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A Social response perspective on treatment allocation in psychiatry Keeley, Kathryn Marie 1989

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A SOCIAL RESPONSE PERSPECTIVE ON TREATMENT ALLOCATION IN PSYCHIATRY BY KATHRYN MARIE KEETLEY B.A., University of Victoria, 1975 M.A., Fuller Theological Seminary, 1981  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  in THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology) (Department of Psychiatry) (Department of Anthropology and Sociology)  We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA October 1989 copyright Kathryn Marie Keetley, 1989  In presenting degree  at the  this thesis  in partial fulfilment  of the  advanced  and study. I further agree that permission for extensive  copying of this thesis for scholarly purposes or  for an  University of British Columbia, I agree that the Library shall make it  freely available for reference department  requirements  by  his  or  her  representatives.  may be granted It  is  by the  understood  that  head  of my  copying  or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department The University of British Columbia Vancouver, Canada Date  DE-6 (2/88)  ABSTRACT Huge mental hospitals are being replaced by units in medium and setting  results  treatment.  in  smaller psychiatric  even small community hospitals. pressure  to adopt  a  more  This biomedical  biological  focus  for  It is, therefore, imperative that hospital psychiatry develop  an alternative model which retains the social context of mental illness.  Social response  theory is used to analyze the research findings  and to emphasize the need for a social perspective in the development of hospital psychiatry, for institutional health care planning, and for society as a whole.  In this study, a cohort of 108 patients admitted to a community hospital psychiatric unit were studied for a period of 2 and 1/2 months. A blend of quantitative and qualitative methods was  used. It was  found  that patient social characteristics, the organization of work, unit norms and  community  resources  were interactive  pressures  which  affected  treatment allocation.  The  study  understanding  concludes  that social response  theory  is useful in  the relationship between treatment allocation and  social  processes that center around the social characteristics of the patient institution and the community.  iii TABLE OF CONTENTS Abstract  ii  List of Tables  vii  List of Figures  .  viii  Acknowledgements CHAPTER ONE:  .  .  ix  THE CONTEXT AND OUTLINE OF LABELING THEORY  1  Psychiatry Within the Biomedical Model.....  3  Psychiatry Outside the Biomedical Model  4  Biomedicine Within the Social Response Perspective  5  Demographic Characteristics Influencing Diagnosis and Treatment  11  Organizational Practices Influencing Diagnosis and Treatment  13  CHAPTER TWO:  17  METHODOLOGY ......7..7J...7......J.........  Study Site.....77.71. I. II.  Insight Group Activity Group  19 ..  Study Design I.  17  20 ..  Quantitative Methods A. The Description of Study Population 1. 2. 3. 4.  Sampling Methods Demographics Reasons for Admission How Patients Arrived at Hospital  B. Outcome Variables 1. Length of Stay 2. Medication Distribution..... a) Anti-psychotics b) Minor tranquilizers and anxiolytics c) Hypnotics and analgesics  21 24 26 26 26 31 33 34 .....34 37 39 40 40  iv d) Anti-depressants e) Anti-manic medication 3. Assignment and Attendance at Group Treatment II.  42  Qualitative Methods A. Field Notes B.  ,  44 46  Interviews  C. Reliability and Validity..  48  D. The Role of the Researcher  49  CHAPTER THREE:  .....51  FINDINGS •  Length of Stay  •  I. Patient Social Characteristics II.  Institutional Practices and Beliefs  52 ...53 54  A. Ward Work Structure  55  B. Institutional Norms  57  1. Patients Benefit from Asylum  57  2. Patients Benefit from Group Treatment  58  III. Community Resources  IV.  40 40 41  60  A. Accommodation  61  B. Out-patient Follow-up Services  62  Social Processes in the Production of Short and Long Stays in Hospital  63  A. The Production of a Long-Stay Admission  64  1. The Patient Resisted Discharge 2. The Patient is Benefitting from the Ward Program..... 3. Communication Problems Exist Between Staff and Psychiatrist... 4. The Patient Undergoes Various Investigations or There are Non-Psychiatric Done  64 65 66 67  V  B.  The Production of a Short-Stay Admission  68  1.  The Patient Wanted to Leave and Was Not Committable 2. The Patient Had a Place to Live and a Job 3. The Patient Had an Extensive History on the Ward and was Disliked by Staff..... 4. The Patient Was Viewed as the Responsibility of Another Place..  68 69 70 71  Summary  71  Medication  72  I. Effect of Patient Personal Characteristics on Medication Distribution  II.  73  A.  Patients Who Received No Medication  73  B.  Patients Who Received Medication  74  1. Sex 2. Education Effect of Institutional Characteristics: Service Organization and Structure.... A.  77 79 84  Service Organization  84  1. 2.  Decentralization of Physician Services Ward Funding...  84 88  3.  Ward Structure  91  Summary  ••  Group Treatment..  ....  I. Assignment to Group Treatment  92 •  93 93  A.  Consequences of Being Assigned to Insight Group  94  B.  Consequences of Being Assigned to Activity Group  95  II. Characteristics of Patients Attending Each Group  97  A.  Sex  97  B.  Education  99  III. Organizational Factors in Group Treatment Allocation  101  A.  Decentralization of Physician Services  101  B.  Barriers to Group Attendance  102  Summary..  105  CHAPTER FOUR: CONCLUSIONS  ..106  Limitations of This Study  107  Critical Components of a Social Perspective  108  I.  The Significance of the Commonplace  108  II.  The Significance of Social Processes  110  The Necessity of a Social Perspective  Ill  I.  As a Model for Hospital Psychiatry  II.  For Planning and Evaluating Hospital Psychiatry Services  III. For Society  .....112 113  .  113  References  .  .114  Appendix I:  Chart Abstract Form  123  Appendix II:  Example of Verbatim Staff Conference Notes on Patient #59  127  Appendix III: An Example of Data Compiled by Topic: Patient Discharge.... Appendix IV:  Notes About  Excerpts from Three Patient Conferences on the Topic of Medication  132 133  \-  Appendix V:  Letter of Approval from Lion's Gate Hospital  140  vii  List of Tables Table 2.1  Primary and Secondary Reasons for Admission  31  Table 2.2  Primary and Secondary Discharge Diagnosis  32  Table 3.1  Patient Education by Length of Stay  77  viii  List of Figures Figure 2.1  Distribution of Patient Sample by Sex  28  Figure 2.2  Distribution of Patient Sample by Age  29  Figure 2.3  Distribution of Patient Sample by Education  Figure 2.4  Distribution of Patient Sample by Length of Stay..  Figure 2.5  ,  30 36  Distribution of Patient Sample by Medication Type  38  Figure 3.1  Percentage of PRN Medication by Type  76  Figure 3.2  Percentage of Patients Medicated by Gender  78  Figure 3.3  Percentage of PRN Medication by Gender;  80  Figure 3.4  Percentage of Patients Medicated by Education  Figure 3.5  Percentage of Patients Medicated PRN by  -.. 82  Education Figure 3.6  Percentage of Patients Attending Group by Sex  Figure 3.7  Percentage of Patients Attending Group by Education .  83 >  98 100  Acknowledgements  This project was  possible because of the help and encouragement from  my advisor Dr. Nancy Waxier-Morrison, the computer services (UBC)  and  emotional support provided by Douglas Forst and Bonnie Gable, and  the  patience and  skill of Susan Johnston who  produced the final document,  several times.  I would like my  Committee for their assistance, as well as the staff at  Lion's Gate Hospital for their time and supported in part by  cooperation.  a Graduate Fellowship  This thesis  from the  was  University of  British Columbia.  This thesis is dedicated to my support,  time and  Thank you.  love  parents and to Bill, who  over an  extended period  gave me material  with  little  return.  1 Chapter One THE CONTEXT AND OUTLINE OF LABELING THEORY  The purpose of the literature review is to present social response theory relative to the prevailing biomedical model.  However, these  models are not presented as either/or ways of interpreting the same phenomena.  Instead, they are understood to represent different ways of  looking at different aspects of the same phenomena.  Medical research undertaken from the social response perspective is concerned with describing and understanding the social impact of medical belief systems and organizations on society and vice versa. Traditional biomedical model research does not address this aspect of medicine.  Medical sociologist  Renee Fox (1989) finds that belief systems  about health, illness and medicine are linked to the most universal experiences of any given society. death.  These include birth, pain, aging and  She emphasizes that sociocultural factors influence "what is  defined as illness in a given society, what it is called, how it is interpreted and experienced, and how and whenever it is detected and diagnosed."  This system of beliefs determines how a society deals with  those members who are labeled as ill, their relationships to one another and their role performance.  2  Such belief systems, which explain natural phenomena and sense out of what is puzzling or disturbing, are called models.  make Veatch  (1981) defined a model as "a complex integrated system of meaning used to view, interpret and understand a part of reality."  In Mishler's (1981)  opinion, the biomedical model is only one representation of reality, and one which may  Mishler  benefit from critical examination.  (1981)  criticizes  modern  medicine  for  perspective which focusses "on the concepts, methods and the biological sciences", and  stresses that health and  as well as biological facts.  He  the biomedical  its  narrow  principles of  illness are social  identifies four assumptions inherent to  model and, through his critique of these assumptions,  lays the groundwork for an expanded perspective.  A cornerstone  of biomedicine is the  defined in relation to a biological standard.  belief that disease can  be  This, according to Mishler,  ignores normalcy as a property of a collective group at a particular time and place.  The  doctrine of specific etiology is another facet of  biomedical  theory which tries to isolate the singular etiological factors responsible for the anatomical lesion.  Mishler feels this focus ignores those multiple  and interactive processes which produce disease.  The third assumption is that there are specific and distinguishing features which universally identify various diseases.  This assumption  3  equates biological  signs and symptoms to  illness  and ignores  the  considerable unexplained variance in the symptoms which constitute the diagnosis of the same disease.  "Scientific neutrality" and "objectivity" constitute the fourth tenet of biomedicine.  Claiming these values, practitioners have not examined  the impact of their own values on their practice and society.  Psychiatry, as one of the more recent specialities of medicine, has an uneasy relationship with the biomedical model.  At present, it is a  profession at the crossroads, with three perspectives competing for its allegiance.  The choices include opting completely into or out of the  biomedical model or  changing  the  biomedical model to  reflect  the  influence of social factors.  Psychiatry Within the Biomedical Model  Pasnau Association,  (1987), calls  for  Past the  President  of  the  "remedicalization  of  American  Psychiatric  psychiatry".  This  approach stresses the importance of a standardized diagnostic system such as the DSM III, that groups signs and symptoms that are regularly found together into a particular class.  It is implied that these systems  of classification will all one day be related to underlying structural or functional abnormality.  4  Pasnau represents many who feel this rigorous emphasis on the organic  basis  of  psychological  disturbance  psychiatry as a speciality within biomedicine.  will  firmly  establish  He feels this will bolster  the image of psychiatry and, consequently, brighten its future.  Psychiatry Outside the Biomedical Model  Other theorists, such as Laing (1960), Rosenhan (1973) and Szasz (1977), would like to see the biomedical model remain concerned with organic disease, but relinquish authority over psychological  distress,  which Szasz calls "problems of living". He regards psychiatric diagnosis and treatment as mechanisms that society uses to maintain social control.  Mirowsky and Ross (1989) critique the practice of using diagnosis for anything beyond describing the patient.  They view the biomedical  use of diagnosis in psychiatry as the fallacy of "misplaced concreteness" because dysphoria describes an unhappy patient, but it is not "real". Guimon (1989) argues that most psychopathology cannot be defined in terms of structural pathology.  These  theorists are  critical of  the  use  of  biomedical model  concepts and solutions, which they feel are inappropriately applied to social problems.  Social deviance exists relative to collective  social  norms; it is not a problem that can be solved by treating the individual for organic disease.  5  Biomedicine Within the Social Response Perspective  Engel (1976) points to the necessity of a third alternative.  He  sees the crisis facing psychiatry as part of a larger crisis that has its roots in the biomedical model itself.  He calls for the expansion of the  biomedical model, which he describes as no longer adequate for medicine because it ignores the psychological, social and cultural processes that influence diagnosis and treatment.  A third position would consider illness and health issues from both a social and biological perspective.  In this study, social response  is described and used as a framework within which a social perspective could be developed.  Social response theory focusses on the role of societal reaction to deviance.  It is concerned more with "what is made of an act socially  than what may have led the individual into the behaviour in the first place" (Shur, 1973). analysis  away  Schur describes labeling theory as "redirecting the  from those  who offend  to the  explanation  of  the  interaction between rule violators and those who respond to their behaviour."  This theory has been applied to a wide variety of topics,  including juvenile delinquency (Schur, 1973), mental retardation (Mercer, 1973), and psychiatry (Scheff, 1966).  Central to social response theory is the concept of deviance, which only exists relative to social processes and is not inherent in the  6  person or the behaviour.  Becker (1973) sees deviance as the product of  social groups which create deviance by making rules whose infraction constitutes deviance, and by applying these rules to particular people and labeling them as outsiders. Kitsuse (1962) defines deviance as a process by which members of a group or society interpret behaviours as deviant, define persons who so behave as a certain kind of deviant and accord them treatment considered appropriate to a person so labeled. Because not all rule breaking results in a label of deviance, the factors associated with being or not being labeled are of particular interest to social response theorists.  According to Scheff (1963), societal response to deviance is a function of three things:  the degree, amount and  visibility  of the  deviance; the social status of the deviant relative to the agents of social control; and the tolerance of the community or organization towards that particular behaviour at that point in time.  Schur (1973) argues that tolerance is itself the product of the goals and limits of the organization relative to the behaviour of the individual.  Therefore, he suggests that key variables in the study of  deviance are organizational practices that will influence the response to deviance.  7  Waxier (1980) summarizes key social response theory concepts as follows: Who is to be called "ill" is determined by the individual's social position and society's norms rather than by universal and objectively defined signs and symptoms. Further, a person is labeled as "ill" in the course of social negotiations between himself, his doctor, his family, sometimes ward staff and others. The outcome of such social negotiations is influenced by each person's beliefs and training and also by the social and organizational contexts in which the negotiation occurs. Once labeled as "ill" the individual may find himself caught in the midst of a self-fulfilling prophecy. Depending upon his social position he may find that de-labeling is difficult, that continued illness is expected and therefore that his symptoms continue, (p. 283)  The literature based  on social  response  theory  centers  around three core aspects of the theory.  Theorists are concerned with:  how  identified  deviance  is  conceptualized  and  in  a  society  or  organization; the process and factors which determine if the deviant label is given; and the effect of labeling on the person who accepts it.  Most of the recent literature focuses on the second aspect of the theory.  This research attempts to describe and define the social  processes, apart from disease, which influence health care.  The third component of labeling theory remains controversial. Lemert (1967)  calls  this  third  aspect  "secondary  deviance".  This  is  hypothesized to occur when the person is labeled by others and accepts the identity and the role of the deviant. deviant behaviour.  This results in stabilizing the  This aspect of labeling theory is perhaps the most  8  difficult to empirically study.  Theorists differ in how much weight they  ascribe to the power of secondary deviance.  In support of this aspect of labeling theory, Brown (1966) studied similar patients who were labeled as schizophrenic from three hospitals that differed in the amount of follow-up five-year  period,  he  found  that  offered to patients.  patients  in the most  Over a  integrated  treatment system and who received up to eight times more treatment did slightly worse than patients who were offered far fewer services after discharge.  The explanation  labeling theorists have for this finding is that  whether or not patients can shift from being  "mentally  i l l " to being  "well" depends on the messages they are given at discharge.  This  message depends more on the belief system and organizational practices of the institution than on the state of the patient. In support of this argument, Waxier (1976) found that the psychiatric patient's social experience after discharge, in particular the messages given by the treatment system, family and friends, made a significant contribution to clinical outcome and social performance several months later. In this study patients from hospitals with no follow-up were given the message that they were "well" upon discharge.  services Facilities  with out-patient services implied the patient was still "sick" and must therefore  continue treatment.  Patients  who  continued  in treatment  9  retained their symptoms longer than patients who were expected to have recovered by the time of discharge.  Until recently, few studies utilizing a research framework offered convincing evidence that psychiatric patients were indeed more harshly labeled by themselves or others.  Beiser et al. (1987) developed the  Social Response Questionnaire for use as an operational measure of this labeling  construct.  