Perceived ward climate and treatment outcome

Lockdown during the early phase of Covid-19 - effects on specialized mental health services and vocational activities for patients with psychotic disorders

PURPOSE

People with psychotic disorders may be particularly vulnerable to adverse effects from restrictions implemented to limit the COVID-19 pandemic. Mental health professionals may also be at risk of adverse effects. The aim of this study was to investigate the impact of potential changes in accessibility, quality of care and vocational activity on people with psychotic disorders and the impact on clinicians working in these conditions.

MATERIALS AND METHODS

Patients and clinicians in specialized mental health services for psychotic disorders answered questionnaires regarding changes in treatment, quality of treatment, vocational activity, and well-being. Data was analyzed with nonparametric tests.

RESULTS

Inpatients appeared more influenced by the restrictions than outpatients, however, quality of treatment was regarded relatively unaffected. Clinicians seemed satisfied working under these conditions, though a larger portion of clinicians reported changes in treatment compared to patients. The patients who reported being affected by changes in vocational activity tended to report negative effects, but the majority reported being unaffected.

CONCLUSION

Overall, patients and clinicians appeared to cope well with the changes they experienced in accessibility, quality of care and vocational activity during the early phases of the pandemic.

A Prospective Biopsychosocial Repeated Measures Study of Stress and Dropout from Substance Addiction Treatment

Introduction

This prospective, repeated-measures observational study tested biopsychosocial variables as risk factors for dropping out of inpatient substance addiction treatment. Substance use disorder (SUD) is viewed as a chronic relapsing disease caused by an interaction between biological, psychological, and social factors. However, there is a lack of prospective studies that combine biopsychosocial variables when assessing dropout. The aims of this study were to investigate whether there was 1) An association between biopsychosocial factors and dropping out of inpatient substance addiction treatment, 2) An interaction with SUD diagnosis and cortisol, and 3) Different dropout rates between short-term and long-term institutions.

Materials and Methods

Patients (n = 173) were recruited from two inpatient treatment centers in Norway between 2018 and 2021. The following biopsychosocial variables were measured at four timepoints: ward atmosphere (Ward Atmosphere Scale, WAS), psychological distress (Hopkins Symptom Checklist 10, HSCL-10), motivation (M-scale of the Circumstances, Motivation, Readiness, and Suitability questionnaire), and concentration of salivary cortisol (CORT- nmol/L). Cortisol levels were measured for two consecutive days at each timepoint and calculated by two cortisol indices, daytime cortisol slope (DCS) and area under the curve with respect to the ground (AUC_G). A multivariate logistic regression analysis was performed to find an association between dropout rates and the biopsychosocial variables.

Results

The results suggest a lower dropout odds for patients with high motivation (OR = 0.76, p = 0.022) and patients admitted to short-term treatment (OR = 0.06, p = 0.005). An interaction with stimulant SUD and DCS (OR = 13.74, p = 0.024) also revealed higher dropout odds. No statistical significance was found for psychological distress, WAS, and cortisol AUC_G.

Conclusion

The results support monitoring motivation during treatment and further investigating biopsychosocial variables when assessing dropout risk together with SUD diagnosis.

Rules and ward climate in acute psychiatric setting: Comparison of staff and patient perceptions

The ward climate or atmosphere refers to its material, emotional and social conditions. A good ward climate in psychiatric settings can influence the mood, behaviour and self-concept of patients and staff members and improve patient outcomes. Many studies have examined the relationship between ward climate and aggression, but only a few have investigated the effect of a ward's environment, rules and activities. This multicentric observational study aimed to assess the relationship between the rules/activities and the climate of four acute psychiatric units of Northern Italy. The Essen Climate Evaluation Scheme (EssenCES) questionnaire, which was administered to patients and staff, was used to evaluate the different dimensions of ward atmosphere. There was a good response rate (79%) in patients and staff members who completed the questionnaire (114 patients and 109 staff). Safety perception appeared to be quite different in patients and staff. The patients who were authorized to have more visiting hours and more time to use their mobile phone had higher scores on Experienced Safety subscale. A negative correlation between the Therapeutic Hold and Experienced Safety subscales was found in the staff members, and this was due to their negative perception. The ward climate seemed to be affected by the unit's rules, especially with respect to visits and the smartphones use. Nurses need to be aware of the importance of ward climate and how their own perception may differ from and that of patients: this gap could lead to decisions detached from the patients' needs.

