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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 this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that 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 smaller psychiatric units in medium and even small community hospitals. This biomedical setting results in pressure to adopt a more biological focus for treatment. 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 concludes that social response theory is useful in understanding 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 . . ix CHAPTER ONE: 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: METHODOLOGY 17 Study Site.....77.71. ......7..7J...7......J......... 17 I. Insight Group 19 II. Activity Group .. 20 Study Design .. 21 I. Quantitative Methods 24 A. The Description of Study Population 26 1. Sampling Methods 26 2. Demographics 26 3. Reasons for Admission 31 4. How Patients Arrived at Hospital 33 B. Outcome Variables 34 1. Length of Stay .....34 2. Medication Distribution..... 37 a) Anti-psychotics 39 b) Minor tranquilizers and anxiolytics 40 c) Hypnotics and analgesics 40 iv d) Anti-depressants 40 e) Anti-manic medication 40 3. Assignment and Attendance at Group Treatment 41 II. Qualitative Methods 42 A. Field Notes , 44 B. Interviews 46 C. Reliability and Validity.. 48 D. The Role of the Researcher 49 CHAPTER THREE: FINDINGS .....51 Length of Stay • • 52 I. Patient Social Characteristics ...53 II. Institutional Practices and Beliefs 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 60 A. Accommodation 61 B. Out-patient Follow-up Services 62 IV. 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 64 2. The Patient is Benefitting from the Ward Program..... 65 3. Communication Problems Exist Between Staff and Psychiatrist... 66 4. The Patient Undergoes Various Investigations or There are Non-Psychiatric Done 67 V B. The Production of a Short-Stay Admission 68 1. The Patient Wanted to Leave and Was Not Committable 68 2. The Patient Had a Place to Live and a Job 69 3. The Patient Had an Extensive History on the Ward and was Disliked by Staff..... 70 4. The Patient Was Viewed as the Responsibility of Another Place.. 71 Summary 71 Medication 72 I. Effect of Patient Personal Characteristics on Medication Distribution 73 A. Patients Who Received No Medication 73 B. Patients Who Received Medication 74 1. Sex 77 2. Education 79 II. Effect of Institutional Characteristics: Service Organization and Structure.... 84 A. Service Organization 84 1. Decentralization of Physician Services 84 2. Ward Funding... 88 3. Ward Structure 91 Summary •• 92 Group Treatment.. .... • 93 I. Assignment to Group Treatment 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 I l l I. As a Model for Hospital Psychiatry .....112 II. For Planning and Evaluating Hospital Psychiatry Services 113 III. For Society . 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: Notes About Patient Discharge.... 132 Appendix IV: Excerpts from Three Patient Conferences on the Topic of Medication 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 , 30 Figure 2.4 Distribution of Patient Sample by Length of Stay.. 36 Figure 2.5 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 -.. 82 Figure 3.5 Percentage of Patients Medicated PRN by Education 83 Figure 3.6 Percentage of Patients Attending Group by Sex > 98 Figure 3.7 Percentage of Patients Attending Group by Education . 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 cooperation. This thesis was supported in part by a Graduate Fellowship from the University of British Columbia. This thesis is dedicated to my parents and to Bill, who gave me material support, time and love over an extended period with little return. Thank you. 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. These include birth, pain, aging and death. 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 make sense out of what is puzzling or disturbing, are called models. 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 benefit from critical examination. Mishler (1981) criticizes modern medicine for its narrow perspective which focusses "on the concepts, methods and principles of the biological sciences", and stresses that health and illness are social as well as biological facts. He identifies four assumptions inherent to the biomedical model and, through his critique of these assumptions, lays the groundwork for an expanded perspective. A cornerstone of biomedicine is the belief that disease can be defined in relation to a biological standard. 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 (1987), Past President of the American Psychiatric Association, calls for the "remedicalization of 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 will firmly establish psychiatry as a speciality within biomedicine. 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). Schur describes labeling theory as "redirecting the analysis away 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 deviance is conceptualized and identified 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. This results in stabilizing the deviant behaviour. 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 offered to patients. Over a five-year period, he found that patients in the most 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 services were given the message that they were "well" upon discharge. 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 work through which a particular social reality is constructed." 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 rest on the concept of secondary deviance. 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 decision-making, 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 antisocial personality disorder were found to be sex-based diagnoses. Warner also found that substance abuse team members tended to diagnose more alcoholism and psychiatrists diagnosed 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 may influence whether or not patients are given ECT. Thompson and Blaine (1987) studied rates of electroconvulsive therapy from the National Institute of Mental Health from 1975 to 1980. This form of treatment decreased by 46% during that time. The authors speculate that this was due to organizational factors, such as an increased unwillingness of facilities to maintain staff and equipment. Those who continue to receive ECT 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. These were mainly younger girls from Anglo families. 