objected that the period of observation chosen (9.30 A.M. to 5.00 P.M.) gave an unduly poor picture of ward activity levels as a result of it not coinciding with the most active part of the patient’s night-day cycle, which had become out of phase with the normal cycle. To this objection we would make the following points: 1. The correction of sleep/waking cycles to the normal pattern has been suggested as an important component in the rehabilitation of drug addicts (Freedman, 1965), i.e., even if
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the patients were more active after the observation period was over, a legitimate therapeutic goal would be to have them wake earlier and be active in the “normal working day.” 2. Excluding the observations when the patients were asleep, the proportion of time spent on constructive activity is still low, i.e., once they have got out of bed they are still not very productively occupied. 3. Informal reports from nursing staff suggested that, while the ward was generally “livelier” in the evening than during the day, this increased liveliness did not result in much of what we have called “constructive activity.” 4. As pointed out above, the period of the day in which observations were made coincided with the presence on the ward of the largest number of staff; the number of staff on duty in the evenings and at night was small. If treatment can be seen as the modification of the patients’ behavior by the staff, then it would be most appropriate to look at patients’ behavior at the time when there are most staff around. Another variable possibly reducing the activity levels in the ward might be the effects of opiate withdrawal or of the methadone used in the withdrawal process. It seems unlikely that these factors were of much importance; for example, in the period 1/2/71 to 5/2/71, which was the period with the highest incidence of Category C observations, of the nine patients in the ward, five had completed their withdrawal regime at least 2 months previously, three had completed it from 10 days to 1 month previously, and one was undergoing withdrawal in the period of observation. The last patient did not show a greater than average percentage of inactive behavior (Categories A C L accounted for only 17% of her observed behavior) nor a lower than average percentage of constructive behavior (Categories J and K accounted for 16% of her observed behaviour). Thus it seems unlikely that the withdrawal regime was the direct cause of lowered activity levels although, of course, long-term residual withdrawal effects might have some influence on these.
+ +
WARD ATMOSPHERE Method
The instrument used to assess ward atmosphere was the Ward Atmosphere Scale (Moos and Houts, 1968; Moos 1969). This is a questionnaire
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in which patients and staff are asked t o endorse a number of statements relating to different aspects of ward environment as being true or false of the ward they are in. It was administered on six occasions, from December 1968-March 1969 to April 1971. On the first occasion of testing, the questionnaire was administered individually. For the other occasions, group testing was used with the experimenter reading out the questions and the subjects responding on a n answer blank. Subjects were required to put their names on the questionnaires. The criteria suggested by Moos (1969) for eliminating invalid records were employed, i.e., subjects with Halo scores of 0, 1, 9, or 10 and with Inconsistency scores of 6 or more were excluded from the analysis. On the first occasion of testing, both patients and staff also completed the Ward Atmosphere Scale to describe the ward “as you would like it to be.” The criteria for eliminating invalid records were not applied to this “ideal” description. The staff completing the questionnaire were nurses and the occupational therapist, when one was working in the ward. As a result of the repeated testing, some patients and staff completed the Ward Atmosphere Scale on more than one occasion. The total 27 staff descriptions included descriptions from nine staff who had completed the scale once, from four staff who had completed it twice, from two staff who had completed it three Tabie 2 Staff Perceptions of Ward Atmosphere on the Closed Occasion
N Spontaneity
December 1968March 1969 5 22/10/1969 4 6/11/69 3 12/12/69 5 JanuaryFebruary 1971 4 7/4/71 5 Ideal (December 1968March 1969) 5
Support Practicality Affiliation
Order Insight
36 21 36 15
18 12 23 49
7 5 28 25
6 21 59 49
1 1 3 3
11 2 9 2
22 14
30 56
41 54
29 17
6 3
30 45
98
94
96
96
69
98
,
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times, and from one staff member who had completed it four times. The total 33 patient descriptions included descriptions from 21 patients who completed the scale once, and from six who completed it twice.