The Effects of the Civility, Respect, and Engagement in the Workplace (CREW) Program on Social Climate and Work Engagement in a Psychiatric Ward in Japan: A Pilot Study

Background: Good social climate and high work engagement are important factors affecting outcomes in healthcare settings. This study observed the effects of a program called Civility, Respect, and Engagement in the Workplace (CREW) on social climate and staff work engagement in a psychiatric ward of a Japanese hospital. Methods: The program comprised 18 sessions installed over six months, with each session lasting 30-min. Participation in the program was recommended to all staff members at the ward, including nurses, medical doctors, and others, but it was not mandatory. A serial cross-sectional study collected data at four time-points. Nurses (n = 17 to 22), medical doctors (n = 9 to 13), and others (n = 6 to 10) participated in each survey. The analysis of variance was used to evaluate the changes in the following dependent variables, the Essen climate evaluation schema (EssenCES), the CREW civility scale, and the Utrecht work engagement scale (UWES) over time. Result: We found no significant effects. The effect size (Cohen’s d) for EssenCES was 0.35 from baseline to post-installation for all staff members. Effect sizes for EssenCES for medical doctors and UWES for nurses were 0.79 and 0.56, respectively, from baseline to post-program. Conclusions: Differences in social climate and work engagement among Japanese healthcare workers between the baseline and post-installation of the CREW program were non-significant.

Influence of nursing staff attitudes and characteristics on the use of coercive measures in acute mental health services-A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Aggressive behaviour is a major problem in clinical practice of mental health care and can result in the use of coercive measures. Coercive measures are dangerous for psychiatric patients and international mental healthcare works on the elimination of these interventions. There is no previous review that summarizes the attitude of nursing staff towards coercive measures and the influence of nursing staff characteristics on attitude towards and the use of coercive measures. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The attitude of nurses shifted from a therapeutic paradigm (coercive measures have positive effects on patients) to a safety paradigm (coercive measures are undesirable, but necessary for the wards' safety). Nurses express the need for less coercive interventions to prevent seclusion and restraint, but their perception of intrusiveness is influenced by how often they use specific coercive measures. The knowledge from scientific literature on the influence of nursing staff on coercive measures is highly inconclusive, although the feeling of safety of nurses might prove to be promising for further research. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is need for increased attention specifically for the feeling of safety of nurses, to better equip nurses for their difficult work on acute mental health wards. ABSTRACT: Introduction The use of coercive measures generally has negative effects on patients. To help prevent its use, professionals need insight into what nurses believe about coercion and which staff determinants may influence its application. There is need for an integrated review on both attitude and influence of nurses on the use of coercion. Aim To summarize literature concerning attitude of nurses towards coercive measures and the influence of staff characteristics on the use of coercive measures. Method Systematic review. Results The attitude of nurses changed during the last two decades from a therapeutic to a safety paradigm. Nurses currently view coercive measures as undesirable, but necessary to deal with aggression. Nurses express the need for less intrusive interventions, although familiarity probably influences its perceived intrusiveness. Literature on the relation between staff characteristics and coercive measures is inconclusive. Discussion Nurses perceive coercive measures as unwanted but still necessary to maintain safety on psychiatric wards. Focussing on the determinants of perception of safety might be a promising direction for future research. Implications for practice Mental health care could improve the focus on the constructs of perceived safety and familiarity with alternative interventions to protect patients from unnecessary use of coercive interventions.