He found that  persons  diagnosed  as  having  psychotic disorders labeled themselves and were more negatively labeled by others than were persons with Crohn's disease or "normals".  Brown (1987), Waxier (unpubl.)  and Beiser  et  al.(1987)  offer  evidence that psychiatric patients are negatively labeled and that the de-labeling process is variable, being heavily influenced by prevailing belief systems, the bureaucratic structure and the treatment agents. These studies lend weight to the hypothesis that social factors may contribute to stabilizing deviant behaviours.  Gove (1970), who has led the attack on this theory, cites: ... the inability of the societal reaction theorist to explain the development of mental illness together with their exaggeration of the amount of secondary deviance produced by treating someone as mentally ill ...  as his most serious criticism.  10  However, this perspective need not be concerned with the etiology of mental illness or disease in general.  Most social response theorists  consider disease to be both a biological and social fact.  For example,  Mishler (1981) underscores the importance of social aspects of disease rather than undermining the significance of biological factors.  He claims  that "medicine is best understood, as all other human action, as active, interpretive constructed."  work  through  which  a  particular  social  reality  is  He attempts to heighten awareness of clinical practice as  it is influenced by cultural values, social policies and organizational requirements.  The effect of these social factors on the diagnosis and  treatment of disease may as important as is the disease etiology as understood by biomedicine.  In response to Gove's other major point of contention, it is clear that the credibility of labeling theory does not solely concept of secondary deviance.  rest on the  The center posts of this theory rest on  a broader premise: that our conception of health and illness are socially determined, and that health care is the  product of many political  processes, including how funds are allocated and how services are organized.  Most of the recent health-care literature based on social response theory has focussed on the factors and processes, apart from disease, that influence whether or not the deviant label is given.  This literature  review focusses mainly on current examples of how demographic and  organizational practices have been found to affect health-care decisionmaking, including diagnosis and treatment.  Demographic Characteristics Influencing Diagnosis and Treatment  Patient characteristics, apart from disease, that have been found to influence diagnosis and treatment include socioeconomic status, sex and culture. Epstein (1988), Loring (1988), Warner (1979), and Thompson (1987) represent recent research which continues to find an association between patient demographics and treatment.  Epstein (1988) studied a cohort of 402 patients and found hospital stays were significantly, longer for subgroups of patients with a lower socioeconomic status than for wealthier patients.  This was true whether  socioeconomic status was defined in terms of education, income or occupation.  Poorer patients, however, were not more disabled than  wealthier patients, as measured by the Instrumental Activities of Daily Living  Scale.  He concluded that  poorer patients  required more  resources to be mobilized on their behalf before discharge was possible.  Loring (1988) found that the sex and race of patients influenced the DSM-III diagnosis given by 290 psychiatrists.  Two case studies  were presented, in which the sex and race of the patient varied.  White  female clinicians were most likely to diagnose white female patients as having a "brief reactive psychosis".  Male clinicians were most likely to  diagnose females with a depressive disorder.  Agreement was highest  12  when  patient  sex  and  race  were  omitted.  Loring  concluded  that  diagnosis remains a subjective activity, in spite of DSM-III.  In  a  similar study,  Warner  (1979) studied  173  mental  health  professionals employed at mental health centers in a major U.S.  city.  Presented with four hypothetical profiles of patients, the race of the therapist was  found to influence diagnosis.  Hysterical and  personality disorder were found to be sex-based diagnoses. found that substance abuse team members tended alcoholism and  psychiatrists diagnosed  antisocial  Warner also  to diagnose more  more psychosis.  He  concluded  that therapists tend to use a diagnosis with which they are familiar and which lends itself to their usual therapeutic approaches.  Patient demographic characteristics and organizational factors influence whether or not patients are given ECT. (1987) studied  rates  of  electroconvulsive  Institute of Mental Health from 1975  Thompson and  therapy  to 1980.  from  the  Blaine National  This form of treatment  decreased by 46% during that time. The authors speculate that this due  to organizational factors, such as an  facilities to receive ECT  maintain  staff and  equipment.  may  increased Those  unwillingness who  was of  continue to  are mainly white, voluntary middle class patients in private  hospitals that can afford maintenance.  13  Organizational Practices Influencing Diagnosis and Treatment  Qualitative and quantitative  methodologies  have  been used  to  study the impact of social policy and organizational practices on the health-care  system.  Social  response  theorists  predict how  social  processes allocate money and power will also influence diagnosis and treatment outcomes.  Mercer (1973) found rates of mental retardation in children to be closely correlated with the accessibility of psychologists and family background.  Smaller schools  had more children labeled as mentally  retarded than larger schools because all schools were allotted an equal number of psychologist days, regardless of their size and psychologists were required, by law, to do diagnostic tests.  Since private, Catholic  parochial schools had no school psychologists, no child in this system was labeled as "retarded", even though 1.1% had an LQ. score of less than 80.  Mercer also found that those children who were identified for testing resembled the school district population, however, those who were diagnosed as "retarded" were mainly poor, Mexican-American or black children, with poor language skills.  Out of the 81 children labeled  as "retarded", 10 escaped referral to special classes. younger girls from Anglo families.  These were mainly  14  These findings suggest that, in addition to IQ scores, the process of being given a deviant label is mediated by institutional concerns.  Institutions have many goals that must be met before patients can be looked after, some of which relate to organizational survival.  The  methods by which hospitals, clinics and professionals pursue these goals may not necessarily benefit the patient.  Brown (1987) found that an  institution has many reasons to use the DSM-III diagnostic system. Having analyzed  the diagnostic process at a psychiatric walk-in clinic,  he concluded that the pressure to refine a diagnosis was not patient directed.  Clinicians were often limited and frustrated in their attempts  to describe the patient "in DSM-III".  Their dissatisfaction with the  nomenclature was reflected in the way DSM-III was used.  Brown found  "practitioners to have very personal styles which transcend formal systems."  DSM-III was used as a residency training tool, reflecting the profession's desire to more closely emulate biomedical diagnosis.  The  clinic goals were also served by using a diagnostic system.  The records were used to develop staffing allocation,  plan  training  programs and design  plans, do budget research programs.  Governments, insurance companies and courts and prisons all demanded diagnosis as a basis on which to make decisions.  15  Goodban (1987) identified administrative policies and programs as critical factors to consider before doing any research involving length of hospital stay.  She studied 320 admissions to two public psychiatric  hospital acute care units in the same geographic area.  In spite of  attempts to restructure and make the function of these two facilities comparable, differences persisted.  She concluded that length-of-stay  patterns differed between the  two hospitals partly as a result of different administrative policies. The mental health center defined itself as providing care for a fixed time (34 weeks). The state hospital, however, was under pressure to discharge patients as soon as possible, as well as to provide long-term care. The two length-of-stay distributions closely paralleled hospital administrative policies and processes which, in turn, corresponded to the divergent functions of the two facilities within the state system.  Community pressure and internal goals were factors in another example of organizational decision-making.  Martin (1985) analyzed the  impact of a new short-stay acute ward at the Clarke Institute.  Opened  in response to community pressure for an emergency inpatient service, the Clarke Institute responded, in part, to maintain its credibility as a treatment facility where patients could be referred, and available for research and teaching.  The study concluded that the short-stay ward  maintained community support and served as a pool from which suitable patients could be selected by investigators and subspecialists.  16  Hospital admissions have been studied as organizational behaviour that can be influenced by social processes.  Frank (1989) found that,  when a group of hospitals changed from a per diem reimbursement scheme to a prospectively set budget, the result was a 16% to 22% decrease in admissions.  Frank suggests that these results show that  hospitals do respond to incentives to decrease admissions, and that prospectively set budgets provide such an incentive.  It is clear that organizations respond both to external pressures from the community and to internal needs.  The resulting decisions and  policies influence patient-care decisions.  In summary, psychiatry appears to be in need of a strong social perspective to guide the profession as it develops its role in community hospitals.  Social  response  theory  is  outlined  as  a  basis  for  understanding studies in which treatment and outcomes appear to be influenced by social as well as biological factors.  No attempt is made in  this study to evaluate the relative usefulness of either the biomedical model or social response theory.  This study uses social response theory  as a basis for the development of a social perspective to transform the biomedical model into a more comprehensive perspective, with both biological and social depth.  17  Chapter  Two  METHODOLOGY  The  study design and  Garfinkel's  concept  of  methodology reflect the intent  "ethnomethodology"  to employ  (Heritage, 1984),  referring to the ways people make sense out of everyday life. case, the study attempts to understand how  a  term  In this  psychiatrists and ward staff  organize and understand their work, each other and their patients.  The  intent is to determine if the social response or labeling theory provides a useful hermeneutic for understanding the social processes surrounding treatment allocation.  STUDY SITE  The seminal studies that challenge the biomedical assumptions in psychiatry have been done mainly in large mental institutions (Goffman, 1961; Greenblatt, 1957; Stanton, 1954; Caudill, 1952). units adjacent to acute care hospitals facilities. one  replacing  these large  The result has been a switch from long-term hospitalization of  to two  years to short-term  stays of one  discharge to community group homes. new  are now  Smaller psychiatric  settings  to document their  patient outcomes.  month or less, with  Research must be done in these  impact  on  treatment  allocation  and  18  Lion's Gate hospital, which was hospitals found in larger towns and acute care beds and  chosen as an example of community cities throughout Canada, has  402  serves an estimated population of 140,000+ (Lion's  Gate Hospital publication, 1987).  The  39-bed psychiatric unit is situated  in a separate building, site of the old hospital, around which the hospital has been built.  new  Psychiatric services are delivered as part of  the total health care services provided by this hospital.  The  psychiatric unit consists of two  beds, respectively.  wards, containing  Each ward has its own  17 and  21  area clinician (Appendix V),  nursing manager, social worker, and occupational therapist.  The  larger  ward employs 11 full-time and five part-time nurses.  The  smaller ward  has eight full-time nurses and seven part-time staff.  A roster of relief  staff is used to replace sick or vacationing staff.  The which  wards offer various kinds of treatment to patients, some of  are  allocated  medication and by  patients.  by  the  psychiatrists  electroconvulsive  therapy, and  and/or  nurses,  such  as  some of which are chosen  Although patients are assigned to some ward, activities,  attendance is voluntary.  Each  ward  offers  a  variety  of  activities,  such  as  stress  management training, therapy groups and  structured  leisure groups.  These groups are  of nurses  and  lead  by  a  combination  worker, or nurses and the occupational therapist.  the  social  19  The approximately  different  10  could be divided into two  groups that a patient can  categories.  Groups that  attend  all patients  were  strongly encouraged to attend included exercise class, relaxation group, art therapy two  and the  weeks.  Whether  planning and cooking of a ward meal once or not  patients  participated  in these  every  voluntary  activities was not discussed b y staff at conference.  The other category consisted of "Insight" and "Activity" group to which patients  had to be assigned.  In this  study,  groups to which patients were assigned b y staff  only data on the  was analyzed.  This is  iii keeping with the study focus on staff decision-making processes.  I.  Insight Group  Insight  group  was  described  by  one  social worker  as a  structured, directive, but non-controlling group for expressing and behaviours, as part of the elite  group  that  fulfilled  a  patient care  plan."  similar function  on  referred to b y staff as the "higher" level group.  "non-  thoughts  This describes  each  ward and  an was  It usually consisted  of a small number of patients, four to six, and was sometimes cancelled if there were no suitably articulate candidates.  When it d i d meet, this small number of patients was provided with three staff  members:  nurse  was  who  the social worker who usually led the group, a  present  as a  co-leader, and  a nurse  present as  the  20  observer.  The observer did not talk in group, but reported back to the  daily staff meeting about what happened in the group.  The afternoon version of insight group was not quite as exclusive but being assigned to it conferred a superior status for its members, compared to activity group assignment. insight group was  The afternoon version of the  run by an occupational therapist and a nurse and  included assertiveness training, rational emotive therapy, or self esteem exercises.  II.  Activity Group  Every  patient  not  assigned  to  insight  considered a candidate for activity group.  group  was  usually  Therefore, the number of  patients was much larger in this group.  Only two staff members were  assigned to this group  considered  because it was  to function at a  "lower" level. An activity group session could be a walk to the park or to the quay for coffee. The expectations for this group were very low, and  almost anything  was  tolerated.  Patients were  not pushed to  participate, just to attend.  The afternoon version of activity group game or swimming.  was  often an outdoor  Depending on staffing or the patient population,  both afternoon groups might be put together for an arranged activity.  21  Eleven  community-based  patients to both wards.  psychiatrists  were  Two general practitioners  entitled  to  admit  also had privileges  to admit directly to the psychiatric ward but this did not occur during the study.  Nine psychiatrists admitted and followed their own patients  throughout their inpatient stay.  They saw their patients every day,  and most attended staff conference with the rest of the ward staff once a week at a scheduled time.  Permission to carry out this study was granted by the hospital administrator in charge of psychiatry and the Head of the Department of Psychiatry, who also granted consent to use the computer room as an office.  The nature of the study was explained to each nursing manager,  who allowed staff to hear and ask questions about the research at staff meetings on each ward.  The psychiatrists were approached  individually  for permission to interview them at some point during the course of the study.  Only two, who did not admit many patients and who never came  to staff conferences, were not available to be interviewed.  STUDY DESIGN  This study is an ethnographic between patient  patient  social  treatments  descriptive study record  patient  characteristics,  from utilized  social  investigation of the interaction  a  staff  perspective.  quantitative  characteristics  hospital organization and This  in-  prospective,  methods of data collection to  such as gender and education.  22  Length of stay, medication prescribed and assignment to group therapy were three treatment variables which were also recorded.  Qualitative  methods were used to describe work organization, institutional norms and community resources.....  Many studies, including Loring (1988), Warner (1989) and Epstein (1988) point to the role of patient social characteristics, such as gender and  education  in patient treatment allocation by staff.  Social response  theorists suggest staff respond to patient social characteristics within organizational constraints and that treatment in part is the result of both of these factors.  For example, because men are more capable of  physically harming the mostly female nursing  staff, reduced  staffing  levels could result in nurses giving male patients more medication than females patients.  This study attempts to ethnographically  describe the interactive  nature of these three types of variables in a community hospital setting. The treatment variables were selected on the basis of observing  staff  decision-making and interviewing staff about what they felt were the most important aspects df treatment.  No patients were interviewed was obtained decisions  from patient records.  staff  admissions.  or observed; all patient information  made  regarding  The focus of the study was the  particular patients  in a cohort  of  23  The  study  was  conducted  over  a  2  1/2  month  period  beginning in June of 1987. Although most of the research took place on weekdays during office hours, data were collected over one weekend and during one night shift in an attempt to gain an overview of how the hospital functioned at various times.  Qualitative data on decisions made by staff about these patients were recorded until mid-August.  Quantitative data on length of stay,  medications and group therapy were recorded from the hospital chart until the patient was discharged.  The form  used to collect data is  presented in Appendix I.  Quantitative data were gathered  on patients from  both  wards.  However, qualitative data were collected only on patients (n=58) from the larger of the two wards because conference schedules conflicted.  