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Results
The results for staff perceptions of ward atmosphere are shown in Table 2, and for patient perceptions in Table 3. Scores are expressed as percentiles (calculated via standard scores) relative to the data from a group of 32 wards, comprising the wards of the Bethlem Royal and Maudsley Hospitals, and a small number of wards from other hospitals in the area around London (these data were kindly provided by Dr. R. H. Moos). The Ward Atmosphere Scale gives scores for 12 aspects of ward environment and for two validity scales. Table 4 gives examples of the items contributing to each of the scales, and a summary of staff and patients scores on them on six occasions, with details of the results of statistical tests. Discussion
It is not simple to give an overall picture of such a large number of Ward, DDCRTU, on Six Occasions, Percentile Scores
Involvement
Aggression Variety
Clarity Submission Autonomy
I
Halo
Inconsistency
3 8 21 1
89 69 95 80
14 4 21 35
15 0 0 1
48 18 36
1 35 81 35
3 1 6 14
6 41 41 10
34 16
93 96
21 21
21 42
60 92
35 94
14 14
3 22
89
68
61
99
11
100
100
100
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Table 3 Patient Perceptions of Ward Atmosphere on the Closed
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Occasion
N Spontaneity
December 1968March 1969 10 22110169 6 6/11/69 5 12/12/69 3" JanuaryFebruary 7 1971 7/4/71 3" Ideal (December 1968March 10 1969)
Support
Practicality
Affiliation Order
Insight
48 5 1 0
7 38 5 22
8 0 0 20
17 66 54 54
8 2 3 2
53 1 2 0
63 53
49 1
10 12
63 7
1 0
36 53
100
93
87
99
10
100
Two patients omitted due to invalid records.
Table 4 Staff and Patient Perception of Ward ~
Score on occasions" Scale Spontaneity
Support
Practicality
Affiliation
Order
Example of a true item Patients say anything they want to the doctors Staff go out of their way to help patients Patients are encouraged to plan for the future Patients often do things together on the weekends Thisis a very well organized ward
Example of a false item
1 2 3 4 5 6
Patients tend to Staff hide their feel- Patient ings from one another Patients rarely Staff help each otherpatient There is very little emphasis on making patients more practical There is very little sharing among the patients Theday room is often messy
4 3 4 3 3 2 1 4 4
4 1 1
3 2 3 4 4 4 2 4 1 3 4 1
Staff 2 Patient 2
1 4 4 4 4 1 1 3 2 2
Staff 2 3 4 4 4 3 Patient 3 4 4 4 4 2
Staff 1 1 1 1 2 1 Patient 2 1 1 1 1 1
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Ward, DDCRTU, on Six Occasions, Percentile Scores
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Involvement
Aggression Variety Clarity Submission Autonomy
Halo
Inconsistency
30 3 4 1
81 31 68 54
12 12 7 99
8 3 0 4
6 19 21 21
37 2 2 1
13 11 8 21
20 4 55 57
39
I
98 100
91 18
9 12
46 12
13 0
7 1
6 81
96
91
15
96
3
100
19
21
Atmosphere on Six Occcasions
Significant differences between occasionsb (Occasions) Nil 1 > 3*, 4*; 5 > 2 t , 3*, 4 t ; 6 > 2t, 3t, 4 t Nil 5 > I t , 4 t , 6*; 2 > 6t Nil 4 > 1*
4> Nil
Nil Nil
It
Significant staff/ patient discrepancies'
Real/ideal discrepancies Occasion I
(Occasions) 2 t , 3*, 4*
Stafft I > R Patients** I > R
4*, 6**
Staff* I > R Patients** I > R
3 , 3t, 6 t
Staff* I > R Patients** I > R
Nil
Staff ** I > R Patients** I > R
Nil
Staff** I > R Patients NS
Comment
Staff show correlation ( p = .89*) between score and occasion of testing
(continued)
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Table 4
Scale
Example of a true item
Example of a false item
Score on occasionsa 1 2 3 4 5 6
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~
~~
Insight