Ward Atmosphere and Patient Satisfaction in Psychiatric Hospitals With Different Ward Settings and Door Policies. Results From a Mixed Methods Study

Background: Open-door policies in psychiatry are discussed as a means to improve the treatment of involuntarily committed patients in various aspects. Current research on open-door policies focuses mainly on objective effects, such as the number of coercive interventions or serious incidents. The aim of the present study was to investigate more subjective perceptions of different psychiatric inpatient settings with different door policies by analyzing ward atmosphere and patient satisfaction. Methods: Quantitative data on the ward atmosphere using the Essen Climate Evaluation Scale (EssenCES) and on patient satisfaction (ZUF-8) were obtained from involuntarily committed patients (n = 81) in three psychiatric hospitals with different ward settings and door policies (open, facultative locked, locked). Furthermore, qualitative interviews with each of 15 patients, nurses, and psychiatrists were conducted in one psychiatric hospital with a facultative locked ward comparing treatment in an open vs. a locked setting. Results: Involuntarily committed patients rated the EssenCES' subscale "Experienced Safety" higher in an open setting compared with a facultative locked and a locked setting. The subscale "Therapeutic Hold" was rated higher in an open setting than a locked setting. Regarding the safety experienced from a mental health professionals' perspective, the qualitative interviews further revealed advantages and disadvantages of door locking in specific situations, such as short-term de-escalation vs. increased tension. Patient satisfaction did not differ between the hospitals but correlated weakly with the EssenCES' subscale "Therapeutic Hold." Conclusion: Important aspects of the ward atmosphere seem to be improved in an open vs. a locked setting, whereas patient satisfaction does not seem to be influenced by the door status in the specific population of patients under involuntary commitment. The ward atmosphere turned out to be more sensitive to differences between psychiatric inpatient settings with different door policies. It can contribute to a broader assessment by including subjective perceptions by those who are affected directly by involuntary commitments. Regarding patient satisfaction under involuntary commitment, further research is needed to clarify both the relevance of the concept and its appropriate measurement.

Prison Climate and Its Role in Reducing Dynamic Risk Factors During Offender Treatment

Although several offender treatment experts have suggested that therapeutic relationships play an important role in offender treatment, empirical finding supporting those arguments are scarce. The present study has therefore examined the relationship between prison climate, treatment motivation, and their influence on changes in risk factors in N = 215 inmates and detainees in four correctional facilities in Berlin, Germany. The inmates' perception of prison climate significantly correlated with their attitudes towards treatment. More positive climate in terms of therapeutic hold and more positive treatment attitude in terms of trust in therapy were also the best predictors of stronger decreases in dynamic risk factors measured by the Level of Service Inventory-Revised (LSI-R). Our results support the importance of treatment relationship factors within the course of offender rehabilitation.

Systematic review of studies of mental health nurses' experience of anger and of its relationships with their attitudes and practice

WHAT IS KNOWN ON THE SUBJECT?: It is generally felt that it is helpful for mental health nurses to control their emotions during their work. There are different approaches, but there is growing acceptance that different emotions may need different coping strategies. There is lots of evidence that nurses sometimes feel anger in a number of situations, but the research about anger in mental health nurses has never been examined as a whole. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We have systematically identified all previous research where nurses completed measures that tried to measure their anger in certain situations, compared it to other people or investigated how it affected them or what its relationship was with their practice. Only a few studies have measured nurses' anger. However, it seems that while nurses are not generally angrier than any other group, they do often feel anger in relation to management of patient aggression and their job situation more generally. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Anger is the most commonly reported problematic emotion for mental health nurses. It may influence their practice and affect their well-being. This has implications for staff support and training.

ABSTRACT

Introduction Emotional regulation is important in mental health nursing practice, but individual emotions may require different regulation strategies. There is ample evidence that nurses experience anger specifically during their work, for example when experiencing patient aggression. It is, therefore, important to consolidate what is known about how anger manifests in mental health nursing practice.

AIM

We aimed to systematically identify, evaluate and synthesize results from studies about mental health nurses and anger, where anger was measured objectively.