24  A typical day on the ward was spent as follows:  DAILY SCHEDULE Time  Place  Activity  8:30-10:30  A4 Nursing Station  Talking to staff, having coffee, recording data on new admissions from hospital chart.  10:30-12:00  A2 Nursing Station  Recording data on new patient admissions from hospital chart.  12:00-12:30  Researcher's Office or Cafeteria  Lunch  12:30-2:00  Staff Conference  Taking verbatim notes on all patients admitted June 1-Aug. 1.  2:00-4:00  Researcher's Office  Writing up notes, interviewing  I. Quantitative Methods  The data on a variety of patient social characteristics, diagnosis and treatments were collected mainly from the patients' charts.  These  data were collected on a form (Appendix I) designed to record a broad range of information.  Not all the data collected on the chart abstract  form were entered on the computer and analyzed.  Quantitative data collection procedures involved recording charted data in two stages.  Much of the information was recorded onto the form  25  within a day or two of the patient's admission.  At this point, the chart  was easily accessible on the ward, and any missing information could be obtained  from  staff or their  daily  nursing  notes,  which  were not  retained as a permanent record of admission.  The  second  stage of chart data collection took place in Medical  Records in the six months following data collection on the ward.  After  discharge, the chart was sent to Medical Records within a day and, some time later, the psychiatrist's discharge summary was added. By the time the second phase of quantitative data recording took place, missing data had been identified and were collected at this time.  The quality of the quantitative data was addressed by ensuring that most chart data on each patient was checked at least three times: when first recorded, when entered into the computer, and in Medical Records.  Reliability of coding was addressed by using DBXL, a data base program which enables the researcher to input data into the computer on  a screen  resembling  the form  on which  the data  was written.  Although a code book was used to translate some data from the form to the computer, the DBXL  program permitted  character entries.  For  instance, instead of assigning numbers to different diagnoses, fourletter abbreviations of terms, such as "schiz", were used.  This reduced  the chance of incorrect numbers replacing hand-recorded  data.  Where  26  numbers were used to replace categorical data, the computer beeped when out-of-range values were entered.  Descriptive statistics, such as percentages, were used to describe the age, sex and education of the cohort and compare these social characteristics to the relative amounts of treatment given.  Tests of  significance were not used because the purpose of this study is not to propose and test a hypothesis.  This research is intended to describe  the factors involved in the staff decision-making process.  A. Description of Study Population  1. Sampling Methods  The size of the study cohort (n=108) was a function of the total time the researcher was on site, (2 1/2 months) and the average length of stay for patients in Lion's Gate psychiatric unit (17 days).  The  cohort included all patients admitted to the psychiatric ward during the first two months of the study, June and July 1987.  2.  Demographics  The  sample consisted of 108 psychiatric patients, the majority  (56%) from North and West Vancouver, 12% from Vancouver, and 11% from the Sunshine Coast communities.  The majority of the remaining patients  came from Richmond, Burnaby and the Fraser Valley.  27  More female patients (58%) were admitted than males (Figure 2.1). Patients ranged in age from 17 to 80 years.  The highest  percentage  (40%) of patients in any age group were between 21 and 35 years old (Figure 2.2).  Forty-one percent of patients  had  completed education beyond  grade 12, 39% had gone up to grade 12, and 29% had not completed high school (Figure 2.3).  Distribution of Patient Sample by Sex  tN  Distribution of Patient Sample by Age  Age < 21, n=8, (7%)  Age 36-50. n=28, (26%)  Age > 50, n=28, (26%)  Distribution of Patient Sample by Education  31  Table 2.1 PRIMARY AND SECONDARY REASONS FOR ADMISSION Primary Suicide Threat or Behaviour  32 (29%)  1  Psychotic Behaviour  23 (21%)  8  From Psychiatrist Office Visit  10 (09%)  2  Drug/Alcohol Dependence  9 (08%)  11  Family Problems  9 (08%)  15  18 (18%)  8  For Observation and Court Assessment  1 (01%)  0  Transfers from Other Hospitals  4 (4%)  0  Missing Cases  2 (2%)  0  Depressed/Dysfunctional  TOTAL  3.  Secondary  108  45  Reasons for Admission  Data on the circumstances of patient admission were collected from the chart by recording, two main reasons for admission.  Table 2.1 shows  nine categories which were constructed after listing all the reasons for admission found in the charts. This information provided a clearer idea of why a patient was admitted than did the admitting diagnosis.  32  Although it would have been interesting to compare admitting and discharge diagnosis, this was not possible.  Most of the physicians who  admitted 75%  of the  emergency  psychiatrists  and,  categories with any  cohort through  consequently, degree  the  did  not  of consistency.  initial intake diagnosis made by "anxiety", and "psychosis NYD"  use  room  DSM-III  were not diagnostic  Typical examples of the  G.P.'s were:  O.D.  (drug overdose),  (not yet determined).  One psychiatrist  routinely used "emotional" when unwilling to label a new  patient, feeling  that a diagnosis of mental illness carried a stigma which may  negatively  impact on the patient's future.  The first reason for admission was coded as "1" and the second reason, which may or may not have been mentioned, was coded " 2 " .  It  is assumed that the most important factor was mentioned first, but this was not a formal chart requirement.  There were seldom more than three  contributing factors mentioned on the initial admitting documentation.  The  most-often  cited reason  suicidal threats or actions. used  behaviour  described as  if the patient was "grossly  admitted because inappropriate",  themselves or others" or "out of touch with reality". "dysfunctional" was admission.  the  was  The second most frequent reason, psychotic  behaviour, was was  given for inpatient admission  next most often noted  his or her  "a danger  to  "Depressed" and  reason for inpatient  This category was used when the patient was described as  "depressed" and or "unable to function" at home or at work.  33  4.  How Patients Arrived at Hospital  Most of the cohort (75%) were admitted on an emergency basis. It proved impossible  to obtain  consistent data from the chart on  accompanied the patient to hospital, or if they came alone.  who  However, it  was possible to record if they arrived by ambulance or RCMP escort. One-third and  of the cohort were brought to hospital by ambulance (n=25)  police (n=ll).  One-quarter (n=28) were admitted as involuntary  patients.  Diagnosis was not used in this study as an independent variable because this implies that diagnosis was a known patient attribute or characteristic.  Only the admitting diagnosis was on the chart  during  the patient's stay on the ward and this functioned as a descriptor of the patient's behaviour at the point he or she was admitted, rather than a prescriptive label.  Discharge diagnosis was made usually after the  patient left the ward and was attached to the chart in Medical Records. It was therefore unknown during the inpatient stay.  Complete DSM-III axis data were not used in the chart.  The  diagnostic categories in Table 2.2 represent the range recorded from the charts.  34  Table 2.2 PRIMARY AND SECONDARY DISCHARGE DIAGNOSIS Primary Diagnosis  #  %  Adjustment Reaction  22  20%  7  Schizophrenia  20  19%  3  Affective-Bipolar  19  18%  4  Major Depression  16  15%  3  Affective-other  16  15%  7  S chizo-Affective  7  06%  2  Paranoid Disorder  3  02%  2  No Mental Disorder  2  02%  No Organic Psychosis  1  01%  Missing Cases  2  02%  108  TOTAL  With Personality Disorder  (100%)  29 (26%)  B. Outcome Variables  1.  Length of Stay  Length of stay was calculated by counting the day of admission as the first day and the day of discharge as the last day.  Length of stay  was chosen as an outcome variable because it was always recorded in the chart and because it has significance for both biomedical and social response theories.  35  Biomedical model theory related aspect of treatment. those who that  Patients who  are the most ill.  there  are  other  posits that length of stay is a  disease-  stay the longest should  be  Social response theorists point to evidence  factors which  also influence  length  of  stay.  Epstein (1975), for example, reported  that length of stay varied as a  function  status,  with  poorer  suggested  that  this  of  socioeconomic He  patients  was  because  staying  significantly  longer.  poorer  patients had  more trouble organizing the formal and informal economic  and support systems that facilitate discharge.  A scatter plot of all patient admissions showed that length of stay ranged from one to 57 days.  A cluster of patients had stays of one to  four days and another group was two  spread out beyond 29 days.  These  cut-off points were chosen to determine which patients would  considered  short- or long-term admission.  Short-stay  be  patients were  admitted for less than five days, and long-stay patients for more than 29 days.  Medium-stay ranged from 5 to 28 days  (Figure  2.4).  Distribution of Patient Sample By Length of Stay 80 r  :  —  :  •  60  40  20  0 < 5 days  5 - 29 days Length of Stay  > 29 days  37  2.  Medication Distribution  Medication distribution was chosen as the second outcome measure, based on the social response theory hypothesis characteristics allocation.  and  institutional  factors  can  that patient social influence  medication  Biomedical model theory predicts that medication is given in  response to diagnosis.  Medication  distribution was  recorded  by  amount,  whether or not the medication was given on a PRN basis.  type, and The amounts  of medication each patient received of any one type is reported in terms of daily average dosages in milligrams.  The amount of medication for  each patient was divided by the length of stay.  For those patients who  were given major tranquilizers, each medication was converted into chlorpromazine equivalent dosages because of the wide variation in dose equivalency (Baldessarini, 1985).  For the purposes of this study, all the medications given to patients were recorded. excluded  from  Any medications to control side effects were  analysis.  Five  categories,  as  derived  from  the  Compendium of Pharmaceutical and Specialties (1987), comprise all the medications of interest.  (See Figure 2.5)  00  co  Distribution of Patient Sample By Medication Type 100 in CN  W OH D O  — i< tn  ? II  o  •4-*  CL  80 60 40  "S 20 0 Min Tn  a n c  Maj tranq Lithium L Sedatives " Anti-dep Types of Medication  None  39  a)  Anti-psychotics: These medications were given in response  to perceived psychotic symptoms. controlled by  physicians who  In this study, their use was mainly  left orders on the chart for specific  amounts to be distributed at specified times of the day. Minor amounts were ordered by the physicians, to be distributed at the discretion of the nurses on a PRN basis.  These medications help relieve anxiety in one week, help control mood changes in two weeks, and alleviate difficulty in thinking in six to eight  weeks.  Side  effects  include blurred  vision,  drowsiness  dizziness, all of which affect the ability of the patient to drive.  and  Muscle  spasms and flu-like symptoms, constipation and difficulty urinating are common (Clarke Institute of Psychiatry, 1982).  The anti-psychotic medications used over the course of this study were:  chlorpromazine  (largactil, thorazine), stelazine  (trifluperazine),  haldol (haloperidol), droperidol, mellaril (thioridazin)e, nozinan, trilafon (perphenazine), loxapac (loxapine), fluphenazine (modecate), flupenthixol, piportil.  b) given  Minor tranquilizers or anxiolytics:  in addition  to anti-psychotics, or on  situational anxiety and to calm the patient.  These medications are their  decided by the nurses.  to control  In this study, this type of  medication was ordered by physicians, but mostly discretion of the nurses.  own  distributed at the  Patient requests for such medication was also  40  These medications included lorazepam, ativan, alprazolam, xanex, seraX  (oxazepam), sodium amytal  and librium.  The  side effects can  include amnesia, confusion, drowsiness, blurred vision, slurred  speech  and skin rash (Clarke Institute of Psychiatry, 1981).  c)  Hypnotics, sedatives and analgesics:  were combined for the purpose of this study.  These  medications  Hypnotics and sedatives  were medications used to induce sleep; analgesics were given for pain. On some occasions, anxiolytics, such as serax, were also used to aid sleep; however, hypnotics were seldom, if ever, used during the day to reduce anxiety. Physicians left orders for these medications to be used as needed, and most were given at the discretion of the nurses.  The  medications  in this  group  included: halcion  restoril, tegratol, talwin, tylenol, exdol, and aspirin. include  morning  grogginess,  upset  stomach  (triazolam),  Side effects can  or nightmares  (Clarke  Institute of Psychiatry, 1982).  d)  Anti-depressants: These medications were given in response  to depressive symptoms. over  several  generally  weeks  ordered  by  They reach peak effectiveness if administered  in sufficient physicians  amounts to be distributed by nurses.  amounts. with  no  Therefore, they provision  were  for additional  41  Included  i n this  category  were:  elavil  (amitriptyline), doxepin  (sinequan), trazadone (desyrel), anafronil, desipramine, ludiomil, parnate, surmontil and  nardil.  Side effects often include weight gain, flu-like  symptoms, constipation, difficulty urinating, and  b l u r r e d vision  (Clarke  Institute of Psychiatry, 1981).  e) that was  Antimanic  medication:  used in this study was  The  only medication in this category  lithium.  over the course of several weeks and plasma levels  from  reaching toxic  It is given in high dosages  carefully  monitored  concentrations.  to prevent  Side effects  can  include fine trembling of the hands, increased t h i r s t , weight gain, and general malaise (Clarke Institute of Psychiatry, 1982).  3.  Assignment and Attendance at Group Treatment  The t h i r d outcome measure used i n this study was assignment attendance at two  kinds of treatment groups.  hypothesizes that the reflect staff values and  selection  of patients  and  Social response theory  for treatment groups  can  management concerns as much as it does patient  needs.  Although data were collected about attendance at all groups, data from  the two  groups  that  generated  staff  discussion  were analyzed.  Each day staff met to discuss the events that had occurred in these two groups.  Membership in the groups was through staff assignment only.  42  Two  variables were constructed:  attended each group and  (1) whether the patient ever  (2) proportion of meetings the patient attended  (e.g., number of meetings attended divided by patient's length of stay on the ward).  Data regarding the Activity Group was the  occupational  therapist which  activity group that day group  the  day  membership was keep  weekly  and  before.  collected daily by asking  patients were supposed  which patients had Data  on  Insight  to be  actually attended  Group  assignment  at the and  collected by asking the social workers on each ward to  statistics  on  a  sheet  designed  for this  purpose  and  collected every week.  II.  Qualitative Methods Berger  and  Luckmann  proponents of a theory socially constructed by  (1967) are  among  the  members of groups who According  categorize and  meaningless.  In  this  order  to this theory, meaning is  not intrinsic to events or things, it is attributed. Raw inherently  eloquent  of knowledge that states that all reality is  systems of beliefs and meaning.  is  most  study,  perception itself  social response  theory  provides a socially constructed system of beliefs and categories that are used to give meaning to what is perceived.  Qualitative research and  techniques,  such as participant observation  open-ended interviewing, are used to collect data on the role of  43  Qualitative research techniques, such as participant observation and open-ended interviewing, are used to collect data on the role of social  processes  in medicine.  These  techniques  are the tools of  ethnography, which Spradley (1980) defines as "the work of describing a culture", with culture being "the knowledge that people have learned as members of a group."  Ethnographic methodology allows the researcher to describe what people actually do and say.  Garfinkle stated the importance of "keeping  a grip on primary data of the social world - raw material of specific singular events of human conduct" (Heritage, 1984). ethnographic psychiatric  methods services  to  explore  are. organized  treatment decision-making  the  possibility  around  This study uses that,  although  the biomedical  model,  processes also reflect the influence of the  social characteristics of the patient, the organization and the community.  Other strengths of the method include the period of time over which this study took place. Observations over time yielded a breadth of understanding that is not possible through measurements taken at a single point. researcher. patterns  of  Time allowed the staff to adjust to the presence  of a  Consequently, the researcher was able to conclude that the behaviour  and  the patterns  of interaction  between  individuals and groups of staff, which were observed and recorded at conferences and in casual contacts, clearly predated the study.  44  A.  Field Notes  Written notes and records comprise the most important aspect of an ethnographic record.  What is written, the impact of taking notes,  and the processing of this record form substantive methodological issues in participant observation research (Ellen, 1984).  Two types of notes comprised the primary written record for this study.  General  impressions and researcher. reasons.  research notes were kept  as  a  record of events,  summaries, written in the voice and  language  of the  Verbatim notes were considered more important for several  Using the language of the informants in its context provides  much more useful data about the culture being studied than does a summary in the  researcher's language.  Language as portrayed  by  Mishler (1985) and Heritage (1984) is an elastic medium of social action, illuminating personalities and relationships in conversational interaction.  The  staff  initially  expressed  unease about  the  presence  of a  stranger openly taking verbatim notes at staff conferences. However, after a formal presentation, at which the staff were told that information about  treatment allocation was  diminished.  the focus of the  study, this anxiety  Staff eventually accepted notetaking and, after  several  weeks, ceased to mention the study to newcomers to staff conference.  Verbatim notes were taken at all 40 staff meetings and conferences about  patients since this  was  when treatment  plans  were formally  45  discussed and negotiated.  These daily  meetings consisted of staff  discussion of treatment groups that had been held that morning.  