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 plans, do budget allocation, plan training programs and design 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 (3-4 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 methodology reflect the intent to employ Garfinkel's concept of "ethnomethodology" (Heritage, 1984), a term referring to the ways people make sense out of everyday life. In this case, the study attempts to understand how 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). Smaller psychiatric units adjacent to acute care hospitals are now replacing these large facilities. The result has been a switch from long-term hospitalization of one to two years to short-term stays of one month or less, with discharge to community group homes. Research must be done in these new settings to document their impact on treatment allocation and patient outcomes. 18 Lion's Gate hospital, which was chosen as an example of community hospitals found in larger towns and cities throughout Canada, has 402 acute care beds and 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 new hospital has been built. Psychiatric services are delivered as part of the total health care services provided by this hospital. The psychiatric unit consists of two wards, containing 17 and 21 beds, respectively. Each ward has its own 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 wards offer various kinds of treatment to patients, some of which are allocated by the psychiatrists and/or nurses, such as medication and electroconvulsive therapy, and some of which are chosen by patients. 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 lead by a combination of nurses and the social worker, or nurses and the occupational therapist. 19 The approximately 10 different groups that a patient can attend could be divided into two categories. Groups that all patients were strongly encouraged to attend included exercise class, relaxation group, art therapy and the planning and cooking of a ward meal once every two weeks. Whether or not patients participated in these voluntary activities was not discussed by staff at conference. The other category consisted of "Insight" and "Activity" group to which patients had to be assigned. In this study, only data on the groups to which patients were assigned by staff 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 " n o n -structured, directive, but non-controlling group for expressing thoughts and behaviours, as part of the patient care plan." This describes an elite group that fulfilled a similar function on each ward and was referred to by staff as the "higher" level group. 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 did meet, this small number of patients was provided with three staff members: the social worker who usually led the group, a nurse who was 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. The afternoon version of the insight group was 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 group was usually considered a candidate for activity group. Therefore, the number of patients was much larger in this group. Only two staff members were assigned to this group because it was considered 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 was often an outdoor game or swimming. Depending on staffing or the patient population, both afternoon groups might be put together for an arranged activity. 21 Eleven community-based psychiatrists were entitled to admit patients to both wards. Two general practitioners 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 investigation of the interaction between patient social characteristics, hospital organization and in-patient treatments from a staff perspective. This prospective, descriptive study utilized quantitative methods of data collection to record patient social characteristics 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 or observed; all patient information was obtained from patient records. The focus of the study was the decisions staff made regarding particular patients in a cohort of admissions. 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 admit-ted 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, four-letter 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 Secondary 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 Depressed/Dysfunctional 18 (18%) 8 For Observation and Court Assessment 1 (01%) 0 Transfers from Other Hospitals 4 (4%) 0 Missing Cases 2 (2%) 0 TOTAL 108 45 3. 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 cohort through the emergency room were not psychiatrists and, consequently, did not use DSM-III diagnostic categories with any degree of consistency. Typical examples of the initial intake diagnosis made by G.P.'s were: O.D. (drug overdose), "anxiety", and "psychosis NYD" (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 given for inpatient admission was suicidal threats or actions. The second most frequent reason, psychotic behaviour, was used if the patient was admitted because his or her behaviour was described as "grossly inappropriate", "a danger to themselves or others" or "out of touch with reality". "Depressed" and "dysfunctional" was the next most often noted reason for inpatient admission. 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 who accompanied the patient to hospital, or if they came alone. However, it was possible to record if they arrived by ambulance or RCMP escort. One-third of the cohort were brought to hospital by ambulance (n=25) and 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 # % With Personality Disorder Adjustment Reaction Schizophrenia Affective-Bipolar Major Depression Affective-other S chizo-Affective Paranoid Disorder No Mental Disorder No Organic Psychosis Missing Cases TOTAL 22 20 19 16 16 7 3 2 1 2 108 20% 19% 18% 15% 15% 06% 02% 02% 01% 02% (100%) 7 3 4 3 7 2 2 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 posits that length of stay is a disease-related aspect of treatment. Patients who stay the longest should be those who are the most ill. Social response theorists point to evidence that there are other factors which also influence length of stay. Epstein (1975), for example, reported that length of stay varied as a function of socioeconomic status, with poorer patients staying significantly longer. He suggested that this was because 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 spread out beyond 29 days. These two cut-off points were chosen to determine which patients would be considered short- or long-term admission. Short-stay 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 > 29 days Length of Stay 37 2. Medication Distribution Medication distribution was chosen as the second outcome measure, based on the social response theory hypothesis that patient social characteristics and institutional factors can influence medication allocation. Biomedical model theory predicts that medication is given in response to diagnosis. Medication distribution was recorded by amount, type, and whether or not the medication was given on a PRN basis. 