INTERACTION

PATTERNS

BETWEEN PSYCHIATRIC AIDES AND PATIENTS R o b e r t N. Glenn, Ph.D. Betsy Davis, R.N. J o A n n B l u h m , B.S. Pamela Motley, B.S.

The present study investigated the mariner in which psychiatric aides used their time when not involved in staff meetings or off-ward activities. Aides' behaviors on two shifts were observed during times they had the greatest likelihood of interacting with patients. It was found that aides were most likely to be observed in the Nursing Station on both shifts. Aides typically had a specific purpose for interacting with patients when they were on the wards. It was concluded that increased structuring of patient-aide interactions was necessary along with more stringent guidelines regarding the use of the Nursing Station. A f r e q u e n t complaint voiced within the hospital is that the time cons u m e d by staff meetings results in less direct patient care. This complaint has b e e n m o r e f r e q u e n t l y e x p r e s s e d with the r e c e n t a d o p t i o n o f the Problem O r i e n t e d R e c o r d System a n d team concept at Central State Hospital. T h e a r g u m e n t p r e s e n t e d is that if staff were not obligated to attend such meetings, they would be devoting this time to the patients. A classic article by R o s e n h a m t indicates that staff-patient interactions may be less f r e q u e n t than c o m m o n l y assumed. Pseudopatients m a d e unobtrusive observations o f interactions between a t t e n d a n t staff a n d patients in f o u r public mental hospitals, and f o u n d considerable s t a f f - p a t i e n t segregation. An operational m e a s u r e o f in and out o f the n u r s i n g station was used to m o n i t o r staff m o v e m e n t s . T h e average a m o u n t o f time spent outside o f the n u r s i n g station was only 11.3%, with a r a n g e f r o m 3 to 52%. Aides' time o n the ward r e p r e s e n t e d all activities, including folding laundry, supervising shaving, a n d cleaning the ward. Few aides spent time in m o r e sustained At the time this article was written, Dr. Glenn was the director of federal grants at Central State Hospital. He is now a staff psychologistat Commonwealth PsychiatricCenter. Mrs. Davisis Unit Administrator, Westside Unit, Central State Hospital. Ms. Bluhm and Ms. Motley were associated with Virginia Commonwealth University, Richmond, Va., at the time this article was written. Reprint requests should be addressed to Dr. Glenn at the Commonwealth Psychiatric Center, 3001 Fifth Avenue, Richmond, Virginia 23222. This research was supported in part by Hospital Improvement Program Grant No. 03R-000, 812-03, from the Department of Health, Education, and Welfare, Washington. 316

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317 R.N. GLENN, B. DAVIS,Jo BLUHM, AND P. MOTLEY

patient interactions such as talking with patients, or playing games with them. Rosenham's results seem to offer substantial cause for further evaluation of interactions between staff and patients. T h e objective of the present study was more specific in focus; namely to assess how psychiatric aides use their time when uncumbered by staff meetings or other activities that keep them away from their assigned wards. Psychiatric aides were chosen for observation because they spend the most time with patients, and are the most easily observable of all staff members. I f the complaint is valid that the time in off-ward responsibilities (such as meetings) would otherwise be directed to patient care, frequent staffpatient interactions are predicted when aides are free from these activities. Infrequent interactions between staff and patients would conversely indicate that the complaint is not valid.

METHOD

Subjects Two practicum students in behavior technology at Virginia Commonwealth University observed a total of 24 psychiatric aides. The aides had been assigned by their nursing supervisor to one of the following wards: female open, female closed, male open, or male closed. Fourteen aides were observed on the day shift and ten on the evening shift.

Procedure The students introduced themselves to the aides and explained that they would be on the wards to gather data for a class assignment. T h e aides were not informed that their behaviors were being observed. The students made their observations approximately 15 feet away from the nursing station.

Sampling Both shifts of aides were observed on two consecutive Wednesdays. This day was chosen for the observations because it has the fewest number of staff meetings and treatment activities scheduled, hypothedcatly allowing aides more time on the wards with patients. Aides on the day shift were observed from 12:30 PM to 4:00 PM and 12:40 eM to 4:05 PM; the night shift from 4:30 P~ to 7:55 I'M, and from 4:30 PM to 7:50 PM. T h e hours were divided into 10-minute intervals. Each of the four wards was observed for 10 minutes during every hour on a prearranged randomized schedule. A randomized schedule was selected to allow

318 PSYCHIATRIC AIDES AND PATIENTS

generalization of aide behavior. T h e students used the 5 minutes between intervals to move from ward to ward. For observational purposes, the 10-minute intervals were further subdivded into 2-minute intervals. Whole-interval time sampling was used to code the aides' behavior; a behavior was coded if one or more aides exhibited the behavior during a 2-minute interval. Shift changes and an unscheduled staff meeting during the second session resulted in an unequal number of observational intervals.

Behavioral Categories Behaviors were initially event sampled and later summarized into eight categories of behavior. Behaviors observed in each category are presented below.