Personal probPatients are Staff 2 1 2 1 4 4 lems are openly rarely asked Patient 4 1 1 1 4 4 talked about personal questions by the staff
Involvement
Patients put a lot of energy into what they do around here
A lot of patients Staff 1 2 4 1 4 3 just seem to be Patient 4 1 1 1 4 1 passing time in the ward
Aggression
Patients often criticize or joke about the ward staff
Patients here Staff 6 4 1 5 6 1 rarely become Patient 5 4 4 4 1 7 angry
Variety
New treatment approaches are often tried on this ward
The ward always Staff 2 1 4 4 4 4 stays just Patient 2 2 2 7 6 3 about- the same
Clarity
If a patient breaks a rule, he knows what will happen to him
People are Staff 3 1 1 1 4 4 alwayschang- Patient 2 1 1 1 2 2 ing their minds here
Submission
In this ward
2 4 3 4 4 6 Staff do not Staff order the Patient 2 3 4 4 4 2 patients around
everyone knows who is in charge
Autonomy
Patients are There is no expected to take patient govleadership in ernment in the ward the ward
1 4 5 4 4 6 Staff Patient 4 1 1 1 2 1
"Labels represent the following percentile ranges: 1 (very low) 0-5; 2 (low) 6-14; 3 (low average) 15-24; 4 (average) 25-15; 5 (high average) 7 6 8 5 ; 6 (high) 86-94; 7 (very high) 95-100.
WARD ENVIRONMENT. I
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(continued)
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Significant differences between occasionsb Nil; mean 1 , 2, 3, 4< mean 5, 6* 1 > 2t, 4 t ; 6 > 47 5 > 4*, 3 > 4 t Nil
6 > 27 5 > 2*, 3*, 4*; 6 > 2*, 3*, 4*; 1 > 27
Significant staff/ patient discrepanciesC
Real/ideal discrepancies Occasion I
Comment
Nil
Staff* I > R Patientst I > R
Group meetings started between occasions 4 5
It
Staff** I > R Patients** I > R
I*, 2*, 3*, 4**
Staff NS Patients* I > R
Nil 5 > 1*, 2*, 3,
6
> 2*, 3*
6 > 1*, 37 5 > It
Nil
I*, 2*, 5 t , 6*
Nil
1 < 2*, 4*, 5*, 6**; I*, 2 t , 6** 6 > 2 t , 4 * , 57 6 < It, 5t
+
Staff NS Patients* I > R
Staff* I > R Patients** I > R
Staff NS Patients NS
Staff** I > R Patients NS
b t = p < . l ; * =p
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Ward Environment in an Inpatient Drug Dependence Treatment Unit. I. Activity Levels and Ward Atmosphere John Teasdale, Dip Psych, Sheila Greene, David Hemsley, Caryl Hitchcock, Heather Hunt & Phillip Connell To cite this article: John Teasdale, Dip Psych, Sheila Greene, David Hemsley, Caryl Hitchcock, Heather Hunt & Phillip Connell (1975) Ward Environment in an Inpatient Drug Dependence Treatment Unit. I. Activity Levels and Ward Atmosphere, International Journal of the Addictions, 10:3, 401-416, DOI: 10.3109/10826087509026724 To link to this article: http://dx.doi.org/10.3109/10826087509026724
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 2
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum19 Download by: [Monash University Library]
Date: 16 April 2016, At: 06:44
Downloaded by [Monash University Library] at 06:44 16 April 2016
The International Journal of the Addictions, 10(3), 401-416, 1975
Ward Environment in an Inpatient Drug Dependence Treatment Unit. I. Activity Levels and Ward Atmosphere John Teasdale," M.A., Dip. Psych., Ph.D. Sheila Greene, B.A., M.Phil. David Hemsley, M.A., M.Phi1. Caryl Hitchcock, M.A., M.Phil. Heather Hunt, B.A., M.Phil. Phillip Connell, M.D., M.R.C.P., D.P.M., F.R.C. Psych. Drug Dependence Clinical Research and Treatment Unit Maudsley and Bethlem Royal Hospitals; Psychology Department Institute of Psychiatry University of London London, England
* Present address (to which requests for reprints should be sent): Dr. John Teasdale, University of Oxford Department of Psychiatry, The Warneford Hospital, Oxford OX3 7JX, England. 401 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
402
TEASDALE ET AL.