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. Any medications to control side effects were excluded from 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 i n CN W OH D O i—< tn Distribution of Patient Sample By Medication Type 100 ? 80 I  60 •4-* o CL 40 "S 20 0 Min Tn Maj tranq a n c L Sedatives " Anti-dep Types of Medication Lithium None 39 a) Anti-psychotics: These medications were given in response to perceived psychotic symptoms. In this study, their use was mainly controlled by physicians who 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 and dizziness, all of which affect the ability of the patient to drive. 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) Minor tranquilizers or anxiolytics: These medications are given in addition to anti-psychotics, or on their own to control situational anxiety and to calm the patient. In this study, this type of medication was ordered by physicians, but mostly distributed at the discretion of the nurses. Patient requests for such medication was also decided by the nurses. 4 0 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: These medications were combined for the purpose of this study. 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 (triazolam), restoril, tegratol, talwin, tylenol, exdol, and aspirin. Side effects can include morning grogginess, upset stomach or nightmares (Clarke Institute of Psychiatry, 1982). d) Anti-depressants: These medications were given in response to depressive symptoms. They reach peak effectiveness if administered over several weeks in sufficient amounts. Therefore, they were generally ordered by physicians with no provision for additional amounts to be distributed by nurses. 41 Included in 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 blurred vision (Clarke Institute of Psychiatry, 1981). e) Antimanic medication: The only medication in this category that was used in this study was lithium. It is given in high dosages over the course of several weeks and carefully monitored to prevent plasma levels from reaching toxic concentrations. Side effects can include fine trembling of the hands, increased thirst, weight gain, and general malaise (Clarke Institute of Psychiatry, 1982). 3. Assignment and Attendance at Group Treatment The third outcome measure used in this study was assignment and attendance at two kinds of treatment groups. Social response theory hypothesizes that the selection of patients for treatment groups can reflect staff values and 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: (1) whether the patient ever attended each group and (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 collected daily by asking the occupational therapist which patients were supposed to be at activity group that day and which patients had actually attended the group the day before. Data on Insight Group assignment and membership was collected by asking the social workers on each ward to keep weekly statistics on a sheet designed for this purpose and collected every week. II. Qualitative Methods Berger and Luckmann (1967) are among the most eloquent proponents of a theory of knowledge that states that all reality is socially constructed by members of groups who categorize and order systems of beliefs and meaning. According to this theory, meaning is not intrinsic to events or things, it is attributed. Raw perception itself is inherently meaningless. In this study, social response theory provides a socially constructed system of beliefs and categories that are used to give meaning to what is perceived. Qualitative research techniques, such as participant observation and 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). This study uses ethnographic methods to explore the possibility that, although psychiatric services are. organized around the biomedical model, treatment decision-making 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. Time allowed the staff to adjust to the presence of a researcher. Consequently, the researcher was able to conclude that the patterns of 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 research notes were kept as a record of events, impressions and summaries, written in the voice and language of the researcher. Verbatim notes were considered more important for several reasons. 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 the focus of the study, this anxiety diminished. 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 on 4" X 6" cards. Appendix II contains a record of all staff 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, themes emerged, such as "medication" and "discharge planning". 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 second method of collecting field notes involved describing events on the ward and recording the explanations of events volunteered by staff members. 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. Daily notes were compiled into weekly notes. As information categories emerged, references to "medication conflicts between nurses and psychiatrists" or "staff shortages" were entered under these topic headings. B. Interviews Mishler (1986) challenges the promise of scientific reliability surrounding the quest for, and the claims of, various structured interview schedules. He argues that interviewing is a form of discourse 47 that is dependent on the joint construction bf meaning. For this reason, he urges the use of research methods that respect the respondent voices and the ways in which they construct meaning. Therefore, open-ended, semi-structured 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. The remaining psychiatrists did not attend conferences on the ward, admitted very few patients, and were never seen by the researcher. 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. These informants 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 and validity are not the same in participant observer research as they are in experimental studies, concerns about the impact of the researcher on the data and the validity of the researcher's analysis must be addressed. This includes questioning not only if the researcher actually saw "what really happened", but if the researcher's description of the culture is recognizable to the informants. The assimilation of the researcher into the setting over time generally resolves the problem of hidden or deliberately misleading facts. In this setting, the large number of informants and the continual presence of the researcher precluded the possibility of informant collusion. In fact, rather than trying to hide conflicts, the social workers, nurses and psychiatrists were very concerned that their point of view was clearly understood by 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 on the findings of the study, the researcher was asked for suggestions to improve the unit. This implied that the observations from the study were recognized by the informants and of value to them. 4 9 D. The Role of the Researcher The role of the researcher in 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 members and showing interest in every aspect of ward routine. 