This  was followed by discussion about individual patients as the psychiatrists scheduled for that day joined the meeting to report on their patients.  References to individual patients admitted after June 1 or before August 1 were recorded on a separate dated card containing the name of patient, the psychiatrists who were present, the names of staff who spoke and what they said.  On 211 occasions, an individual patient in the sample (n=58) was discussed at conference.  This data was recorded  Appendix  record  II contains  a  of all staff  on 4" X 6" cards.  conference  discussion  regarding patient #59. Thirty-two patients (55%) were discussed on five occasions and seven (12%) were discussed between eight and 11 times. One patients was discussed on 17 occasions.  Sixteen patients (27%) were  never discussed at staff conference.  The rest of the conference was recorded verbatim, in a notebook, including the names of all who attended, the times they left and the date of the meeting.  The verbatim material was analyzed by ordering  the conference notes by time and indexing each page by the topics it contained.  From  this  index  system,  "medication" and "discharge planning".  themes  emerged,  such  as  46  Three variables emerged as the verbatim data was being cross referenced by topic.  It was evident that medication, length of stay and  group therapy were the issues around which staff focussed the most time and attention.  Patient cards were sorted into a historic record for each patient and then sorted in various groupings, such as education and age, to see if similar treatment allocation processes could be detected.  The events  second  on  the  method of collecting field notes involved describing ward  and  recording  volunteered by staff members.  the  explanations  of  events  These were usually done after the fact  because verbatim note-taking is intrusive in such situations.  Appendix  II contains all notes on references made about discharges.  The analysis of these notes was carried out in a similar way to the verbatim notes. information  Daily notes were compiled into weekly notes.  categories  between nurses  emerged, references  to "medication  As  conflicts  and psychiatrists" or "staff shortages" were entered  under these topic headings.  B.  Interviews  Mishler surrounding  (1986) challenges the quest  interview schedules.  the promise  for, and  the claims  of scientific  reliability  of, various structured  He argues that interviewing is a form of discourse  47  that is dependent  on the joint construction bf meaning.  reason,  the use of research  he urges  methods  respondent voices and the ways in which they Therefore, open-ended, semi-structured  that  For this  respect the  construct meaning.  interviews  were deemed the  appropriate the method to obtain information about the belief systems that ward staff used to make treatment decisions.  Nine out of the 11 psychiatrists who admitted patients from June 1 to August 15, 1987 were interviewed. not attend conferences  The remaining psychiatrists did  on the ward, admitted  were never seen by the researcher.  very few patients, and  The psychiatrists who consented to  be interviewed were asked to participate in a 20-minute discussion about their role on the ward. -The conversation was semi-structured and notes were made throughout and after the interview.  Discussions with the psychiatrists included their opinions about three  general  topics:  how  and why  they  admitted  and  discharged  patients, what they viewed as the most important aspects of inpatient treatment, and issues they identified as requiring change.  Other  staff  who  were  interviewed  included  both  unit  social  workers, both nursing managers, both occupational therapists, and the psychologist who worked part-time with the psychiatric unit. informants  These  were asked to describe what they did, how they selected  patients for treatment, and about issues in working relationships on the wards.  48  C.  Reliability and Validity  Although issues of reliability participant concerns  observer  about  research  as  and validity they  are not the same i n  are i n experimental  the impact of the researcher  on the data  studies, and the  validity of the researcher's analysis must be addressed.  This includes  questioning  not  only  "what  happened",  but  i f the  if the  researcher  researcher's  actually  description  saw  of the  really  culture is  recognizable to the informants.  The  assimilation  generally facts.  resolves  of the researcher  the problem  into  of hidden  the setting  or deliberately  over  time  misleading  In this setting, the large number of informants and the continual  presence  of  collusion.  the  researcher  precluded  In fact, rather than  trying  the  possibility  to hide  of  informant  conflicts, the social  workers, nurses and psychiatrists were v e r y concerned that their point of view was clearly understood b y the researcher.  By summarizing the various points of view to the satisfaction of each group of ward staff towards the end of the study, the researcher was identified by staff as knowledgeable about the workings of the unit. After a  presentation to the Department staff  study, the researcher  on the findings of the  was asked for suggestions  This implied that the observations from the study the informants and of value to them.  to improve the unit. were recognized  by  49  D.  The Role of the Researcher  The role of the researcher i n this setting was observer, not work participant; however, access to a group cannot be gained without social participation.  In this setting, participation included being friendly with  individual staff routine.  members and showing interest in every aspect of ward  In the early weeks of the study, the marginal role of outsider  was easier to maintain than later, when it was assumed the researcher had acquired some knowledge of the setting.  Because much time was spent with nurses i n meetings and in the n u r s i n g station, it was difficult to avoid being identified b y them as an "ally" against the psychiatrists, the hospital, and even the head nurse on occasion.  When the nurses who answered many questions about "how  things worked" were satisfied that the researcher understood them, they wanted  confirmation that  researcher's  access  to  their  difficulties  all factions,  were  and they  "real", based  wanted  help  in  on  the  making  changes.  This  pressure  to  exchange  information and  act  as  intermediary  increased towards the end of the study, when the researcher could not plead lack of knowledge. r e - a s s e r t i n g that the the  process  of  changes to it.  Requests and expectations were dealt with b y  purpose of this  study  treatment allocation i n this  was limited to describing setting,  not  recommending  50  The  overall reaction by the staff to this response  disappointment.  The data collected through  was one of  relationships formed with  staff benefitted the researcher, but left the staff with no tangible or immediate results.  The promise of a presentation of the results of the  study at a future date was all that could be given in exchange.  The unequal nature of the relationships created during the course Of this research was inevitable given the goals of the researcher and the absence of formal demands from the institution.  In the future,  undertaking a study that is tailored to specifically assist the institution as well as to provide the necessary data for the researcher might avoid the disappointment staff and supervisors experience at the conclusion of research which is about them but not directly for them.  51  Chapter Three  FINDINGS  This  purpose  of  this  chapter  is  response theory in understanding staff variables from a social perspective. other interpretations are not  to  show  to  present  Length  of  and  stay,  utility  decisions about three  of  social  treatment  This is not meant to suggest that  equally  important or valuable; they  however, beyond the scope of this study. is  the  are,  The intent of these findings  analyze  the  data  using  medication  and  treatment  social groups  response are  theory.  discussed  in  relation to social factors such as patient  sex and education, beliefs  of  the institution and community resources.  In this study,  organizational  structure, the belief systems, and the community setting around treatment  is  organized  are  considered  as  intervening  which  variables,  or  critical factors that mediate the impact of. other social characteristics on treatment findings  allocation. that  Each  result  from  section  analyzing  is  summarized  the  data  to  i n the  highlight light  of  the social  response theory.  Patient diagnosis, an important variable i n both biomedical model and social response theory, is not analyzed in this study. spend  time  discussing  at  conference,  patient  on  diagnosis.  the  chart  or  The  emphasis  in was  casual on  Staff d i d not conversation formulating  a  treatment plan relative to patient behaviour and social issues, such  as  52  family, drug or job problems.  Diagnosis was not used to rule out or  include any particular treatment.  Light (1980) described a study in which he found an alternate diagnostic language used by staff in the day-to-day management of patients.  Light  referred to this non-formal diagnostic system  as  "dynamic diagnosis", in which the significance of such issues as love, anger and loss are discussed.  Psychiatrists at Lion's Gate tended to  use this to describe new patients at staff conference in terms of his or her social context and issues to be taken into account during inpatient treatment.  Nurses in this study tended to use the equivalent of another informal diagnosis that Light encountered.  The "managerial diagnosis"  was used to describe patient participation or non-participation in the ward program and potential behaviour problems resulting from specific medications.  LENGTH OF STAY  In this  section, two types of social data were collected and  analyzed relative to patient length of stay.  Quantitative data collected  from charts compared length of stay to patient social characteristics such as gender and level of education.  The qualitative data from staff  interviews, observations and verbatim records was also used to identify intervening variables such as  organizational structure, institutional  53  norms and community resources and the mediating effect of patient social characteristics and social process on length of stay.  I.  Patient Social Characteristics  In this study, only patient education appeared to be associated with length of stay; patient marital status, age and gender did not. Education was used as a synonym for socioeconomic status.  The Blishen  Scale (1971), an index of socioeconomic status, uses highest occupational status attained, and incorporates education required, salary and prestige of the job.  For some patients who were admitted only briefly, detailed  occupational histories were not available.  Patients for whom data on  occupational achievement was obtained were plotted on a graph to compare how achieved  closely  education  occupation and education  and  occupational  status  as  matched. rated  by Blishen  generated a curve similar to one using only education. purposes  of  this  study,  education  was  used  as  a  Highest  For the  measure  of  socioeconomic status, and can be interpreted as a rough measure of access to resources.  Table 3.1 shows that the most-educated patients had fewer long stays than any other group.  The average length of stay for long-stay  patients with Grade XII or less was 47 days compared to an average of 34 days for patients with higher than Grade XII.  54 Table 3.1 PATIENT EDUCATION BY LENGTH OF STAY  (Total n=108)  < GRADE 12 (n=34)  GRADE 12 (n=29)  >GRADE 12 (n»45)  7 (20%)  6 (20%)  10 (22%0  MEDIUM (>4 <29 days) (n»59)  17 (50%)  14 (48%)  28 (62%)  LONG (>28 days) (n=26)  10 (29%)  9 (31%)  SHORT (<5 days) (n=23)  7 (15%)  While the most-educated group (>Grade 12) did not appear more likely to have more short stays, they had more medium stays than the other groups.  The most-educated patients who did have long stays (>29  days), stayed 13 days less than the average long stay for the leasteducated (<Grade 12), long-stay patients.  II.  Institutional Practices and Beliefs  In this section, length of stay is discussed as a product of how work is organized, the beliefs held in this psychiatric unit, and  55  community resources.  Examples of long and short patient stays are  examined to discover how these social processes affect length of stay in this hospital.  Social Response theorists would expect that the organization of work and the values held in an institution could influence patient length of stay.  Values and beliefs held within an institution define work and  how it will be organized, which in turn affects what work will be done. Martin and Segal (1977) found that halfway house staff expectations of clients and client outcomes were related to the size of the organization in a way that could not be explained by personal characteristics of the staff or clients.  A.  Ward Work Structure  Length of stay can be, in part, the product of how work is organized.  At Lion's Gate Hospital, a system of decentralized medical  authority meant that authority was in the hands of many psychiatrists who admitted and followed their own patients.  Because there was no  full-time medical authority on each ward, the nurses took on the responsibilities of day-to-day ward management.  This system led to communication problems between doctors and ward staff in two ways.  Because it was necessary for many personnel  to maintain contact with each other, when psychiatrists were unable to attend conference, which was common, they missed the opportunity to  56  provide  information  to the nurse,  social  worker  and  occupational  therapists all at the same time.  Physicians who had the most authority spent the least time on the ward. Nurses, on the other hand, who spent all their time on the ward, had  to obtain their  physicians.  directions regarding  patient treatment  from the  They therefore had to communicate much information in the  short time that the physician was on the ward.  The  collective aspect  of conference  was important  because of the opportunity for mutual support.  to the staff  One nurse would not  bring up concerns about patient care, including length of stay, without the support of other staff.  No one staff member wished to be perceived  as telling the physician what to do.  When the topic of nurse/physician relations came up in a staff conference,  the area  clinician,  a  physician,  asked  nurses  what  intimidated them about offering a dissenting opinion to a physician. was told that she feared a negative reaction from the physician. Area Clinician:  What is a negative reaction?  Nurse: You are not a Dr., and you are made to feel small in front of others or, no reply at all, ignored in group. So, the next time, you won't, or just say, "Yes, Dr." No, nurses aren't Drs., but a patient with side effects or a patient who is too drowsy for program ... if you get a negative response, you don't do it again.  He  57  The collective aspect of staff conference was important in another way.  Because nursing staff, social workers and occupational therapists  carried out different roles with a patient, no single staff member could fully inform the physician about that patient.  B.  Institutional Norms  Psychiatric inpatient treatment at this hospital was based on a consensus which acknowledged that inpatient treatment should address two non-medical patient needs.  Asylum and group treatment were two  aspects of treatment identified by the psychiatrists interviewed in the course of this study.  1.  Patients Benefit from Asylum  Patients  were  admitted  for  physical  asylum  if  they  were  considered a danger to themselves or others and, also, for psychological asylum if the patient environment was a contributing stress from which they needed to be removed.  Length of stay was extended when  problems could not be solved by treatment to the individual alone. For example, when ward staff  were asked to consider adding adolescent  treatment beds, they refused to consider it until a community boarding facility for adolescents discharge.  was in place to accept these patients after  Staff knew that length of stay would be extended if there  were no alternate living arrangements and adolescents were particularly difficult to place after discharge.  58  2.  Patients Benefit From Treatment Groups  Patients were seldom treatment groups.  admitted  to hospital only  They were, however, sometimes  after the urgent need for asylum or supervised  to attend  the  encouraged to stay  medication had  passed  because nurses believed that the program could help the patient gain insight  into problems and  occupational  therapists  had  behaviour. total  content of treatment groups and groups.  Nurses,  control over  social  workers  decisions  about  and the  which patients were assigned to what  They believed in the benefits of the program with much more  consistency and passion than the psychiatrists.  Nurse 1: We do have one of the best programs - then we have to say, but does it make a difference? Nurse 2: Length of stay has something to do with it. Short stay patients do not benefit from the program. Social Worker: We believe in our program. Nurse 3:  But people that admit (psychiatrists), don't.  Social Worker: Doctors are not consistent. Nurse 2: They have one view of what hospital is: it's for them. We have a different view of what things are important. Nurse 1: One hour of stress management (for the patient) is more important than two minutes with Dr. S. Interviews with the  psychiatrists revealed  support for the ward program.  varying  degrees  of  Most believed that some patients were  too ill to attend groups or talk about their feelings.  59  Interview With Dr. Y Researcher: groups?  Do you know what happens in treatment  Psychiatrist: No, it's a recognized nursing decision what goes on there. Researcher:  Do you want to see any program changes?  Psychiatrist: No, it helps most people. Keeps patients doing activities and keeps them busy. They are usually too sick to talk about feelings. Interview With Dr. Q. Researcher:  Do you want to see any program changes?  Dr. Q.: The occupational therapy department used to be activity oriented and structured toward specific goals. Now it's therapizing. I prefer the old approach. The (psychiatry) Department needs the collective will to change, then to re-educate the occupational therapy department. That would require a lot of time. We need an area clinician with a lot of time to provide leadership.  None of the  psychiatrists  interviewed said  they  would  admit  patients primarily for participation in the treatment group, nor would they discharge patients whom they considered ill for not participating in groups.  Physicians did not always  insist a patient attend the treatment  groups because, although a patient may may  not  necessarily  benefit  from  the  require admission, he or she program.  One  psychiatrist  60  acknowledged  that  allowing  patients  to  stay  on  the  ward  without  attending the program led to occasional conflict: Area Clinician: "Sometimes I get a bad patient, a character disorder, who will not benefit from the program, but who needs to be here. This is a bad patient for the nurses too, critical, demanding, challenging, then I must deal with the staff on this issue.  