Downloaded by [Monash University Library] at 06:44 16 April 2016
INTRO D UCTION As part of the attempt to curb the spread of drug abuse in the United Kingdom, the second report of the Brain Committee, published in 1965, recommended the establishment of inpatient treatment and research units (Ministry of Health and Scottish Home and Health Department, 1965). A number of these have been set up, mainly in the London area, from 1968 onwards. In the memorandum issued by the National Health Service (1967) offering guidance on the management of such centers, it is suggested that “In order to meet the needs of young addicts, who are often of high intelligence, some intensification of the industrial or occupational therapy usually provided for adults will be necessary. It is important that young addicts should be fully occupied in a manner likely to extend their intellectual and creative abilities and to reinforce a generally weak sense of personal worth through opportunities for short-term achievement.” This suggestion stressed the importance of the ward milieu or environment as a therapeutic factor in the treatment of addicts, a suggestion endorsed by Rosenthal’s (1969) opinion that the therapeutic community was the treatment of choice in the vast majority of addicts. Taken with the frequently noted ineffectiveness of traditional individual therapy with this type of patient (e.g., Lowinson, 1971) these statements suggest that it might be profitable to investigate aspects of ward environment which might be considered therapeutic in an inpatient drug dependence treatment unit. This and a companion paper report the results of preliminary investigations of ward environment in the Drug Dependence Clinical Research and Treatment Unit, Bethlem Royal Hospital.
DESCRIPTION OF THE UNIT The establishment and running of this unit have previously been described (Connell, 1968, 1970). Briefly, it consists of two separate wards, an 1 1-bed unlocked ward for patients dependent on orally administered drugs, and a 10-bed locked ward for patients dependent on intravenously administered drugs, mainly heroin and other opiates. The latter has been the main object of the investigations reported here. Both wards were single-roomed, mixed sex, and staffed by nurses, occupational therapists, psychiatrists, a psychiatric social worker, and psychologists. To reduce contact between the intravenous drug users and other patients in the hospital, patients on the locked ward did not visit the Occupational Therapy Department of the hospital, but instead space and
Downloaded by [Monash University Library] at 06:44 16 April 2016
W A R D ENVIRONMENT. I
403
facilities were provided on the ward for a range of occupational therapy activities, including woodwork, metalwork, painting, typing, sewing, pottery, and table-tennis. It was intended that both wards should have a general “therapeutic community” orientation (Connell, 1968), but, with the exception of additional restrictions intended to reduce the risk of patients absconding, bringing in drugs, or having a harmful affect on other patients in the hospital, no specific regime of ward management different from that on other wards in the hospital was planned. It was hoped that methods of dealing with the management problems presented by addicts would be evolved over time. The nursing staff received no special training prior to the opening of the unit. In addition to “milieu therapy” received in the ward, patients in the closed ward received a number of specific therapies including individual interviews with psychiatrists and the social worker, behaviorally oriented therapy from the psychologists, opiate withdrawal via methadone over a period of 2 to 4 weeks, other medication where necessary, and (from February 1970) weekly group meetings. The investigations to be reported in this paper used two main measures of ward environment in the closed ward of the unit: activity levels and ward atmosphere.
ACTIVITY LEVELS It was thought that a useful, if somewhat crude, source of information as to what actually occurred on the ward would be a “time budget” derived from frequent, direct observation of each patient’s behavior.
METHOD The period in which observations were scheduled was 9.30A.M. to 5.00 P . M . on the first four days of each week of observation, and 9.30 A.M. to l.OOP.M. on the fifth day. This represented the period in which the largest number of medical, nursing, psychological, and occupational therapy staff were present in the unit. Observations were made at intervals varying randomly about a mean of 30 min. The observers were the staff psychologist working on the unit and the assistant psychologists working under his supervision. The technique of observation was as follows: The observer walked to the ward and through the lounge and dining area, noticing what each
TEASDALE ET AL.