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 in meetings and in the nursing station, it was difficult to avoid being identified by 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 their difficulties were "real", based on the researcher's access to all factions, and they wanted help in 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. Requests and expectations were dealt with by re-asserting that the purpose of this study was limited to describing the process of treatment allocation in this setting, not recommending changes to it. 50 The overall reaction by the staff to this response was one of disappointment. The data collected through 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 to show the utility of social response theory in understanding staff decisions about three treatment variables from a social perspective. This is not meant to suggest that other interpretations are not equally important or valuable; they are, however, beyond the scope of this study. The intent of these findings is to present and analyze the data using social response theory. Length of stay, medication and treatment groups are 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 which treatment is organized are considered as intervening variables, or critical factors that mediate the impact of. other social characteristics on treatment allocation. Each section is summarized to highlight the findings that result from analyzing the data in the light of social response theory. Patient diagnosis, an important variable in both biomedical model and social response theory, is not analyzed in this study. Staff did not spend time at conference, on the chart or in casual conversation discussing patient diagnosis. The emphasis was on 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 closely occupation and education matched. Highest achieved education and occupational status as rated by Blishen generated a curve similar to one using only education. For the purposes of this study, education was used as a 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) SHORT (<5 days) (n=23) 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%) 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 least-educated (<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 directions regarding patient treatment from the physicians. 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 to the staff because of the opportunity for mutual support. 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. He 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. 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 was in place to accept these patients after discharge. 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 admitted to hospital only to attend the treatment groups. They were, however, sometimes encouraged to stay after the urgent need for asylum or supervised medication had passed because nurses believed that the program could help the patient gain insight into problems and behaviour. Nurses, social workers and occupational therapists had total control over decisions about the content of treatment groups and which patients were assigned to what groups. 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 varying degrees of support for the ward program. Most believed that some patients were too ill to attend groups or talk about their feelings. 59 Interview With Dr. Y Researcher: Do you know what happens in treatment groups? 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 require admission, he or she may not necessarily benefit from the 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 much a patient would benefit by group treatment. 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 arrived on a Monday may not be ready for group for a day or two due to medication effects. 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 person on the last day of the group week. 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 was the availability and suitability of accommodation and follow-up support services. 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. For example, Patient #82 was hospitalized for drug 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? How long will he last? If he smokes pot ... Nurse: He sneaks. She (the Marineview supervisor) will never know. Area Clinician: He'll never last a week. Doctor: Any other houses? Social Worker: Not that I know of. Area Clinician: Is he at a high enough level for Marineview? 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 of immediately available Community Care Team arrangements, day care, and drug and alcohol treatment center placements extended length of stay. A patient was usually not 63 discharged if community resources were not available and staff knew that the patient would be unlikely to make the inpatient\nonpatient transition alone. 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 with institutional organization and beliefs and community resources. 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 centre. They resisted discharge until they were ready to leave. 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 room-mate 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: What does Dr. B. expect us to do with her? 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 patients who were seen to benefit from and contribute to the group. 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 thought she was ready for discharge yesterday. Dr. Y: I didn't admit her, and I don't think I r -responsible for her. This type of communication problem 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 Non-Psychiatric 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 were not discharged if they were judged unlikely to keep these 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 medium-stay patient can become a long-stay patient. Patients who stayed a long time at Lion's Gate Hospital were not necessarily any more ill than patients who stayed shorter periods of time. Social response theory is concerned with the messages patients inadvertently receive by being kept in hospital. The very word "patient" is a label that implies a person is ill. This can cause the patient and family to become disease focussed, with the stigma continuing long past the inpatient experience. Waxier's study (1980) suggests that the way we 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. Most patients averaged a stay of 17 days, however, short-stay patients left hospital within four days of being admitted. At Lion's Gate, the most important factor that separated a short stay patient from others was the desire and the ability of the patient to leave. 