In addition to the attitudes and behaviours of physicians, nurses identified length of stay  as a factor in how  benefit by group treatment.  much a patient would  It was unlikely that short-stay patients (<5  days) would have to attend many, if any, group sessions.  A patient admitted for one week or less would probably not attend either Insight or Activity group. For instance, a patient who a Monday  may  not  medication effects.  be  ready  for group  for a  day  or  arrived on two  due  to  By the time the staff discussed this patient amongst  themselves and  with the psychiatrist, the week would be nearly over.  It was usually  considered inappropriate to include a new  last day  of the group week.  person on the  Groups do not meet on Friday, so  one  week or more could go by before a patient began this part of treatment.  III.  Community Resources  The third major non-medical factor affecting length of stay the availability and services.  suitability of accommodation and follow-up  was  support  61  A.  Accommodation  In general, patients were not discharged until they had somewhere to go.  The need for accommodation ranged  from  rental housing or  boarding home, alcohol and drug programs, or long-term-care facilities. A scarcity of rental accommodation within the patient's price range or long waiting lists for supervised accommodation could extend length of stay.  For example: Dr. C: I talked to Connections (Drug and Alcohol Program). She is wait-listed there, maybe 10 or 20 days. Social Worker: She said she had a place in Victoria. Dr. C:  She is at the top of the wait list.  Head Nurse:  So we are going for 10 (days)?  Dr. C: If we sent her out now, she will get drunk. We are backing up a hospital bed because Drug and Alcohol has no place.  There were time problems for some patients even if availability of accommodation was not a concern.  In order to make a down payment, a  patient must first apply for Unemployment Insurance or Welfare before looking for a place to live.  Even  when  boarding  homes  were available, the societies and  groups who operate them had criteria that could make the patient an unsuitable  candidate.  A  patient  who  used  drugs  or alcohol  was  62  unwelcome if house rules were strictly enforced. #82 was hospitalized  for drug  For example, Patient  abuse and, while an inpatient, was  suspected of continuing to use marijuana.  His doctor and his primary  nurse wanted him discharged. Doctor: When can we get him into Marineview? Area Clinician: Are you serious? last? If he smokes pot . . . Nurse: He sneaks. will never know. Area Clinician:  How  long will he  She (the Marineview supervisor)  He'll never last a week.  Doctor: Any other houses? Social Worker: Not that I know of. Area Clinician: Marineview?  Is he at a high enough level for  Doctor: He will fit.  In this example, the staff and the patient's doctor contemplated a discharge to a boarding house with strict rules about the use of illicit drugs.  If the patient was to be placed there, the area clinician realized  that the patient would end up back in hospital when the placement broke down.  B.  Outpatient Follow-up Services  The  lack  arrangements, placements  of  day  extended  immediately care, and length  available  drug  of stay.  Community  Care  and  alcohol  treatment  A  patient  was  Team center  usually not  63  discharged  if community resources  that the patient would transition alone.  were not available and staff knew  be unlikely to make the inpatient\nonpatient  In the case of Patient #96, nurses were so eager to  have her discharged,  they  did not protest when  she was  suddenly  discharged without community support.  Patient #96  had been  in hospital for 29  days.  She  was  discharged against her will on a weekend, with an appointment as an outpatient at the mental health centre  two weeks later.  She  was  readmitted by the end of the first weekend. After a brief time, she was discharged on a week day, with an outpatient appointment immediately following discharge.  The  ability of the community to absorb about-to-be-discharged  patients was often a factor in length of stay.  In the social worker's  opinion, outpatient services were not adequate and the day centre was discouraging chronic patients.  IV.  Social Processes and the Production of Short and Long Stays in Hospital  In this study, length of stay was seen to be a product of patient social  characteristics and  social  processes,  which  interacted  institutional organization and beliefs and community resources.  with  64  A.  The Production of a Long-Stay Admission  There were, five frequently occurring elements present to differing degrees in the case of most long-stay patients (>29 days).  1.  The Patient Resisted Discharge  Many patients used the hospital as a live-in crisis resisted discharge until they were ready to leave.  centre.  They  It required less time  to discharge a patient who wanted to leave, than one who did not. Patients would often bargain with the psychiatrist about a discharge date and were allowed to stay an extra week until> for instance, a roommate left or an apartment became available, provided that they did not cause trouble on the ward.  Patient #59 is an example of someone who did not want to be discharged.  When the staff threatened to discharge her, she would  slash herself.  Social Worker: her?  What does Dr. B. expect us to do with  Nurse 7: She just wanted to be in here. Social Worker: Confront her and she will slash. Nurse 8: It is a containment thing. Nurse 5: It's good for hospital business - Dr. 0. is going away for four weeks, and I bet she won't get discharged.  65  The patient was unpleasant to the nurses and did not attend the group treatment.  Until this patient decided to leave, however, the  staff were defeated in their attempts to discharge her, especially in the impending absence of her psychiatrist.  Most psychiatrists  told the  researcher they would not discharge a difficult patient who belonged to a colleague for whom they were covering, especially if the patient did not want to leave.  If satisfactory discharge arrangements were not in  place, the covering psychiatrist would be responsible for an outpatient he or she was not be familiar with.  2.  The Patient is Benefitting from the Group treatment  Staff did not pressure  psychiatrists to discharge  were seen to benefit from and contribute to the group.  patients who  Patient #80 was  very well liked for both these reasons. Nurse 1: She is still getting things out of the group. Nurse 2: She is beneficial to the group. Nurse 3: Social Worker wants to keep her to help facilitate the group!  While this last comment was made in jest, this popular, articulate patient was not discharged  in the middle of the week because of the  resulting disruption to the group.  On every  occasion on which this  patient was discussed, it was noted how good she was for the group.  66 3.  Communication Problems Exist Between Staff and Psychiatrist  One psychiatrist who did not admit very many patients never came to conference. In the case of an adolescent patient, nurses claimed that the  admission  was  extended  because  the psychiatrist  successfully  avoided staff confrontation by seeing the patient only in the evenings. The patient did not want to leave and his family were not anxious to have him return home.  This adolescent patient was supposed to have a brief admission: Nurse 1: A two-day admission turned into a month. Nurse 2: He was at his best 12 to 15 days ago, he is learning bad behaviors. Dr. Y.: I said he should go, it is the Social Worker's problem. Another example illustrates the many problems related to discharge that developed when psychiatrists were not available to direct staff and to hear their concerns.  When Dr. Y did not appear at conference to discuss a patient for two weeks in a row, the ward staff complained to the head nurse and demanded that something be done about this patient. Head Nurse: Patient X is in trouble on the ward. We have concerns about her being disruptive. She won't go to bed, incites rebellion, and is disrespectful to staff. There has to be consequences to misbehaving. Cut her passes, and if she doesn't want treatment, discharge her.  67  Nurse: Another nurse discharge yesterday.  thought  Dr. Y: I didn't admit her, and responsible for her.  This  type  of  communication  problem  she  was  ready for Ir-  I don't think  happened  when  general  practitioners sometimes admitted patients to the care of a psychiatrist, who  may  or may  not have been notified ahead  of time.  In several  instances, at least three days passed before the psychiatrist learned that a patient had been admitted to his or her care. 4.  The Patient Undergoes Various Investigations or There Are NonPsychiatric Procedures Done  Patient stay was sometimes extended to allow time for further tests or other medical procedures to be carried out.  It was decided that one patient would not be discharged so that she could have knee surgery.  Otherwise, she would have been on a  waiting list for a hospital bed, which would have taken several months.  Other patients were scheduled for further investigation, such as scans  or  psychological testing.  Patients  requiring  EEGs  discharged if they were judged unlikely to keep these  were not  appointments  after leaving.  These were five elements common to a long stay in hospital.  While  these factors or events do not, in themselves, create a long stay, they  68  explain why  a  Patients who  medium-stay patient stayed  necessarily any  a  long  can  become a long-stay  time at Lion's  more ill than patients who  Gate Hospital  stayed  patient. were  not  shorter periods of  time.  Social response theory inadvertently  receive  by  is concerned with the messages patients  being  kept  in hospital.  "patient" is a label that implies a person is ill. patient  and  continuing  family  to  become  disease  suggests that the way  we  very  This can  focussed,  long past the inpatient experience.  The  with  word  cause the the  stigma  Waxier's study (1980)  label a person as a patient can  result in  prolonged symptoms.  B.  The Production of a Short-Stay Admission  Social process centered around four factors, which were associated with short-stay patients. however, short-stay admitted.  Most patients averaged a stay of 17 days,  patients left hospital within four days of  being  At Lion's Gate, the most important factor that separated  short stay patient from others was  the desire and  a  the ability of the  patient to leave.  1.  The Patient Wanted to Leave and Was  The discharged.  majority  of the  Not Committable  short-stay patients (<5 days) asked to  be  Many short-stay patients left AM A (against medical advice),  69  indicating that they were considered ill enough to warrant admission, but could not legally be held involuntarily.  Of the 13 patients  discharged "against  medical advice" (AHA),  seven were short-stay patients (<5 days), and four had medium stays, (5-29 days).  Only one patient who had a long stay (>29 days) was  discharged AMA.  Five of these seven short-stay patients were admitted for crisis circumstances  precipitated  by  relationship  problems.  For example,  Patient #21, a patient with a previous psychiatric history, had tried to force his way into his ex-wife's apartment, after breaking up with his girl friend.  He was brought to hospital by his children.  In general, these patients had not been previously admitted as psychiatric patients.  The psychiatrists were not familiar with them or  their history and were reluctant to authorize a discharge until staff had time for assessment.  Usually these patients were not in hospital long  enough to be discussed in staff conference, so information on discharge came mainly from the chart.  2.  The Patient Had a Place to Live and a Job  A patient who wanted to leave and who had the resources to live outside the hospital was discharged without much resistance from the psychiatrists,  especially  if a more lengthy  admission was likely to  70  jeopardize a job.  Typically, the patient was given  medication and  agreed to see the psychiatrist as an outpatient in return for a prompt discharge.  For example, Patient #68 was admitted  for suicidal thoughts and  agitation about an upcoming job interview.  She negotiated  discharge  with her psychiatrist so that she could go to the interview.  She was  discharged with a prescription for ativan and an agreement to continue to see the psychiatrist as an outpatient.  In this case, the psychiatrist  had been seeing this patient as an outpatient for some time.  3.  The Patient Had an Extensive History on the Ward and Was Disliked by Staff  Patient #56 was unpleasant hospital several weeks.  and demanding, and had been in  When she was discharged, against her will, she  immediately tried to be readmitted  "because I pay taxes".  When she  returned to hospital late one night, the emergency physician noted an extensive  psychiatric  history  and admitted  her.  The next day, her  psychiatrist immediately discharged her, much to the relief of the staff. Her admitting circumstances  and symptoms on both occasions were not  very different, but the treatment response was.  She was not less ill in  the eyes of the staff, but all agreed that "she was as good as she was going to get".  71  4.  The Patient Was Viewed As The Responsibility of Another Place  A patient with AIDS and a psychotic patient from Portugal were admitted and transferred within days.  These patients were as " i l l " as  anyone else, but they were seen as "belonging" to other places. Lion's Gate  was  viewed  as  a  community  hospital  and  people  from  other  countries or with connections to other hospitals were sent there as soon as possible.  SUMMARY  In  this  study,  patients  with  a  higher  socioeconomic  status  appeared to be the least likely of all groups to remain in hospital for a long time.  One  way to interpret this data, using social response theory,  is to propose that patients with access to more social and  economic  resources are less likely to have discharge delayed because of problems such as income assistance or housing arrangements through the Ministry of Human Resources.  A decentralized organizational structure was perceived to influence length of stay in two  ways.  Anything  that prevented nurses, social  workers, and occupational therapists from meeting with physicians once a week resulted in poor staff-physician communication which, in turn, affected discharge.  72  The  belief that patients should not be discharged if they have  nowhere to go and the practice of the hospital arranging accommodation did extend length of stay for some patients in this study. belief in the importance  The nurses'  of group treatment influenced length of stay.  Patient stays in hospital were extended because nurses were reluctant to urge discharge for a patient who  had not had the opportunity to  attend treatment groups.  MEDICATION  The prevailing biomedical model theory suggests that medication is given in response to identifiable disease. assumption  Social theorists question this  since no physiological markers of structural pathology are  used to uniformly diagnose the existence of the disorder, to assess the severity, or to judge the success of the treatment given.  Social response theorists argue that psychiatric diagnosis is the product of social processes (Lemert, 1951; Scheff, 1963). Social response or labeling theory also identifies the social factors that can influence treatment, including the distribution of medication. study of medication  distribution  on a  psychiatric  Craven (1987), in a ward, noted  that  medications given out at the initiative of nurses were more related to ward management factors than the symptoms of the patient.  In this study, the data on medication distribution was analyzed as an outcome measure.  Social response theory was used to suggest that  medication  distribution patterns reflect the influence of two  determined variables:  socially  patient personal characteristics, such as sex and  education, and social processes, which are determined  by institutional  characteristics, such as work organization, layout, and funding.  1.  Effect of Patient Personal Characteristics on Medication Distribution  This section focuses on the sex and education of two groups of patients; those  who  received no medication  and those patients  who  received varying kinds and amounts of medication.  A.  Patients Who Received No Medication  Only nine (8%) of 108 patients did not receive any medication. Social response  theory considers that these patients receive a very  different message about their health status, compared to those who are given medication.  "No Medication" patients are hypothesized to be less  likely to label themselves as sick.  Eight of nine patients in the "No Medication" group were admitted for drug- and alcohol-related problems.  However, these eight represent  only 18% of the drug- and alcohol-related admissions.  It is unlikely  that the "No Medication" group was treated differently because of their admitting circumstances.  74  Only 22% of the "No Medication" group had a previous psychiatric history compared to 37% of all patients admitted during the course of the study.  It is possible that the judgment not to use medication  may  have been  influenced  not  by  the  knowledge that this  patient  had  previously been labelled as a psychiatric patient.  The  data on the "No  group of patients was for  drug-  or  Medication" group suggest that this small  admitted to a psychiatric unit for the first time  alcohol-precipitated  crisis.  Because  it was  a  first  admission, the patients were less likely to have medication begun on the basis of previous treatment.  B.  Patients Who  The  Received Medication  majority of patients admitted to the psychiatric unit were  given at least one type of medication.  Social response theory can  be  used to suggest that the distribution of medication by type and amount may  be the product of several social factors.  These include the staff  response to patient personal characteristics, such as' sex and education.  Biomedical model  theory  would  not  expect  that  the  sex  and  education of patients influence the quantity or likelihood of receiving PRN  medication, such as minor tranquilizers.  Less than two-thirds of all patients (51%) were given any tranquilizers and  even  fewer  tranquilizers and  even  major  fewer patients  75  received  antidepressants  However,  when  (25%)  psychiatrists  or  lithium (15%)  were interviewed,  (See  Figure  most regarded  2.5). the  supervision of complex medication protocols, such as major tranquilizers, a course of antidepressant therapy, or monitoring lithium blood levels as the most important reasons they admitted patients.  Most patients were  given minor tranquilizers.  Figure 3.1 shows the amount of medication that is prescribed by physicians  but distributed by nurses.  This  graph indicates  that  psychiatrists' orders alone determined the amount of major tranquilizers, sedatives and analgesics that patients were given.  However, 70% of all  minor tranquilizers given to patients was distributed at the discretion of nurses7 "  --  These data show that 75% of all patients were given some amount of minor tranquilizers, and that two-thirds of it was given by nurses on a PRN basis.  While patients could ask for PRN medication, the nurse  decided if the patient would receive it.  