Downloaded by [Monash University Library] at 06:44 16 April 2016
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patient was doing at the time he was first seen. These observations were noted down, and the rest of the ward was covered until every patient had been observed or accounted for, if off the ward. The observers attempted to remain as inconspicuous as possible, and the strong impression obtained was that patients rapidly habituated to being observed in this way, and that the process of observation had very little effect on the behavior being observed. The method of observation employed is obviously somewhat imprecise. Measures of inter rater agreement were obtained between the staff psychologist and each assistant psychologist participating in the observation. In terms of agreement between two raters making observations at the same time, agreement in the behavior category to which a patient’s behavior was assigned was obtained for at least 85% of observations (minimum sample size, 36) on each occasion. This suggests that the method of measurement, while crude, could give replicable results.
RESULTS Observations were made over a total period of 11 weeks, from October 1969 to March 1971. The percentage of observations falling in each category of behavior for each period of observation is shown in Table 1. The behavior categories directly relevant to the National Health Service Memorandum’s suggestions that “some intensification of the industrial or occupational therapy usually provided for adults will be necessary. It is most important that young addicts should be fully occupied in a manner likely to extend their intellectual and creative abilities . . .” would be J and K. Together these account for between 6 and 11% of the total number of observations on each occasion. If we can directly transform this into the average time the average patient spent on such activities in the period 9.30 A.M. to 5.00 P.M. each day, we arrive at a figure of between 26 and 50min. Category B included some occasions when the patients were off the ward as a result of playing squash, swimming, etc. in another part of the hospital. These occasions were only noted separately from other occasions when patients were off the ward for the last period of observation, when they amounted to 2% of the total number of observations. If this level can be assumed to be that existing on the other occasions of observation, and if such activities are considered “occupational therapy,” then the average time spent on “constructive activities” in the period 9.30 A.M. to 5.00 P.M. is from 35 to 59 min. In contrast to this small amount of time spent on “constructive activities,” the total percentage of occurrence of apparently inactive and
z
P
a
Total
Sitting doing nothingllying down doing nothing Out of ward (patients off the ward for the whole day excluded) Asleep Talking with another patient or staff member Reading other than academic study Playing cards/chess/scrabble Walking from one part of the ward to another Eatingldrinking Seeing doctor/psychologist/PSW/having EEG Cooking and preparing meals/snacks “Constructive” activities other than J (washing up, cleaning, tidying, setting out meals, drawing, mending, making models, woodwork, studying, writing, pottery, table tennis, singing, playing ball, painting, knitting, sewing, etc.) Standing, doing nothing else Toilet/washing/personal care Watching TV Other
Due to rounding off of percentages.
N 0
M
L
H I J K
G
C D E F
A B
Behavior Category
2 100 __ 100
0 1
2 2
4
1
100
4
5
2 3
7
2 3 5 3
11
~
99”
0 0
2 4
3
9 1 5 3
10 11 10
7
15
1
4
6 4
10
10 10
8 20
11 25
18 12 8 8 7 3 4 5
14 14
12
8
14
14
26/1/10 to 30/1/10
Occurrence, %
5/1/10 to 9/1/10
24/11/69 to 12/12/69
20/10/69 to 14/11/69
Table 1 Time Budget for Closed Ward on Six Occasions
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10 32 14
9 34 6 7
101”
2 3
2 4 3 7 -
100
5
1
4
5
1
4 2 2 3
0 4 4 4 5
8
10
23/3/71 to 26/3/11
7
1/2/71 to 5/2/71
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inert behavior (A + C + L) varies from 28 to 44%. If these can be translated into the average time spent in this way by the average patient in the period 9.30 A.M. to 5.00 P.M. each day, a figure varying from 2 hr 6 min to 3 hr 18 min is obtained. The proportion of this time accounted for by the patients being asleep appears to increase from the earlier periods of observation to the later. By February and March 1971 approximately a third of all observations fell in Category C.