1. The Patient Wanted to Leave and Was Not Committable The majority of the short-stay patients (<5 days) asked to be discharged. 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 and demanding, and had been in hospital several weeks. 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. The nurses' belief in the importance 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. Social theorists question this assumption 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. Craven (1987), in a study of medication distribution on a psychiatric 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 socially determined variables: 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 by the knowledge that this patient had not previously been labelled as a psychiatric patient. The data on the "No Medication" group suggest that this small group of patients was admitted to a psychiatric unit for the first time for drug- or 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 Received Medication The 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 major tranquilizers and even fewer tranquilizers and even fewer patients 75 received antidepressants (25%) or lithium (15%) (See Figure 2.5). However, when psychiatrists were interviewed, most regarded 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 may influence the type and amounts of medication given by nurses. In this study, nurses responded to the gender of patients in two 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 staff than female patients. The organizational factors which contribute to staff vulnerability are discussed in detail in the next section. Physicians, who do not have the collective responsibility for the patients, would not be expected to respond to the sex of a patient in the same 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 physicians, especially sedatives and analgesics. 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 type and quantity of medications distributed regularly or as PRNs. 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 more-educated 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. All three groups seem equally likely to be 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). These findings suggest that prescribing physicians may be 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 > Grade 12 Patient Education % OF PATIENTS MEDICATED PRN BY EDUCATION 100 < Grade 12 Grade 12 > Grade 12 Patient Education 84 II. Effect of Institutional Characteristics: Service Organization and Structure Social response theory is used to suggest that personal characteristics interact with institutional characteristics to affect medicine distribution patterns. 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 to attend staff conference once a week. The concern of the physician was for the welfare of the individual patient. During the study, an attempt was made to re-establish the position of area clinician. 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-to-day, hour-by-hour ward management decision making. In contrast to the patient-focussed physicians, nurses were responsible for the ward as a whole. This difference in responsibility and 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 of conflict between doctors and nurses centered around medication orders. Nurses often relied on chemical management of individual patients to carry out their duties on the ward. Physicians, on the other hand, not faced with these collective responsibilities, often did not order enough medication 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 was a tool that they used to manage the ward. The authority to * dispense medication gave 86 nurses the ability to prevent potentially disruptive situations. A major problem did occur on one of the wards when a psychotic 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 - during 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-of-control patient". Nurses used various strategies to obtain "adequate" medication orders. One option was to approach the physician directly for a PRN order. This was risky, however 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 in which they can't support decisions made by the treating physician? Nurse: An example? Area Clinician: About medication or a recommended approach. Nurse: 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 patient. Staff usually hesitated to call the doctor after 12:00 a.m. 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 staff depended upon which physician they were dealing with. One new physician who admitted few patients, left an "inadequate" PRN 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 psychiatric ward was responsible for meeting a ward budget, he or she had little or no control over its allocation. Psychiatrists could order constant or close nursing observation without consulting the nursing manager. "Constants" were round-the-clock nurses for a psychotic patient in restraints. The intensive nursing coverage of very few patients consumed a large share of staff budget. The consequence of "constant" or "close" observation of a few patients was less staff to look after the other patients. Hospital cutbacks meant that each ward had less money than was needed to staff and run the ward. Since staff salaries was the largest 89 budget item, understaffing became a major factor in everyday decision-making on the ward. Staff cuts became a union issue when staff complained of unsafe working conditions. As a result of hospital cutbacks, sick and vacationing staff were 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 began with a complaint about staffing levels. An excerpt from 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 staff meant that available nurses had to attend to more patients and had less time for them. As a result, only top priority tasks were carried out. Tasks that were audited by the hospital accreditation committee were given high priority. These included putting certain information on a patient's 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 main priorities of staff were attending the treatment groups that they were assigned to lead each day and the 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 meetings, lunches and coffee breaks was often quite limited. The nursing activities that had low priority were the unaudited, unscheduled tasks, such as "one-to-one" 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 that this was not always possible, given time constraints. 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. 