Social theorists would expect  nurses to differentially distribute minor tranquilizers to patients as a reflection of the organizational and physical limitations imposed on them.  vO  % OF PRN MEDICATION BY TYPE 100i  :  80  Minor Tranq Sedative/Analgesic Major tranq Types of Medication  77  1.  Sex  Social response theory hypothesizes that the sex of a patient influence the type and amounts of medication given by nurses. study, nurses responded to the gender of patients in two  may  In this  ways:  they  were more likely to give minor tranquilizers to male patients than to female patients, and they gave male patients much greater quantities of minor tranquilizers than female patients.  Male patients were predicted to pose more of a threat to the predominantly  female  nursing  organizational  factors  which  staff  than  contribute  female  to  staff  patients. vulnerability  The are  discussed in detail in the next section. Physicians, who  do not have the  collective responsibility for the  be  patients, would  respond to the sex of a patient in the same  not  expected  to  way.  Figure 3.2 looks at medication differences associated with gender. It shows that males were more likely to receive minor tranquilizers (70% of which is distributed by nurses), and that females were more likely to receive the  types of medication distributed by  sedatives and analgesics.  physicians, especially  00  % OF PATIENTS MEDICATED BY GENDER CN  co  W Oi D O  8 II  J -*-»  o  CL  o  Minor Tranq Sedative/Analgesic Major tranq Types of Medication  79  Figure 3.3 shows the effect of gender on the amount of medication that was distributed by nurses.  Compared to 15% for females, males  received 83% of all minor tranquilizers on a PRN basis, which were authorized by physicians but distributed at the nurses' discretion.  These findings support the social response theory prediction that gender  affects  the  regularly or as PRNs.  type  and quantity  of  medications  distributed  Sedatives and analgesics were more likely to be  prescribed regularly for females than for males, while males received a much greater quantity of minor tranquilizers than females.  2.  Education  Education is another personal characteristic that was examined in relation to medication distribution.  Social response theory was used to  predict that the more-educated patients could be expected to verbally communicate more easily with the staff.  Consequently, these patients  would be perceived by psychiatrists and staff to benefit from a more psychotherapeutic approach, i.e., talking to staff.  Both nurses and  physicians would be expected to be less likely to heavily medicate moreeducated patients with major tranquilizers because heavy medication can make a patient too drowsy to participate in Insight group.  o oo  % OF PRN MEDICATION BY GENDER  Minor Tranq Sedatives/Analgesic Major tranq Types of Medication  81  Figure 3.4  shows the percentage of patients in each of the three  education levels who received each of three types of medications. three  groups seem equally  likely to be  All  given minor tranquilizers,  suggesting that the likelihood of receiving a minor tranquilizer was not related to patient education.  Physicians are the least likely to order major tranquilizers for the more educated group (>Gr. 12). physicians  may be  These findings suggest that prescribing  somewhat influenced  by the  education level of  patients.  Figure 3.5 shows that,  of all the  medications distributed by  nurses, they are the least likely to give the minor tranquilizers and sedatives/analgesics to the more-educated patients.  This suggests that  education has some effect on the distribution of PRN medication by nurses.  These findings suggest that, although the likelihood of receiving a minor tranquilizer at the discretion of the nurses is not related to \ education, education may influence whether or not a patient is given a major tranquilizer or sedatives/analgesics by nurses.  % GF PATIENTS MEDICATED BY EDUCATION  < Grade 12  Grade 12 Patient Education  > Grade 12  % OF PATIENTS MEDICATED PRN BY EDUCATION 100  < Grade 12  Grade 12 Patient Education  > Grade 12  84  II.  Effect of Institutional Characteristics: Organization and Structure  Social  response  characteristics  theory  interact  with  medicine distribution patterns.  is used  Service  to  institutional  suggest  that  characteristics  personal to  affect  Three facets of the institution will be  examined in this section, including how services are organized, funded, and the facilities in which treatment takes place.  A.  Service Organization  The  two main  determinants that  shaped  ward  work  were the  decentralized role of physicians and the ward funding system.  1.  Decentralization of Physician Services  Psychiatric services at Lion's Gate Hospital were organized in such a way that physicians with the most authority were not in charge of the ward as a whole.  Psychiatrists and some general practitioners admitted  and treated only their own individual patients. Each physician came in once a day to see the patient and was scheduled conference once a week.  to attend  staff  The concern of the physician was for the  welfare of the individual patient.  During  the study,  position of area clinician.  an attempt  was  made  to re-establish the  On one ward, two psychiatrists were asked to  85  spend 3 1/2 hours each on the ward.  These psychiatrists could not  begin to fulfill the job description of the area clinician which, by their own admission, would include a full-time administrator.  Therefore, the  psychiatrists, and even the area clinician, remained outside the day-today, hour-by-hour ward management decision making.  In contrast to the patient-focussed responsible for the ward as a whole. and  physicians, nurses  were  This difference in responsibility  perspective resulted in two groups with different goals, treating  the same patients.  These differences inevitably caused conflict between  physicians and nurses.  One of the sources centered around  medication  of conflict orders.  between  doctors  and  Nurses often relied on  nurses chemical  management of individual patients to carry out their duties on the ward. Physicians,  on  the other  hand,  responsibilities, often did not order  not faced  with  these  enough medication  collective  to prevent a  patient from disrupting the ward. Some physicians prefer the nurses to take time talking with patients rather than offering them sedation when the  patient was agitated.  Several  psychiatrists, when  interviewed,  longed for the days when nurses gave "TLC" (tender, loving care) to patients rather than just offering medication.  They saw older nurses as  more likely to listen to patients.  From the nurses' point of view, medication used to manage the ward.  was a tool that they  The authority to * dispense medication  gave  86  nurses the ability to prevent potentially disruptive situations. problem did occur on one of the wards  when a psychotic  A major  patient  was  admitted without the usual means of sedation.  The nurse told the psychiatrist she wanted:  a "proper order" and that "one mg. of Ativan was like giving an out-of-control person a Smartie, nights you want more - d u r i n g the day you can put up with the noise".  This same nurse described this patient as:  "a problem at nights. I want something so the rest of the ward can sleep, that's my priority, over an out-ofcontrol patient".  Nurses orders. order.  used  various  strategies  to  One option was to approach the This  was  risky,  however  obtain  "adequate"  medication  physician directly  for a PRN  because  nurses  stood  to  be  embarrassed by the psychiatrist who could refuse, and/or question their judgment.  An area clinician, at a conference asked staff:  "How do staff deal with situations i n which they can't support decisions made by the treating physician? Nurse:  An example?  Area Clinician: approach. Nurse:  About  medication  or a  recommended  It comes up a lot of times.  Area Clinician: Staff feel powerless, some discuss it with Dr. S. but receive a negative reaction sometimes, so staff, worried about feedback, retreat, and so its just between staff.  87  Nurse: I will ask another (staff member) to tell the doctor it has happened to them too, so it isn't just me, so the doctor hears it from someone else too. Some are easier to ask." When staff decided to take the risk of directly approaching the physician, the head nurse recommended "to remember to give a polished presentation of symptoms and time of last dose.  We can do better."  Another option for nurses was to talk over the problem with the area clinician, unless the area clinician was the source of the problem. On one ward, one of the psychiatrists who admitted the most patients was  the area clinician.  He was also  Head  of the Department of  Psychiatry.  The other option for staff was to wait until a problem developed with the undermedicated doctor after 12:00 a.m.  patient.  Staff usually hesitated to call the  When one doctor asked why he would not be  called after this time, the nurse told him it was "common courtesy". However, when this  doctor left an inadequate  PRN  order, he was  threatened by a nurse who vowed to call him at 3:00 a.m.  This "wait and see" approach caused  problems for nurses. It  robbed them of their control and ability to prevent trouble.  In one  incident, a nurse was injured by a violent patient because of a late response by the intern on call, who was in another part of the hospital. When nurses lost control over one patient, other patients were disturbed by the incident.  88  The  options  open  to the  nursing  physician they were dealing with. patients, left an "inadequate" PRN  One  staff  new  depended  physician who  upon  which  admitted few  order.  Nurse: "We told her to come in and give it. We told her we would not do it. I was not that intimidated, she is new here, she will listen and not respond (negatively). I'm intimidated by Dr. X."  Nurses could choose to "close the ward" and refuse to admit  new  patients, but this option was offered more as a threat to physicians  who  under medicated patients.  2.  Ward Funding  Although the  nursing  manager for each  responsible for meeting a ward budget, he control over its allocation. nursing  observation  consumed "constant"  The a  large  without  consulting  intensive nursing share  or she  had  little or  was no  Psychiatrists could order constant or close  "Constants" were round-the-clock nurses restraints.  psychiatric ward  of  staff  or "close" observation  the  for a  coverage of budget.  of a few  nursing  manager.  psychotic  patient in  very The  few  patients  consequence  patients was  of  less staff to  look after the other patients.  Hospital cutbacks meant that each ward had less money than needed to staff and run the ward.  was  Since staff salaries was the largest  89  budget item, understaffing making  on the  ward.  became a major factor in everyday  Staff  cuts  became  a  union issue  decision-  when  staff  As a result of hospital cutbacks, sick and vacationing staff  were  complained of unsafe working conditions.  no  longer  replaced  and  the  "float"  or  extra  help  available  on  an  emergency basis was no longer employed.  When the area clinician asked how things were going on the ward, understaffing  was the  predominant complaint of the  nursing  manager.  In the discussions on medication (Appendix IV), each conversation with a  complaint about  staffing  levels.  An excerpt  from  began  conference  revealed that the area clinician agreed with nurses about the impact of fewer staff and suggested unofficially closing the ward (Appendix IV, p.  1).  Less patients tasks  staff  meant  and had less  were  accreditation  carried  that  nurses  time for them.  out.  committee  available  Tasks were  attend  to  more  As a result, only top priority  that  given  had to  were  high  putting certain information on a patient's  audited  priority.  by  the  These  hospital included  chart within a specified time  after admission, making a specified number of entries on the chart per shift, and giving and recording medications.  The other groups that they  main priorities of staff  were attending  were assigned to lead each  the  day and the  treatment daily  staff  90  meeting.  Although attendance at these meetings was not audited, the  time allocated to these activities was never questioned.  The  time remaining after  groups, staff  coffee breaks was often quite limited.  meetings, lunches and  The nursing activities that had  low priority were the unaudited, unscheduled tasks, such as "one-toone" contact with patients.  The more serious the staff reductions, the  less time staff had for this kind of activity.  The term "one-to-one" meant different things to nursing staff and psychiatrists.  Some nurses thought it was the responsibility of the  nurse to see each of his or her primary patients alone, once per shift. Most of these nurses  also acknowledged  possible, given time constraints.  that this  was not always  Some nurses defined "one-to-one" as  time given to patients who requested it.  Psychiatrists seemed to understand the term "one-to-one" to mean time spent helping patients to manage anxiety without medication.  Two  psychiatrists had noticed the decline of the practice of "one-to-one" by nurses and attributed it to a change in nursing philosophy, which had resulted in the more widespread use of medication. Another psychiatrist attributed less "one-to-one" time to budget cuts, but noted the same result:  an increased reliance on medication to manage patients.  91  3.  Ward Structure  The  physical layout of a ward can make it more or less time  consuming to monitor.  On A4, a hallway bisected the nursing station.  The nurses had to check on a patient on suicide precautions, or "close observation" as it was called by staff, every five or ten minutes. usually meant that the nurse had to leave the nursing neither  the day room  nor patient  rooms  were  visible  This  station since from  Although the layout of the wards differed, neither provided  there. enough  visibility to avoid leaving the station to see patients.  Lion's Gate Hospital has no monitored "quiet rooms", a place where an acutely....psychotic patient can be left in safety until they are no longer a danger to themselves or others.  Instead, the psychiatric units  provided a 24-hour staff nurse to monitor a psychotic patient who was kept in leather restraints. several staff were required administer medications, etc. member being  Keeping a patient in restraints meant that to take the patient to the washroom, During the study, this resulted in one staff  injured by a patient and off work for at least three  weeks. 9  Social response theory  can be used to show that the physical  layout of the ward determines how patient activities  on the ward.  much time staff spend monitoring  It is expected that more medication  would be used on hospital wards that require staff time to physically monitor patient safety than on wards that had  built-in safety features.  92  SUMMARY  An alternate educated  females  and, when they  perspective were  least likely  d i d , why the  amounts males were account for  the  may be helpful in explaining why  this  given.  to  receive  minor tranquilizers  amount was v e r y small compared to  the  Social response theory provides a way  differential distribution of medication  by  seeing  distribution of minor tranquilizers as a n u r s i n g decision. have less  more  need to medicate females  most problems for nurses.  to the  Nurses may  because it is males who cause  Male patients may be medicated to  the  prevent  ward management problems for nurses.  The head nurse, who managed the budget for the ward, had little control  over  the  kind  or  number of  admissions.  When she  was  required to cut 10% from her budget, staff time was the only area where this cut  could be  made.  individual patients. and  staff  The result was less available  Comments b y psychiatrists  conversation  at  conferences  staff  d u r i n g the  revealed  that  time for  interviews, staff  relied  increasingly on medication when n u r s i n g manpower was strained.  Education and  gender  are  characteristics  of  patients  respond to because of the way in which work is organized. are  in  charge  management. with staff  of  the  ward  use  medication  The importance of this tool was  cutbacks  and a ward layout that  staff to monitor patients.  as  a  tool  that  staff  Nurses who for  ward  hypothesized to increase makes it inconvenient  for  93  GROUP TREATMENT  The physicians and ward staff see themselves as providers of two types of treatment to patients. hospital offered theory  admission through  and  medication,  group  is used to  They provide medical treatment and  treatment.  analyze  the  In  psychological this  section,  through  intervention social  data on the allocation of  is  response  psychological  treatment.  Although many different treatment, the study  group were offered as part of the  deals only with the two types of groups to which  patients were assigned by staff.  Both Insight and Activity groups had  morning and afternoon sessions five days a week. Insight group was cancelled for lack of suitable  This  section  attend the two  group  describes  groups  some  and the  Occasionally, morning  candidates.  characteristics  of  ways in which the  the  patients  composition of  who the  groups reflect the organizational constraints of the ward.  1.  Assignment to Group Treatment  Group treatment medical treatment  was  offered  type of treatment existed  to  the  term used  patients  to encompass  on the  psychiatric  all the  non-  units.  This  because of the belief that psychiatric  should be responded to by  promoting patient  psychological, behavioural, and social problems.  illness  insight into contributing  94  Ninety-three they  were  group.  patients  assigned  to.  (86%) attended Fifteen  patients  at least one group d i d not  attend a  meeting  treatment  Most of these patients had a short stay; however, this in itself  did not always  prevent  patients from attending group therapy.  Forty  percent of all short-stay patients did attend some group treatment.  A.  Consequences of Being Assigned to Insight Group  The patients quickly observed the higher status of Insight  group.  If they tried to wander into Insight group on their own, they were told to leave.  When they told their psychiatrist they  group, he or she  might have  agreed but  staff  want to attend  had veto power,  this  which  was frequently used to t u r n down requests from psychiatrists.  One result of this increased staff-to-patient  ratio was that  Insight  group patients were discussed at staff conference in greater length and detail than Activity group patients. group  members were reported  by  In-depth conversations by staff  members whose  Insight  job it was  to  observe who said what to whom in the group.  Membership in Insight group In some cases, progress  a  patients  who  staff  patient were  could also influence length  argued to prolong length was  observed to  assigned  regularly, were labeled by  to  of stay  be  making  Insight  group  because of  in group. but  nurses as "not benefitting"  of stay.  did  the  However, not  from the  attend group  95  program.  Nurses were unlikely to lobby for increased length of stay  for these patients.  B.  Consequences of Being Assigned to Activity Group  Since every patient who was not assigned to Insight group was usually a candidate for Activity group, the number of patients in Activity was much larger. group.  