1. In Nursing Station Performing a Duty. Aide prepares medication for dispensing; aide writes in, or reads patient's charts; aide cleans up nursing station; or aide totals patient's token points on cards. 2. In Nursing Station Idle. Aide stands around, sits, and talks with other staff members; aide sits by self and reads a newspaper, magazine, etc. 3. On Ward Performing a Duty. Aide assists patients with eating; aide provides immediate medical attention if necessary; aide calls patients for off-ward activities; aide requests patients to perform a task; aide calls patient roll; or aide does patients' laundry. 4. On Ward by Self or With Other Staff. Aide sits on ward by self; aide sleeps while on ward; aide plays pool, cards with other staff; aide sits on ward and talks with other staff. 5. Verbal Communication. Any verbal communication that is aide or patient initiated, that is not a reprimand, a request for or to do something, a call to attend an off-ward activity, and it must occur on the ward. 6. Recreational Activity. Any activity which is aide or patient initiated and which is not affiliated with treatment activities (e.g., occupational therapy) or with the daily task (such as cleaning the ward). 7. Nonverbal Communication. If aide initiates a smile, wave of the hand, or shakes hands with patients, pats him/her on back, arm, etc.; or aide responds to patients' initiation of such contacts in the same way. 8. Off-Ward. Aide is neither in the Nursing Station or on his or her assigned ward. This category included a variety of activities, some of which were patient related. However, the distribution of aides' time off the ward

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R.N. GLENN, B. DAVIS, J. BLUHM, AND P. MOTLEY

could not be estimated because coders were frequently uncertain about the exact nature of each activity or the time spent in the particular activity.

RESULTS

The percentage of total agreement between raters was found to be high for all categories (0.90-0.98) except for the categories "nursing station performing duty" (0.77) and "nursing station idle" (0.77). Agreement was probably lower in the latter two categories because the coders' view of aides in the nursing station would sometimes become partially obstructed, and because patients would periodically distract the coders° Figures 1 and 2 summarize aides' behavior patterns on both shifts during the times their behaviors were observed. Total observations between coders were averaged for each 2-minute interval across categories. A range of 0 to 100% is possible for each category, For example, a score of 0% in the category "nursing station performing duty" would indicate that coders never observed this activity occurring during any 2-minute observational interval. A score of 100% would indicate that at least one aide was seen in the nursing station during every 2-minute observational interval. The results illustrate that aides were observed most frequently in the nursing station. This pattern was found on both day and evening shifts for the two weeks that aides were observed.

i

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mm=:::o If:== Figure 1. Time Spent across Categories; Day-Shift Aides

320 PSYCHIATRIC AIDES AND PATIENTS

ZOO~--

Nurs~ Nursing 8tat£em Station ~:efo)cln Idle Duty

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Verbal

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Figure 2. Time Spent across Categories; Evening-Shift Aides

Aides' time on the ward was most frequently observed in the category "performing duty on ward," where the aide had a specific purpose for interacting with patients (e.g., calling roll). Otherwise, aides were about equally likely to be on the ward by themselves or with other staff as they were to be interacting with patients. Considerable variation across wards was found within the unit for both shifts. Total "on-ward" aide behavior (all on ward categories combined) ranged from a low of 5% on the evening shift open ward during week 2 to approximately 82% on the day-shift male closed ward during week 1.

DISCUSSION Observation of aides' behavior during relatively unstructured times clearly indicate that this time is most likely to be spend in the nursing station, not with the patients. Indeed, the frequency with which aides were observed in the nursing station is surprising. A minority of aides did not follow this pattern, however, and were observed to interact with patients much more frequently than the rest of the aides. Even more surprising was the frequency with which evening-shift aides were observed in the nursing station, as the time selected for observation is considered to be the busiest of their shift. Aides were most likely to be on the ward when they had specific reasons for interacting with patients. Otherwise, their activities were centered

321 R.N. GLENN, B. DAVIS,J. BLUHM,AND P. MOTLEY

within the nursing stations. Rosenham 2 suggested that aides are learning this pattern from professional staff in the organizational hierarchy. He reported that such persons are rarely seen on the ward, and spend much of their time in their offices. If these persons ventured near the patients, it was in the nursing station. The implications regarding professional use of time suggest that further investigation be made in this area. Very little evidence was found to support the argument that relatively unstructured time is directed toward patient care. However, it should be noted that these results cannot be generalized to the entire 40-hour week. Partially in response to the results of the present study, a number of changes have taken place on the unit. More explicit rules have been imposed regarding the use of the nursing station, and structured activities with patients have been assigned to aides for a variety of treatment activities. T h e results were also discussed with the aides involved, as well as the rest of the unit staff: Since that time, we have observed a noticeable increase in the frequency of interactions between patients and aides.

REFERENCES 1. RosenhamDL: On being sane in insane places. Science, 179: 250258, 1973. 2. RosenhamDL: Ibid, p. 254.