9 1 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. This usually meant that the nurse had to leave the nursing station since neither the day room nor patient rooms were visible from there. Although the layout of the wards differed, neither provided 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. Keeping a patient in restraints meant that several staff were required to take the patient to the washroom, administer medications, etc. During the study, this resulted in one staff member being 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 much time staff spend monitoring patient activities on the ward. 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 perspective may be helpful in explaining why more educated females were the least likely to receive minor tranquilizers and, when they did, why the amount was very small compared to the amounts males were given. Social response theory provides a way to account for this differential distribution of medication by seeing the distribution of minor tranquilizers as a nursing decision. Nurses may have less need to medicate females because it is males who cause the most problems for nurses. Male patients may be medicated to 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. The result was less available staff time for individual patients. Comments by psychiatrists during the interviews, and staff conversation at conferences revealed that staff relied increasingly on medication when nursing manpower was strained. Education and gender are characteristics of patients that staff respond to because of the way in which work is organized. Nurses who are in charge of the ward use medication as a tool for ward management. The importance of this tool was hypothesized to increase with staff cutbacks and a ward layout that makes it inconvenient for staff to monitor patients. 9 3 GROUP TREATMENT The physicians and ward staff see themselves as providers of two types of treatment to patients. They provide medical treatment through hospital admission and medication, and psychological intervention is offered through group treatment. In this section, social response theory is used to analyze the data on the allocation of psychological treatment. Although many different group were offered as part of the group treatment, the study 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. Occasionally, morning Insight group was cancelled for lack of suitable candidates. This section describes some characteristics of the patients who attend the two groups and the ways in which the composition of the groups reflect the organizational constraints of the ward. 1. Assignment to Group Treatment Group treatment was the term used to encompass all the n o n -medical treatment offered to patients on the psychiatric units. This type of treatment existed because of the belief that psychiatric illness should be responded to by promoting patient insight into contributing psychological, behavioural, and social problems. 94 Ninety-three patients (86%) attended at least one group meeting they were assigned to. Fifteen patients did not attend a treatment group. 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 want to attend this group, he or she might have agreed but staff had veto power, 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. In-depth conversations by Insight group members were reported by staff members whose job it was to observe who said what to whom in the group. Membership in Insight group could also influence length of stay. In some cases, staff argued to prolong length of stay because of the progress a patient was observed to be making in group. However, patients who were assigned to Insight group but did not attend regularly, were labeled by nurses as "not benefitting" from the 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. Only two staff members were assigned to this group. 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 generally focussed on strange or bizarre patient behaviour. 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 because staff who led the group claimed it needed consistency. 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 Activity group was grounds for nurses to lobby for discharge. Nurses felt angry when no one attended the program. "We believe in our program", one staff member stated emphatically at conference. Staff felt that patients were not using every available opportunity to get better when they did not attend groups. Patients often had a different opinion of the value of Activity group outings. Patients who were not assigned to Insight group were often reluctant to be seen with Activity group in public, as it was obvious they were part of a hospital outing. One patient refused to attend Activity group because she didn't want to go to the park for juice and cookies. Friction developed between physicians and nurses when stay was prolonged for patients who did 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. Nurses regarded a patient who did not attend group as "using the hospital as a hotel" and not benefitting from hospitalization. They pressured very strongly for the discharge of such patients. 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 Insight groups they were assigned to compared to males (12%). 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 more-educated 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 > Grade 12 Education Level 101 III. Organizational Factors in Group Treatment Allocation Social response theory predicts that the way in which services are organized impact on how treatment resources, such as group therapy, will be allocated. Organization of services was hypothesized to have two kinds of effect on group treatment allocation. The organization of service may play a part in determining which patients are offered what treatments. In this study, work organization gave nurses control over patient assignment to groups, and their decisions appeared to reflect their concerns about ward management. Organizational factors may also determine how much of any given treatment patients could choose. Unintentional barriers resulting from ward organization may 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 Department of Psychiatry consisted of individual physicians and psychiatrists who treated the patients they each admitted throughout their stay in hospital. The psychiatrist appointed "area clinician" did not alter the responsibilities of the nurses who, by default, were responsible for the ward as a whole. 102 Nursing responsibilities included the structuring and administration of the ward program. Nurses, social 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. When one psychiatrist recommended that one of his patients attend Insight group, staff refused. The psychiatrist was told that Insight group was functioning at a very high level and consistency must be maintained. Nursing decisions about who attended certain groups were made only 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. We choose who goes to what groups. We need that control. B. 