Only two staff members were assigned to this  An Activity group session could be a walk to the quay for  coffee, or making cookies.  There was little opportunity for staff to have  extensive interaction with any one patient.  The observations made by staff about this group and reported back to the staff behaviour.  generally focussed on strange or bizarre patient  The expectations for this group were very low and almost  anything was tolerated.  Patients were not pushed to participate, just to  attend.  When asked, staff stated that patients initially assigned to Activity group could "graduate" to Insight group, as they improved. However, only 25% of patients ever attended both groups.  Some of these patients  were "demoted" from Insight group to Activity group.  In practice, an  initial assignment to Activity group made it unlikely that a patient would ever be re-assigned to Insight group. For example, a patient who was a "bright star" in the eyes of Activity group leaders was suggested as a member of Insight group, only to be rejected by Insight group leaders.  96  This  patient to was  not allowed to attend  group claimed it needed consistency.  because  staff  who led  the  It is possible that being a member  of Activity group labeled a patient in the eyes of staff and patients.  Length of stay was never extended so patients could attend more Activity  group  sessions  and  refusing  to  attend  grounds for nurses to lobby for discharge. one attended  the  program.  "We believe  not using every available  group  was  Nurses felt a n g r y when no i n our  member stated emphatically at conference.  Activity  program", one  staff  Staff felt that patients  were  opportunity to get better when they  did not  attend groups.  Patients  often  had a  group outings.  Patients  often  to  reluctant  obvious they  were  attend Activity  be  different  opinion  of the  value  of  Activity  who were not assigned to Insight group  seen  with  Activity  group  part of a hospital outing.  group because  were  in public, as it  One patient refused  she didn't want to go to the  was to  park  for  physicians and nurses when stay  was  juice and cookies.  Friction developed between  prolonged for patients who d i d not attend groups.  This happened when  physicians separated a patient's desire or ability to attend a group from the patient's need to remain in hospital. did  not  attend  benefitting  group  as  "using  from hospitalization.  discharge of such patients.  the  Nurses regarded a patient who hospital  as  a  hotel"  and  not  They pressured v e r y strongly for the  97  II.  Characteristics of Patients Attending Each Group  Social response theory predicts that the personal characteristics of  patients, such  as  patient gender and  level of education,  could  influence group allocation.  A.  Sex  Based on social response theory, this study predicted that patient assignment to treatment groups would also reflect the nurses' response to patient gender.  One  explanation  is that nurses  may  be  more  comfortable dealing with upset female than upset male patients.  Figure 3.6 confirms that only one-third (37%) of all male patients were assigned to attend at least one Insight group compared to 80% of female patients.  When rates of attendance at Insight group  were  considered, females were marginally (17%) more likely to attend at least 50% of the (12%).  Insight groups they were assigned to compared to males  Males, however, showed a greater propensity to attend Activity  group (n=18 or 45%) than females (n=15 or 29%).  % of Patients Attending Group by Sex  Men  Women Groups  99  These  data  suggest  that  the  higher  percentage  of  females  attending Insight group reflected assignment to groups by nurses. Once patients could choose whether or not they would attend regularly, males and females were equally likely to attend Insight group regularly (>50%).  Males were more likely to attend Activity group regularly,  possibly because the afternoon session was often a sports activity. A higher percentage of patients were assigned to Activity group because everyone who was not initially selected for Insight group was usually assigned to Activity group.  B.  Education  Education is another patient characteristic that may also influence whether or not patients attended group treatment.  The more-educated  patients were expected to be more articulate than less-educated patients, making them better candidates for Insight group.  If education were the  main determinant of patient assignment to treatment groups, the highest percentage of Insight group participants would be from the moreeducated group of patients.  Figure 3.7 . shows that 60% of the more-educated patients ever attended Activity group, compared to much higher percentages for the other two groups.  However, more-educated patients were not more  likely to be assigned to Insight group.  Education did not appear to be  a major factor in being selected for Insight groups.  The less-educated  patients were more likely, however, to attend Activity group.  % of Patients Attending Group by Education  60  < Grade 12  Grade 12 Education Level  > Grade 12  101  III. Organizational Factors in Group Treatment Allocation  Social response theory are  organized  impact  therapy, will be  on  predicts that the way  how  allocated.  in which services  treatment resources,  such  Organization of services was  as  group  hypothesized  to have two kinds of effect on group treatment allocation.  The organization of service may  play a part in determining  patients are offered what treatments. gave  nurses  control over  which  In this study, work organization  patient assignment to  groups, and  their  decisions appeared to reflect their concerns about ward management.  Organizational factors may treatment patients could choose. ward organization may  also determine how  much of any  given  Unintentional barriers resulting from  have determined how  many times a patient  was  likely to attend the groups to which he or she had been assigned.  A.  Decentralization of Physician Services  The and  Department of Psychiatry  psychiatrists  who  treated  the  throughout their stay in hospital. clinician" did  not  alter  consisted of individual physicians patients  The  they  each  admitted  psychiatrist appointed  the responsibilities  of the  default, were responsible for the ward as a whole.  nurses  who,  "area by  102  Nursing administration  responsibilities of the ward  included  program.  the  Nurses,  structuring social  and  workers and  occupational therapists scheduled all group treatment activities and had exclusive control over the assignment of patients to these groups. As a result, psychiatrists forfeited control over assigning patients to groups. attend  When one psychiatrist recommended that one of his patients Insight group, staff refused.  The psychiatrist was told that  Insight group was functioning at a very must be maintained.  Nursing  groups were made only  high  level and consistency  decisions about  who attended certain  from a nursing  perspective, which reflected  their concern for the ward as a whole.  While recognizing  that  patients  regarded  doctors'  orders  with  respect, nurses were reluctant to endanger nursing authority ovr group assignment. Nurse: We did have doctors in the habit of telling them what group to go to. Head Nurse: I threw that out. groups. We need that control.  B.  We choose who goes to what  Barriers to Group Attendance  Group attendance was a source of concern for staff.  The number  of times any one patient attended either of the assigned  groups was  103  low. . Only 41% of all patients attended 50% or more of the possible group meetings they were assigned to.  There are many reasons which contributed to this low rate of attendance.  This study  looked at some of the attendance  problems  which nurses identified.  Nurses  considered  psychiatrists  partly  responsible for poor  attendance at group treatment.  Nurses wanted physicians to tell patients not only to go to group treatment, but to participate:  "Doctors need to tell them (patients) to  go, and participate, otherwise they wreck the group."  Not only did physicians fail to see the importance of groups in the same way as nurses and, hence often fail to reinforce the message that group patients  is important, they often came to see patients while the  were  or should  have  been  attending group.  One  nurse  complained that: "Doctors don't know the program hours, that between 2:00 and 3:00 is a bad time. I've never heard a doctor say "why aren't you in group?". This is opposite to our expectations.  Another psychiatrist agreed that nearly all patients could benefit from being kept busy, but he thought most were "too ill to talk about feelings".  104  Another nurse observed that "patients don't go to group because they are waiting to see their doctor." happened.  In fact, because one  Other staff agreed that this  doctor  consistently arrived  during  group treatment time, staff felt that he wanted to avoid seeing patients! Whatever the  reason, the  result was  group so they would not miss seeing  Another attending  a  organizational group  that patients avoided him.  factor  treatment  was  attending  that the  prevented  competition  a for  patient  from  patient time.  Physicians sometimes ordered a number of investigative procedures and consults,  in addition to the standard  Nurses were required to add  standard  tests ordered by  the hospital.  patient information to the chart  within a specific period of time.  Nurse: We had a terrible audit, but to do care plans and the nursing interview, I have to pull patients out of group. The requirements are too much. Supervisor: If they can do it on the other ward, so can we. I suspect they pull people there too. Nurse: O.K. by me. To get care plan on the chart, with patient input and co-operation, can't get that in 24 hours. When I have time, the patient is in group.  Nurses also blamed patients for poor program turnout.  Patients  were not viewed as responsible consumers of group treatment. were up to the patients to show up for group on their own," commented, "we  could all go home".  It may  "If it  one nurse  have been true that  10  patients did not want to attend groups; however, nursing practices may have also contributed to patient non-attendance.  SUMMARY  Gender appeared to be associated with nursing allocation to group treatment. behaved  One way to interpret this data is to suggest that nurses in  a way  which minimized the  maintaining order on the ward.  problems  they  faced  in  Because men represented a greater  threat to the physical security of the nurses and towards peace, nurses were less likely to assign male patients to Insight group, a group in which they might become upset.  Therefore, more women were assigned  to Insight group treatment than men. -  Group treatment can be viewed as the product of many social processes  which revolve around  nurses' need  for authority, their  responsibility to maintain ward control, and the pressure on all hospital staff to locate the patients they are treating.  106  CHAPTER FOUR  CONCLUSIONS  Seminal studies in psychiatric epidemiology  by  Leighton  (1963),  Hagnell (1966), and Srole (1962) have portrayed mental illness as both a biological and a social fact.  Social characteristics, such as age, sex and  economic status, appeared to influence who and how  was identified as mentally ill  he or she was treated. Life experiences, such as bereavement,  and social events, such as unemployment, were acknowledged as shaping the mental health of both  individuals and  entire  importance of the social context of psychiatry was  communities.  The  not in question; it  was a matter of study.  As the practice of psychiatry moves from large, isolated mental institutions into mainstream  biomedical institutions, the profession is  under increasing pressure to concentrate research and resources in the quest for biochemical solutions to mental illness.  The "remedicalization"  of psychiatry threatens to obscure the importance of the social context of disease.  A  more disease-focussed perspective within psychiatry  means that psychiatric services will be planned, developed and evaluated in response to structural and biochemical pathology.  A review  of the literature suggests  that the profession is not  unanimously in favour of adopting a more biomedical approach.  One  faction suggests that the biological aspects of psychiatry be allocated to  107  medicine  and that  psychiatry  concern  itself  only  with  non-medical  the biomedical  model and  "problems in living" (Laing, 1960; Szasz, 1961).  Engel  (1976) proposes  to expand  acknowledge all diseases to be both biological and social facts. means of implementing  As one  this merger, this study proposes using social  response theory to construct a social perspective that will ensure a biological-sociological balance in the planning, delivery and evaluation of health care.  Historically, social response theory has been used 1) to examine how society shapes our concepts of health and illness; 2) to describe the  social  processes that  influence treatment  allocation;  and 3) to  document the effect of society on shaping the behaviour of an individual by labeling and treating him or her as deviant. This study uses social response theory to describe decision-making relative to social processes and to the social characteristics  of patients, the institution and the  community.  LIMITATIONS OF THIS STUDY  The value of this research has limited significance for the site in which the study was conducted.  The findings suggest that the social  processes identified in this study will vary over time and the impact of these  processes  will  change with  personnel, policies  Because only one of the two wards in this psychiatric  and programs. unit was studied  1  using qualitative methodology, the findings of this study represent the >  social processes  relative to treatment allocation on one  ward, at  one  point in time.  These findings constitute a one-sided interpretation of the data, intended only to demonstrate how  a social perspective is constructed.  Although this research points to the necessity of using a model that integrates findings from both biomedical and social perspectives, such a task was beyond the scope of this project.  The results of this study are of interest because they represent a different perspective, one which can add explanatory power to a model that uses insights generated by both perspectives.  These findings, are  not presented as more important than interpretations using a biomedical model.  CRITICAL COMPONENTS OF A SOCIAL PERSPECTIVE  These  findings  perspective by  contribute  to  the  development  of  a  social  underlining the importance of commonplace events and  facts and by using research methods that demonstrate the existence and influence of social processes.  I. The Significance of the Commonplace  109  An overview of the obvious and a description of the commonplace can  be  a  critical  tool  in  planning  or  evaluating  organizational knowledge is always limited and  services  relative.  since  Knowledge is  limited because no single member of an organization knows every detail of the operation.  Knowledge is relative because the  position of the  employee within the organization determines what he or she knows, and the significance of that knowledge.  This research  points out the significance of facts that are  commonplace they have become invisible.  so  The response to much of the  data collected in the course of this study  was  "I already know that",  but this knowledge was not considered to be important.  For example, the  daily conference  was  considered  an  important  venue for team treatment planning, based on the .information exchanged by all members.  On occasion, nurses had already decided what should  be done for a particular patient and, in these cases, only information supporting this decision would be presented. of ward "politics" was  acknowledged by everyone who  its influence on treatment decision-making  Occasionally, informants other research data. assigned  The  small percentage  worked there, but  was not as obvious.  "knew" things that did not agree with  For example, according to nursing staff, patients  to Activity group were assigned  recovered.  In addition, the existence  to Insight group as  they  research data, however, showed that, in fact, only a of patients were assigned  to both  groups.  This  110  suggests  that  assignment  to group  therapy  was  related to nurse  response to patient gender and/or to the group development processes that made it difficult for a patient to be incorporated into an existing group.  The  nursing  manager and the area clinician may be unaware of  this information because it is not collected by the ward. Psychiatrists may not be very considered  interested because everything  a nursing  decision.  related to groups is  The qualitative and quantitative data  collected from a study such as this may provide administrators and staff with new information  and may correct inaccurate  information.  This  study illustrates the potential significance of collecting data on those aspects of ward functioning that are usually considered  to have no  relationship to treatment allocation.  This study outlines a theory  and methods that  point out the  consequences of the seemingly innocuous.  II. The Significance of Social Processes  Social  processes  are  the  dynamic  product  of  the  social  characteristics of individuals, institutions and society.  However, the  effect  these  of these  demographics.  processes  cannot  be  predicted  For example, when patient  studied relative to length  social  from  social  characteristics are  of stay, the findings indicate that patient  gender and economic status may be factors in determining length of  111  stay.  The data suggest that those patients with the highest levels of  education are the least likely to have a long stay.  This finding also  indicates that those patients with the least resources difficulty getting discharged. another explanation: to  remain  While this may  patient choice.  in hospital may  be  have the most  be true, there is also  Whether or not a patient chooses  just as  significant as  the  economic  difficulties that prevent discharge.  A  social perspective depends on  characteristics to orient the reader. the  social processes  incomplete.  operate  However, without knowledge of how  in the  Qualitative data,  quantitative data about social  such  setting, a as  social perspective is  verbatim  conference, allows the researcher to know how,  why  notes and  from  staff  which social  characteristics affect treatment allocation.  THE NECESSITY OF A SOCIAL PERSPECTIVE  This study illustrates how  a social perspective can be constructed,  using social response theory combined with quantitative and qualitative methodology. as a  The research suggests the value of a social perspective  model for hospital psychiatry, for planning  and  evaluation of  services, and as a tool to be used in the integration of the biological and sociological in all aspects of health care.  1  I. As a Model For Hospital Psychiatry  A well-developed social perspective can be used to fight the total assimilation of hospital psychiatry into the biomedical model.  However,  this research does not claim that a social understanding of psychiatry is more important  than  a  biological  understanding.  Both  social  and  biological models are needed to achieve a comprehensive understanding of mental illness.  