DISCUSSION The results obtained suggest that the ward environment could not be described as one in which the patients were “fully occupied in a manner likely to extend their intellectual and creative abilities and t o reinforce a generally weak sense of personal worth.” On the contrary, it appears that with the exception of the routine functions of life (eating, drinking, washing, etc.) and of seeing individual members of the professional team, the patients spent most of their time asleep, off the ward, talking, reading, playing games, or doing nothing in particular. From the data of the present study it is impossible to assess the therapeutic value of the talking that was observed. The impression obtained was that most of the reading material was either newspapers or comics. Playing games such as cards or Scrabble, while a feature of earlier periods of observation, appeared to have disappeared from the ward culture by the two latest periods of observation. The first period of observation occurred after the ward had been open for 16 months; the last after the ward had been open for 2 years 9 months. In terms of the behavior observations made, there seems to be no consistent trend for the behavior in the ward to become more constructive in the later periods of observation than in the earlier periods. If anything, judged by the percentage of observations on which patients were asleep, the ward appears to be deteriorating in this respect. Most of the observations in which patients were asleep were the result of their late hour of rising. It might be objected that the period of observation chosen (9.30 A.M. to 5.00 P.M.) gave an unduly poor picture of ward activity levels as a result of it not coinciding with the most active part of the patient’s night-day cycle, which had become out of phase with the normal cycle. To this objection we would make the following points: 1. The correction of sleep/waking cycles to the normal pattern has been suggested as an important component in the rehabilitation of drug addicts (Freedman, 1965), i.e., even if
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407
the patients were more active after the observation period was over, a legitimate therapeutic goal would be to have them wake earlier and be active in the “normal working day.” 2. Excluding the observations when the patients were asleep, the proportion of time spent on constructive activity is still low, i.e., once they have got out of bed they are still not very productively occupied. 3. Informal reports from nursing staff suggested that, while the ward was generally “livelier” in the evening than during the day, this increased liveliness did not result in much of what we have called “constructive activity.” 4. As pointed out above, the period of the day in which observations were made coincided with the presence on the ward of the largest number of staff; the number of staff on duty in the evenings and at night was small. If treatment can be seen as the modification of the patients’ behavior by the staff, then it would be most appropriate to look at patients’ behavior at the time when there are most staff around. Another variable possibly reducing the activity levels in the ward might be the effects of opiate withdrawal or of the methadone used in the withdrawal process. It seems unlikely that these factors were of much importance; for example, in the period 1/2/71 to 5/2/71, which was the period with the highest incidence of Category C observations, of the nine patients in the ward, five had completed their withdrawal regime at least 2 months previously, three had completed it from 10 days to 1 month previously, and one was undergoing withdrawal in the period of observation. The last patient did not show a greater than average percentage of inactive behavior (Categories A C L accounted for only 17% of her observed behavior) nor a lower than average percentage of constructive behavior (Categories J and K accounted for 16% of her observed behaviour). Thus it seems unlikely that the withdrawal regime was the direct cause of lowered activity levels although, of course, long-term residual withdrawal effects might have some influence on these.