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 1 0 3 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 is important, they often came to see patients while the patients 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." Other staff agreed that this happened. In fact, because one doctor consistently arrived during group treatment time, staff felt that he wanted to avoid seeing patients! Whatever the reason, the result was that patients avoided attending group so they would not miss seeing him. Another organizational factor that prevented a patient from attending a group treatment was the competition for patient time. Physicians sometimes ordered a number of investigative procedures and consults, in addition to the standard tests ordered by the hospital. Nurses were required to add standard 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. "If it were up to the patients to show up for group on their own," one nurse commented, "we could all go home". It may 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. One way to interpret this data is to suggest that nurses behaved in a way which minimized the problems they faced in maintaining order on the ward. 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. 1 0 6 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 was identified as mentally ill and how 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 communities. The importance of the social context of psychiatry was 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 "problems in living" (Laing, 1960; Szasz, 1961). Engel (1976) proposes to expand the biomedical model and acknowledge all diseases to be both biological and social facts. As one means of implementing 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 and programs. Because only one of the two wards in this psychiatric 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 contribute to the development of a social perspective by 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 services since organizational knowledge is always limited and relative. 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 so commonplace they have become invisible. 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. In addition, the existence of ward "politics" was acknowledged by everyone who worked there, but its influence on treatment decision-making was not as obvious. Occasionally, informants "knew" things that did not agree with other research data. For example, according to nursing staff, patients assigned to Activity group were assigned to Insight group as they recovered. The research data, however, showed that, in fact, only a small percentage 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 interested because everything related to groups is considered a nursing decision. 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 of these processes cannot be predicted from these social demographics. For example, when patient social characteristics are studied relative to length 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 have the most difficulty getting discharged. While this may be true, there is also another explanation: patient choice. Whether or not a patient chooses to remain in hospital may be just as significant as the economic difficulties that prevent discharge. A social perspective depends on quantitative data about social characteristics to orient the reader. However, without knowledge of how the social processes operate in the setting, a social perspective is incomplete. Qualitative data, such as verbatim notes from staff conference, allows the researcher to know how, why and 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. The research suggests the value of a social perspective as a 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. The findings of this study explore the influence of social processes on treatment allocation and point to the existence of social solutions for problems that may have had no biomedical solutions. The result is a variety of solutions based on social facts 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. 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Research Grant Proposal, unpubl. Wolff, N., et al. Treatment Patterns For Schizophrenics in Psychiatric Hospitals. 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 Psychiatrist _G.P. Address: : ; (City) (Prov) (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 Marital Status, '+ Children, . Next of Kin (listed on chart) (City) (Prov) (St.+ Apt.) Employer: ; Occupation Address Length of Time Education: , ADMISSION DATA: Admission Date: ; Time of Day: (weekday, day, mo) To Ward: Kind of Admission: Admitted By: Vol or invol (Psychiatrist) (G.P.) Admitting Circumstances: Through emerg? Y N Seeing this Psy? Y N. patient arrived, with whom, by police, etc.) Admitting Diagnosis: :  Admitting Medication: (include how 1 24 PRN's _____ Existing Medical Condition: Consults Ordered PSYCHIATRIC HISTORY: MRN# Known History: Y or N Length of Time Previous Admissions ; . 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 M R N W a r d 1. M e d i c a t i o n : K i n d P A T I E N T F I L E : P A R T II D a t e s V o l u n t a r y , P a t i e n t S t a t u s : C l o s e , S u i c i d a l C o n s t a n t R e s t r a i n t s B e g a n E n d e d A m o u n t F r e q u e n c y D a t e F r e q u e n c y A m o u n t T i m e o f D a y N u r s e ( * P r i m a r y ) P R N ' s G i v e n 2. P a s s e s U s e d D a t e : L e n g t h o f T i m e P u r p o s e 7. D i s c h a r g e : D a t e : D i s c u s s e d b y W h o m : C o m m e n t s 126 8. Visitors Noted in Chart: Date: Who: Comments? 9. Additional Consults: Date: Who: Results: 10. Primary Nurses Date Nurse Date Nurse Date 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): She was listening, but didn't respond. 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. Same as Celine T. Nurse 1: She knows what to say. July 7, No Doctor Present Social Worker: 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: She complains of too much medication, had to root her out of bed. 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. Dr. 0 should give you orders. Head Nurse: Every pass a separate order because you can't tell. If Dr. 0 won't, whoever takes over should. 