II.. For Planning and Evaluating Hospital Psychiatry Services  Research from a social perspective can help hospital administrators to understand and respond to the fact that social processes on the ward and in the community shape and are shaped by medicine. of this study  The findings  explore the influence of social processes on  treatment  allocation and point to the existence of social solutions for problems that may  have had  solutions based  no on  biomedical solutions. social facts  The  result is a variety of  which, considered in relationship to  biomedical factors, can be implemented even before biological disease is conquered.  Specific recommendation based on the findings in this study  are beyond the scope of this project.  III.  For Society  Every  advancement  in medicine  is enhanced  by  an increased  understanding of the social processes surrounding it because all human activity takes place in a social context.  114  REFERENCES  Baldessarini, R.J. 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Reidel Publishing Co., Dordrecht, Holland, 1980.  122  Waxier, N.  "Sustaining the Sick Role:  A Study of Labeling."  Research  Grant Proposal, unpubl.  Wolff, N., et al. Hospitals.  Treatment Patterns For Schizophrenics in Psychiatric Social Science and  Medicine. 28(4):323-331, 1989.  123  APPENDIX I Chart Abstract Form Patient File:  Part One  DEMOGRAPHICS: Research Number  ; MRN_  Patient Name Address:  Psychiatrist :  (City)  (Prov)  ;  _G.P.  (St. + Apt.)  Length of Stay at Above: Living Situation  (alone, institution, family of origin, own family)  Length of Stay at Above: Age ; Sex ; Date of Birth '+ Children, . Next of Kin (listed on chart) Employer:  (City) (Prov) (St.+ Apt.)  ; Occupation  Education:  Marital Status,  Address  Length of Time  ,  ADMISSION DATA: Admission Date: ; Time of Day: (weekday, day, mo) To Ward: Kind of Admission: Vol or invol  Admitted By: (Psychiatrist) (G.P.)  Admitting Circumstances: Through emerg? Y  N  Seeing this Psy? Y N. (include how  patient arrived, with whom, by police, etc.) Admitting Diagnosis: Admitting Medication:  :  1 24  PRN's  _____  Existing Medical Condition: Consults Ordered  PSYCHIATRIC HISTORY:  MRN#  Known History: Y or N Previous Admissions  Length of Time  ; . dates at L.G. + attending Psy + G.P.  Admissions Elsewhere  :  dates and places Previous Diagnosis (Listed on admission) (Place and yr.) (From Old Charts Previous Outpatient Treatment where and when Previous ECT When, how many treatments, when Medication History (if possible)  .  what and for how long DISCHARGE DATA: Date of Discharge:  ' weekday, day, month  Discharge Plans: medications, residence, treatment Total Length of Hospitalization: including transfers Total Time at L.G. Discharge Diagnosis:  '  125  PATIENT  FILE:  PART  II  Ward  MRN  Dates Voluntary, Patient  Status: Close, Suicidal Constant  1.  Medication: Kind  Began Ended Amount  Date PRN's  2.  Frequency  Amount  Time of  Frequency  Day  Nurse(*Primary)  Given  Passes  Used  Date:  7.  Restraints  Discharge:  Length  Date:  of  Discussed  Time  Purpose  by  Comments  Whom:  126  8.  Visitors Noted in Chart:  9.  Additional Consults:  10.  Primary Nurses  Date  Nurse Date  Date: Who:  Date:  Who:  Nurse Date  Comments?  Results:  Nurse  APPENDIX II Example of Verbatim Staff Conference Notes on Patient # 59  June 29, No Doctor Present Primary Nurse: She took offense at the suggestion that she is disorganized about clothes. She has to wash because she does not have enough clothes here. June 30, No Doctor Present Occupational Therapist (reporting on Activity Group): but didn't respond.  She was listening,  July 2, No Doctor Present Occupational Therapist (Activity Group Report): She stormed out of the room and said: I'm not going to the park to eat cookies and drink juice", she wasn't able to say she didn't want to. Nurse 1:  She is behind the animosity between groups.  Nurse 2:  She is a good manipulator. July 6, No Doctor Present  Nurse 2: She says she may be in for a demotion. The only feeling part of the talk. She is the only one fitting for feelings group, (also called Insight Group). Nurse 3: She is at a different level. Nurse 1:  Same as Celine T.  She knows what to say. July 7,  Social Worker:  No Doctor Present  She did not contribute much.  Nurse 2: She said she would like anti-depressants but the doctor didn't trust her. Social Worker:  She is very groggy.  Nurse 4: She is very sleepy on (CPZ 75 mg. and nozinam 75 mg. TID, with 30 mg. serax given pm at 1930 July 6) and wants them reduced. Nurse 2:  That's hefty.  128  Nurse 4: It is. Social Worker:  Why put her in feelings group and expect anything?  Nurse 4: She will ask for a decrease. July 8, No Doctor Present Social Worker: out of bed.  She complains of too much medication, had to root her  Nurse 2: Her job is stressful, but there is nothing else in her life. Social Worker:  She works at VGH.  Nurse 2: Sounds like a pig stye. Social Worker:  She can't give up the job.  Nurse 5: So she takes off sick time. Social Worker: Should take up disability leave. She gives contradictory information about feeling terrible to be here and working on stuff. We challenged that. Nurse 6:  She comes across as being scattered.  Social Worker:  Do token chats with her. July 14, D. S Present.  Insight Group Report.  She was in bed and did not come. July 15, No Doctor Present.  Social Worker:  What does Dr. 0 expect us to do with her?  Nurse 7: She just wanted to be here. Social Worker:  Confront her and she will slash.  Nurse 5: It's a containment thing. Social Worker: Amazing that she still has a job which is reasonably good. Nurse 8: She is a steno. Nurse 5: She is good for hospital business. Dr. 0 is going away for four weeks. She won't get discharged.  129  Nurse 2: He is going to a course in Europe, with the fare paid. July 16, No Doctor Present Nurse 3: She didn't get up.  Nozinam ...  Nurse 2: Dr. 0 made her passes contingent on group attendance. Head Nurse:  So she isn't showing up, so can't put her in on Friday.  Nurse 2: She couldn't come on Tuesday because of physical things. Nurse 5: How are we going to manage her with the least problems? Social Worker: I'm not going to confront her and have her slash. Nurse 2: It's an awful responsibility.  It will happen.  Nurse 6: She thinks she can get a pass. Head Nurse:  We can do two things: ignore it, or make her stay.  Nurse 8: We are really dealing with Dr. 0. Head Nurse: Whatever we say he will do the opposite! The way the order is written, it is the nurses fault. Make him order specific passes, no global order. Nurse 2: Cover your bottom. Nurse 6: I am not impressed with those orders-nurses will decide differently. Nurse 2: I want to be away from her situation. orders.  Dr. 0 should give you  Head Nurse: Every pass a separate order because you can't tell. 0 won't, whoever takes over should.  If Dr.  Nurse 6: If I let her go he will have something to say, and if I don't let her go, he will. I'm going to cancel until I hear from him. Nurse 2: He may not come in. Head Nurse: Get him to specify. Social Worker: If two or three doctors cover for him, could be five doctors! Nurse 8: She agreed with Dr. 0 to attend the program.  130 Head Nurse: Yes, it may have been her, but Nancy slashed! (A reference to her diagnosis of "multiple personality"). That's her out. Let's put her on the behavioural program. Specify what she has to do. Head Nurse:  It's t r i c k y to treat her like a borderline.  He won't like i t .  Head Nurse:  We have to practice the best n u r s i n g care.  Nurse 6: The best n u r s i n g would be to shoot her! ... You don't want to her complain about being punished or not liking her. Head Nurse:  You are going to get that coming or going.  Nurse 6:  We keep hearing about Nancy.  Nurse 2:  Could we treat her by just telling her to go to emerg?  Nurse 7:  Then emerg complains.  Nurse 2:  Shoot her!  Social Worker: Nurse 2:  A summer holiday!  ... and she works ...  Social Worker: Head Nurse:  VGH and going to be demoted ... ... job sharing ...! July 20, Dr. Q Present  Nurse 6: Dr. Q:  Has the other personality come out yet?  Nurse 6: D r . Q:  She would like to see you (to Dr. Q)  Not yet ...  Even in hypnosis they didn't.  Nurse 6: She is getting pressure from VGH where she works as a steno. She is worrying she will be demoted to ward clerk. Dr. Q:  When d i d she cut her wrists?  Nurse 4  Thursday.  Nurse 9  Again.  Nurse 6 with i t .  There was a reference to Nancy, that she had something to do  131  Nurse 5: She wants plastic s u r g e r y for her wrists, and she is concerned about being demoted, but says work is stressful. Nurse 6: position. Dr. Q:  What are we doing for her?  Nurse 5: Dr. Q:  She does not want to go back and face the others at a lower  It's a containment thing.  She has had multiple admissions lately.  Nurse 5: When discharged, she gets friends to b r i n g her back, her questions at Community Meeting were of someone who planned to be here awhile, not high on the rest of the group's priority list. She expects to be here for the next couple of months. Dr. Q:  Can we teach her other responses to slashing?  Nurse 6:  She needs self esteem and discharge planning.  Nurse 4:  Feelings group was too much.  Nurse 6:. Daily I ask her what her goals are. Dr. Q:  It may  be a relief to get demoted.  Nurse 6:  She is avoiding it.  Nurse 5:  She seems to have her own time schedule. July 21, Dr. Q and Dr. C.  Nurse 8: She was acting out and c r y i n g on the phone (her supervisor had called changing her job). July 22, Dr. Q and Dr. R. Dr. Q:  She is discharged, she wants to go.  132  APPENDIX III An Example of Data Compiled by Topic: Notes about Patient Discharge June 18 - re: discharge of Keith. Dr. U wanted to keep him until Friday but Curt (a nurse) talked him into discharging him that day, Wednesday, because of management problems on the ward. He had "cleared" from an LSD O.D. but would not cooperate with staff. June 22 - patient of Dr. Y's discussed by 2 nurses on A2. One nurse told the other that she would try to get this patient discharged as soon as possible because the patient is driving her crazy - smoking where she was not supposed to, and not attending the ward program. This patient was described as being difficult and uncooperative. To find out: how much say do nurses have about discharge and what are their reasons for wanting a patient discharged? July 6 - Dr. Y discharged a difficult patient of another psychiatrist, for whom he was covering. This surprised everyone. There was no lead time and no warning. This decision endeared this Dr. to nursing staff. July 16 - Curt commented that with medical numbers Drs. don't get paid. They push to discharge a patient whose medical coverage is known to be invalid. He told me that he had in the past helped backdate recently acquired medical numbers. See July 16 conference note. Staff recommend discharge for patient L, to Dr. Q who is seeing her as a second opinion. RM was to be sister, but sister refused husband. Staff are waiting step in the wrong direction,  discharged yesterday to the care of her and patient then decided to go back to to contact Dr. about this but agree it is a and the patient is still here.  Placement seems to be a major aspect of discharge planning. Dr. Q tells staff that Patient #56 is leaving on Friday and she picked the date. Another patient has chosen the end of the month contingent on her agreeing to participate in the ward program during the intervening time. The Dr. thinks she may decide to leave earlier if pushed and confronted, but that is her choice. Patient choice element in the process.  re: discharge  seems to  be  an  July 22 - A nurse told me it was generally considered bad discharge a patient while the Dr. was on holidays. Ask about this in interviews with psychiatrists.  important form to  APPENDIX IV Excerpts from Three Patient Conferences on the Topic of Medication  Conference No. 1  Nurse  1:  Nurse 2:  We have a r u n on profoundly delusional people. Is he (Area Clinician) aware of staff cutbacks?  Area Clinician:  What?  Nurse 2:  We are down to one staff per day.  Area Clinician:  We should hold down the  Nurse  I would like to get down to A2  1:  census. beds.  Nurse 3:  That's opposite of what they want.  Doctor:  Don't close beds officially, just don't admit.  Nurse 4:  Really, weekends are awful.  Nurse 2:  The charge nurse can close beds on weekends.  Nurse 5:  Patients suffer from not getting good care.  Nurse  6:  How many admitted on weekend?  Nurse  1:  In a short space of time, 3 admitted all of sudden our responsibility.  Nurse 2:  A comedy of errors, a patient sent to Dr. X out of the blue, not supposed to get here till next week. When Dr. X saw staff being beaten up, sent him to Riverview.  Nurse  And his meds a mess.  1:  Head Nurse:  That's another thing. Health and Welfare stopped recommending sodium amytal, all Drs. have decided not to use it, but no concept of what to use instead. So not as many staff, 2 down today, and no orders to sedate anymore.  Nurse 1:  Dr. Y should know that 25 mg. haldol is no good.  Head Nurse:  Staff agreed.  Doctor:  That bulletin is a minor recommendation.  Nurse 2:  We have had it for years.  Nurse 3:  And never abused it.  Nurse 2:  It always worked.  Head Nurse:  Droperidol doesn't always work.  Nurse 1:  If injection takes four people, can't do that every four hours.  Nurse 2:  The need is there, patients need to be utterly sedated.  Nurse 3:  Dr. Z suggested nozinan and ativan, but it takes too long, and sometimes doesn't work.  Doctor:  I'll find that letter, I'm sure it's just a warning.  Nurse 2  Interns should be talked to.  Nurse 1  Or I'll call you when it's 3:00 a.m.  Nurse 3  Three of us had to ask for an order of  Nurse 1:  How much sedation did he have when patient nailed nurse? It's reasonable to think he would not have done it if ..  Doctor:  Can give up to 100 mg. haldol in one hour.  Excerpts from Patient Conferences on the Topic of Medication  Conference No. 2  Area Clinician 2: Nurse 1:  And how Was  are things on the ward?  busy and understaffed this week,  (some discussion on Area Clinician 2:  Nurse 1:  groups)  Is this the best forum to discuss - how do staff deal with situations i n which they can't support decisions made by treating physician? An example?  Area Meds or recommended approach. Clinician 2: Nurse 2: Nurse 3:  Comes up a lot of times. Staff feel powerless, some discuss i t with Drs. but negative reaction sometimes, so staff worried about feedback back off. So it's just between staff.  Nurse 4:  I will ask another to tell Dr. i t has happened to them too, so i t isn't just me, so the Dr. hears it from someone else too. Some are easier to ask.  Nurse 3:  Some are more approachable than others, or they ask "what do you think?" to staff.  Nurse 5:  Area Clinician makes a difference too. You have another opinion to give.  Area Clinician 2; Nurse 1:  How  much of an issue is it?  I'm leaving, you (other staff) say. Not all the time.  136  Nurse 2:  Not a constant issue, some staff more than others.  Nurse 3:  So personality is a factor.  Nurse 2:  Oh, definitely, I don't r u n into it that much.  Area Clinician 2 to Nurse 1: Nurse 1:  Area Clinician 2:  Nurse 1:  You are here now. I just wanted to give another more time, depends on working relationship with others and Dr.  You suggest that discussion takes place with nurses not people involved. The doctor is in charge, and that is the way it is. The fear of the past.  Area Clinician 2: Nurse 1:  So nothing can be done? Talking like this is helpful.  Area  What is a negative reaction?  Clinician 2:  You are not a Dr., and you are made to feel small, in front of others, or no reply at all, ignored in group. So the next time, you won't, or just say, "yes Dr." No, nurses aren't Drs., but a patient with side effects or a patient who is too drowsy for program ... if you get a negative response, you don't do it again.  Nurse 2:  Nurse 4:  Why do you ask now?  Area I've heard it periodically. Clinician 2: It's better here than on other side. Nurse 3: Remarkable, how much better it is here. Nurse 2:  1 37  Area Clinician 2:  Situation with patient A is a good example- I gave ativan, and you Nurse, asked for a "proper order". He had been a problem all night, resident ... called, and meds not given as reordered. Were they worried about calling me at night?  Nurse 3:  He spit out the ativan.  Nurse 4:  And threw it up too.  Nurse 3:  But did not chart that.  Area Clinician 2: Nurse 4:  Area Clinician 2: Nurse 3: Intern:  So two problems, communications and meds. He is a problem at nights, want something so rest of ward can sleep, that's my priority, over an out-ofcontrol patient. But would not call you after 1200. Why? Common courtesy and would call intern. They do call.  Area Clinician 2:  That case illustrated a couple of things: why I didn't want him to have neuropleptics should have been included.  Nurse 3:  One mg. of ativan is like giving an outof-control person a Smarty, nights you need more. Put up with noise during the day.  Area Clinician 2:  Nurse 3: Area Clinician 2: Nurse 4:  It is not uncommon to hear nurses say 25 mg of mellaril is inadequate, but not dealt With physician, is that true? We agree. Or nurses tell me through other Drs. Yes, intimidation, fear of being embarrassed.  Nurse 3:  Can think of a lot of nurses who would not speak up to Dr.  Nurse 4:  I got called DR. once, ... I never d i d it again.  Area Clinician 2: Nurse 4: Area Clinician 2: Nurse 3:  I do i t in good f u n . You always do that, b u t I don't take it badly.  We have to work on this. We get irritated when doctor won't come i n , Dr. B is gone for four days, cuts patient off meds over weekend, may have good reasons, but we would appreciate knowing.  Excerpts from Patient Conferences on the Topic of Medication  Conference No. 3 Nurse 1:  We aren't out of school, we have seen patients before.  Nurse 2:  Recite yesterday's conversation with patients before.  Nurse 3:  Patient A screamed all night and the next.  Nurse 2:  He (the physician) was not nice when I wanted something more for him, found myself starting to get angry. He realized that.  Head Nurse:  W.e„need to remember to give a polished presentation of symptoms and time of last dose. We can do better.  Nurse 1:  Cpz, 25 mg, Dr. C. We told her to come in and give it. We told her we would not do it. I was not that intimidated, she is new here, she will listen and not respond. I'm intimidated by Area Clinician 2.  Nurse 4:  He can be nasty, in control. more accepting.  Nurse 3:  Dr. D can do over kill, give everything.  Nurse 4:  I'd never ask Dr.  Nurse 2:  Last week he attacked the intern, knocked her flat.  Nurse 4:  He would take my response as slap in the face.  Dr. (1)  141  APPENDIX VI  PURPOSE OF THE AREA CLINICIAN  Because of the decentralized nature of the physicians' services on the ward, the concept of area simplifying  nurse-physician  clinician was introduced as a means of  communication and to involve at least one  psychiatrist more closely  i n the day-to-day functioning of the ward.  The physician  as area  designated  clinician  was  paid  to spend  seven  hours a week on the ward to do patient and staff education, conflict management and as a liaison between nurses and physicians as a group. On the ward i n which most of this research took place the duties of area  clinician  were split  between two psychiatrists.  One  was i n charge of patient information groups and attending meetings once a week. conferences.  psychiatrist community  The other psychiatrist was to attend all ward  

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