+ +
WARD ATMOSPHERE Method
The instrument used to assess ward atmosphere was the Ward Atmosphere Scale (Moos and Houts, 1968; Moos 1969). This is a questionnaire
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408
in which patients and staff are asked t o endorse a number of statements relating to different aspects of ward environment as being true or false of the ward they are in. It was administered on six occasions, from December 1968-March 1969 to April 1971. On the first occasion of testing, the questionnaire was administered individually. For the other occasions, group testing was used with the experimenter reading out the questions and the subjects responding on a n answer blank. Subjects were required to put their names on the questionnaires. The criteria suggested by Moos (1969) for eliminating invalid records were employed, i.e., subjects with Halo scores of 0, 1, 9, or 10 and with Inconsistency scores of 6 or more were excluded from the analysis. On the first occasion of testing, both patients and staff also completed the Ward Atmosphere Scale to describe the ward “as you would like it to be.” The criteria for eliminating invalid records were not applied to this “ideal” description. The staff completing the questionnaire were nurses and the occupational therapist, when one was working in the ward. As a result of the repeated testing, some patients and staff completed the Ward Atmosphere Scale on more than one occasion. The total 27 staff descriptions included descriptions from nine staff who had completed the scale once, from four staff who had completed it twice, from two staff who had completed it three Tabie 2 Staff Perceptions of Ward Atmosphere on the Closed Occasion
N Spontaneity
December 1968March 1969 5 22/10/1969 4 6/11/69 3 12/12/69 5 JanuaryFebruary 1971 4 7/4/71 5 Ideal (December 1968March 1969) 5
Support Practicality Affiliation
Order Insight
36 21 36 15
18 12 23 49
7 5 28 25
6 21 59 49
1 1 3 3
11 2 9 2
22 14
30 56
41 54
29 17
6 3
30 45
98
94
96
96
69
98
,
WARD ENVIRONMENT. I
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times, and from one staff member who had completed it four times. The total 33 patient descriptions included descriptions from 21 patients who completed the scale once, and from six who completed it twice.
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Results
The results for staff perceptions of ward atmosphere are shown in Table 2, and for patient perceptions in Table 3. Scores are expressed as percentiles (calculated via standard scores) relative to the data from a group of 32 wards, comprising the wards of the Bethlem Royal and Maudsley Hospitals, and a small number of wards from other hospitals in the area around London (these data were kindly provided by Dr. R. H. Moos). The Ward Atmosphere Scale gives scores for 12 aspects of ward environment and for two validity scales. Table 4 gives examples of the items contributing to each of the scales, and a summary of staff and patients scores on them on six occasions, with details of the results of statistical tests. Discussion
It is not simple to give an overall picture of such a large number of Ward, DDCRTU, on Six Occasions, Percentile Scores
Involvement
Aggression Variety
Clarity Submission Autonomy
I
Halo
Inconsistency
3 8 21 1
89 69 95 80
14 4 21 35
15 0 0 1
48 18 36
1 35 81 35
3 1 6 14
6 41 41 10
34 16
93 96
21 21
21 42
60 92
35 94
14 14
3 22
89
68
61
99
11
100
100
100
410
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Table 3 Patient Perceptions of Ward Atmosphere on the Closed
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Occasion
N Spontaneity
December 1968March 1969 10 22110169 6 6/11/69 5 12/12/69 3" JanuaryFebruary 7 1971 7/4/71 3" Ideal (December 1968March 10 1969)
Support
Practicality
Affiliation Order
Insight
48 5 1 0
7 38 5 22
8 0 0 20
17 66 54 54
8 2 3 2
53 1 2 0
63 53
49 1
10 12
63 7
1 0
36 53
100
93
87
99
10
100
Two patients omitted due to invalid records.