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 tricky to treat her like a borderline. He won't like it. Head Nurse: We have to practice the best nursing care. Nurse 6: The best nursing 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: A summer holiday! Nurse 2: ... and she works ... Social Worker: VGH and going to be demoted ... Head Nurse: ... job sharing ...! July 20, Dr. Q Present Nurse 6: She would like to see you (to Dr. Q) Dr. Q: Has the other personality come out yet? Nurse 6: Not yet ... D r . Q: 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 did she cut her wrists? Nurse 4 Nurse 9 Nurse 6 with it. Thursday. Again. There was a reference to Nancy, that she had something to do 131 Nurse 5: She wants plastic surgery for her wrists, and she is concerned about being demoted, but says work is stressful. Nurse 6: She does not want to go back and face the others at a lower position. Dr. Q: What are we doing for her? Nurse 5: It's a containment thing. Dr. Q: She has had multiple admissions lately. Nurse 5: When discharged, she gets friends to bring 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 crying 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 discharged yesterday to the care of her sister, but sister refused and patient then decided to go back to husband. Staff are waiting to contact Dr. about this but agree it is a step in the wrong direction, 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 re: discharge seems to be an important element in the process. July 22 - A nurse told me it was generally considered bad form to discharge a patient while the Dr. was on holidays. Ask about this in interviews with psychiatrists. APPENDIX IV Excerpts from Three Patient Conferences on the Topic of Medication Conference No. 1 Nurse 1: Nurse 2: Area Clinician: Nurse 2: Area Clinician: Nurse 1: Nurse 3: Doctor: Nurse 4: Nurse 2: Nurse 5: Nurse 6: Nurse 1: Nurse 2: We have a r u n on profoundly delusional people. Is he (Area Clinician) aware of staff cutbacks? What? We are down to one staff per day. We should hold down the census. I would like to get down to A2 beds. That's opposite of what they want. Don't close beds officially, just don't admit. Really, weekends are awful. The charge nurse can close beds on weekends. Patients suffer from not getting good care. How many admitted on weekend? In a short space of time, 3 admitted all of sudden our responsibility. 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 1: And his meds a mess. Head Nurse: Nurse 1: Head Nurse: Doctor: Nurse 2: Nurse 3: Nurse 2: Head Nurse: Nurse 1: Nurse 2: Nurse 3: Doctor: Nurse 2 Nurse 1 Nurse 3 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. Dr. Y should know that 25 mg. haldol is no good. Staff agreed. That bulletin is a minor recommendation. We have had it for years. And never abused it. It always worked. Droperidol doesn't always work. If injection takes four people, can't do that every four hours. The need is there, patients need to be utterly sedated. Dr. Z suggested nozinan and ativan, but it takes too long, and sometimes doesn't work. I'll find that letter, I'm sure it's just a warning. Interns should be talked to. Or I'll call you when it's 3:00 a.m. 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: Area Clinician 2: Nurse 1: Area Clinician 2: Nurse 2: Nurse 3: Nurse 4: Nurse 3: Nurse 5: Area Clinician 2; Nurse 1: And how are things on the ward? Was busy and understaffed this week, (some discussion on groups) Is this the best forum to discuss - how do staff deal with situations in which they can't support decisions made by treating physician? An example? Meds or recommended approach. Comes up a lot of times. Staff feel powerless, some discuss it with Drs. but negative reaction sometimes, so staff worried about feedback back off. So it's just between staff. I will ask another to tell Dr. it has happened to them too, so it isn't just me, so the Dr. hears it from someone else too. Some are easier to ask. Some are more approachable than others, or they ask "what do you think?" to staff. Area Clinician makes a difference too. You have another opinion to give. How much of an issue is it? I'm leaving, you (other staff) say. Not all the time. 136 Nurse 2: Nurse 3: Nurse 2: Area Clinician 2 to Nurse 1: Nurse 1: Area Clinician 2: Nurse 1: Area Clinician 2: Nurse 1: Area Clinician 2: Nurse 2: Nurse 4: Area Clinician 2: Nurse 3: Nurse 2: Not a constant issue, some staff more than others. So personality is a factor. Oh, definitely, I don't r u n into it that much. 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. So nothing can be done? Talking like this is helpful. What is a negative reaction? 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. Why do you ask now? I've heard it periodically. It's better here than on other side. Remarkable, how much better it is here. 1 3 7 Area Clinician 2: Nurse 3: Nurse 4: Nurse 3: Area Clinician 2: Nurse 4: Area Clinician 2: Nurse 3: Intern: Area Clinician 2: Nurse 3: Area Clinician 2: Nurse 3: Area Clinician 2: Nurse 4: 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 re-ordered. Were they worried about calling me at night? He spit out the ativan. And threw it up too. But did not chart that. 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-of-control patient. But would not call you after 1200. Why? Common courtesy and would call intern. They do call. That case illustrated a couple of things: why I didn't want him to have neuropleptics should have been included. One mg. of ativan is like giving an out-of-control person a Smarty, nights you need more. Put up with noise during the day. 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 did it again. Area Clinician 2: I do it in good fun. Nurse 4: You always do that, but I don't take it badly. Area Clinician 2: We have to work on this. Nurse 3: We get irritated when doctor won't come in, 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: Nurse 2: Nurse 3: Nurse 2: Head Nurse: Nurse 1: Nurse 4: Nurse 3: Nurse 4: Nurse 2: Nurse 4: We aren't out of school, we have seen patients before. Recite yesterday's conversation with patients before. Patient A screamed all night and the next. He (the physician) was not nice when I wanted something more for him, found myself starting to get angry. He realized that. W.e„need to remember to give a polished presentation of symptoms and time of last dose. We can do better. 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. He can be nasty, in control. Dr. (1) more accepting. Dr. D can do over kill, give everything. I'd never ask Dr. Last week he attacked the intern, knocked her flat. He would take my response as slap in the face. 141 APPENDIX VI PURPOSE OF THE AREA CLINICIAN Because of the decentralized nature of the physicians' services on the ward, the concept of area clinician was introduced as a means of simplifying nurse-physician communication and to involve at least one psychiatrist more closely in the day-to-day functioning of the ward. The physician designated as area 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 in which most of this research took place the duties of area clinician were split between two psychiatrists. One psychiatrist was in charge of patient information groups and attending community meetings once a week. The other psychiatrist was to attend all ward conferences. 

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