Table 4 Staff and Patient Perception of Ward ~
Score on occasions" Scale Spontaneity
Support
Practicality
Affiliation
Order
Example of a true item Patients say anything they want to the doctors Staff go out of their way to help patients Patients are encouraged to plan for the future Patients often do things together on the weekends Thisis a very well organized ward
Example of a false item
1 2 3 4 5 6
Patients tend to Staff hide their feel- Patient ings from one another Patients rarely Staff help each otherpatient There is very little emphasis on making patients more practical There is very little sharing among the patients Theday room is often messy
4 3 4 3 3 2 1 4 4
4 1 1
3 2 3 4 4 4 2 4 1 3 4 1
Staff 2 Patient 2
1 4 4 4 4 1 1 3 2 2
Staff 2 3 4 4 4 3 Patient 3 4 4 4 4 2
Staff 1 1 1 1 2 1 Patient 2 1 1 1 1 1
WARD ENVIRONMENT. I
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Ward, DDCRTU, on Six Occasions, Percentile Scores
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Involvement
Aggression Variety Clarity Submission Autonomy
Halo
Inconsistency
30 3 4 1
81 31 68 54
12 12 7 99
8 3 0 4
6 19 21 21
37 2 2 1
13 11 8 21
20 4 55 57
39
I
98 100
91 18
9 12
46 12
13 0
7 1
6 81
96
91
15
96
3
100
19
21
Atmosphere on Six Occcasions
Significant differences between occasionsb (Occasions) Nil 1 > 3*, 4*; 5 > 2 t , 3*, 4 t ; 6 > 2t, 3t, 4 t Nil 5 > I t , 4 t , 6*; 2 > 6t Nil 4 > 1*
4> Nil
Nil Nil
It
Significant staff/ patient discrepancies'
Real/ideal discrepancies Occasion I
(Occasions) 2 t , 3*, 4*
Stafft I > R Patients** I > R
4*, 6**
Staff* I > R Patients** I > R
3 , 3t, 6 t
Staff* I > R Patients** I > R
Nil
Staff ** I > R Patients** I > R
Nil
Staff** I > R Patients NS
Comment
Staff show correlation ( p = .89*) between score and occasion of testing
(continued)
412
TEASDALE ET AL.
Table 4
Scale
Example of a true item
Example of a false item
Score on occasionsa 1 2 3 4 5 6
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~
~~
Insight
Personal probPatients are Staff 2 1 2 1 4 4 lems are openly rarely asked Patient 4 1 1 1 4 4 talked about personal questions by the staff
Involvement
Patients put a lot of energy into what they do around here
A lot of patients Staff 1 2 4 1 4 3 just seem to be Patient 4 1 1 1 4 1 passing time in the ward
Aggression
Patients often criticize or joke about the ward staff
Patients here Staff 6 4 1 5 6 1 rarely become Patient 5 4 4 4 1 7 angry
Variety
New treatment approaches are often tried on this ward
The ward always Staff 2 1 4 4 4 4 stays just Patient 2 2 2 7 6 3 about- the same
Clarity
If a patient breaks a rule, he knows what will happen to him
People are Staff 3 1 1 1 4 4 alwayschang- Patient 2 1 1 1 2 2 ing their minds here
Submission
In this ward
2 4 3 4 4 6 Staff do not Staff order the Patient 2 3 4 4 4 2 patients around
everyone knows who is in charge
Autonomy
Patients are There is no expected to take patient govleadership in ernment in the ward the ward
1 4 5 4 4 6 Staff Patient 4 1 1 1 2 1
"Labels represent the following percentile ranges: 1 (very low) 0-5; 2 (low) 6-14; 3 (low average) 15-24; 4 (average) 25-15; 5 (high average) 7 6 8 5 ; 6 (high) 86-94; 7 (very high) 95-100.
WARD ENVIRONMENT. I
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(continued)
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Significant differences between occasionsb Nil; mean 1 , 2, 3, 4< mean 5, 6* 1 > 2t, 4 t ; 6 > 47 5 > 4*, 3 > 4 t Nil
6 > 27 5 > 2*, 3*, 4*; 6 > 2*, 3*, 4*; 1 > 27
Significant staff/ patient discrepanciesC
Real/ideal discrepancies Occasion I
Comment
Nil
Staff* I > R Patientst I > R
Group meetings started between occasions 4 5
It
Staff** I > R Patients** I > R
I*, 2*, 3*, 4**
Staff NS Patients* I > R
Nil 5 > 1*, 2*, 3,
6
> 2*, 3*
6 > 1*, 37 5 > It
Nil
I*, 2*, 5 t , 6*
Nil
1 < 2*, 4*, 5*, 6**; I*, 2 t , 6** 6 > 2 t , 4 * , 57 6 < It, 5t
+
Staff NS Patients* I > R
Staff* I > R Patients** I > R
Staff NS Patients NS
Staff** I > R Patients NS
b t = p < . l ; * =p