METHODS

Systematic literature review based on PRISMA guidelines.

RESULTS

We identified 12 studies. A range of validated and nonvalidated instruments was used. Mental health nurses may have lower levels of anger than normative samples, but anger is commonly reported as an issue for them. Anger was studied in relation to its links with (1) clinical management of patients, notably violence containment; and (2) employment issues more generally, notably job motivation. Anger is related to nurses' attitudes about the acceptability of coercion, but there is no evidence that it results in more coercion.

IMPLICATIONS FOR PRACTICE

Nurses should be aware of the potential influence of anger on their practice. Anger, specifically, should be considered when supporting mental health nurses, for example in clinical supervision. Emotional regulation training should target anger.

Ward Climate Within a High Secure Forensic Psychiatric Hospital: Perceptions of Patients and Nursing Staff and the Role of Patient Characteristics

Within this study the relationship between patient characteristics (age, length of stay, risk, psychopathy) and individual perceived ward climate (n=83), and differences between staff's and patient perceptions of climate (n=185) was investigated within a high secure forensic hospital. Results show that therapeutic hold was rated higher among staff compared to patients, while patients held a more favorable view on patient cohesion and experienced safety. Furthermore, patient characteristics (age, risk and psychopathy) were found to be related with individual ratings of ward climate. The findings underline the importance of assessing ward climate among both patients and staff in clinical practice.

The impact of a randomised trial on TC environments

Purpose

– The purpose of this paper is to investigate the possible impact of a randomised controlled trial on the therapeutic environment of participating therapeutic communities (TCs).

Design/methodology/approach

– The authors compared the environment in four democratic day TCs involved in a randomised trial (experimental TCs) with a similar democratic day TC not involved in the trial (the control TC) by administering the Community Oriented Environment Scale (COPES) to 28 TC members.

Findings

– TC members’ views of the real psychosocial environment at the experimental TC and control TC showed similar high levels for spontaneity, autonomy and personal problem orientation and similar intermediate levels for practical orientation and staff control. The TC members at the experimental TC rated significantly higher levels for order and organisation and clarity, while members at the control TC rated a significantly higher level for involvement.

Originality/value

– The study provided no evidence of a significant adverse impact on the culture of democratic day TCs due to participation in a randomised trial. This finding answers one of the most common arguments in the debate on the ethics of RCTs in TCs.

Clinicians Ought to View Anger Contextually

Constructions of the experiential sources of anger, both in ordinary language accounts and in scientific studies, are characterised by a proximity bias. Anger is commonly represented as being due to acute, proximate occurrences. However, anger can be alternatively understood to be a product of contextual conditions, which may involve distal or ambient determinants. The themes of embeddedness, interrelatedness, and transformationality, derived from the contextual perspective of Stokols in environmental psychology, are presented for the understanding of anger as pertinent to clinical concerns and as heuristics for anger management interventions.

Person-environment interaction in a new secure forensic state psychiatric hospital

This study examined the person-environment interaction effects of environmental design on ward climate, safety, job satisfaction, and treatment outcomes within a new high security forensic psychiatric facility. Participants included male and female adult psychiatric inpatients and staff members at different security stages. Data were collected once before and twice after the experimental group moved into the new building. The control group remained in the same facilities. Contrary to expectations, the new building had limited effects on the measured variables.

The influence of physical environmental qualities on the social climate of supported housing facilities for people with severe mental illness

The study investigates the extent to which the perceived physical environmental quality of housing facilities for people with severe mental illness accounts for perceived social environmental quality. Twenty facilities were assessed by people with psychiatric disabilities (residents), staff, and experts with regard to the physical environmental aspects of visual pleasantness, indirect environmental effects, overall physical quality, and the social environmental indicator of social relationship. The results suggest that residents' and staff's physical environmental quality perception accounts for social relationship quality perception, whereas experts' environmental assessment does not. Moreover, the staff reported a more positive social relationship perception than the residents.

Patient or treatment centre? Where are efforts invested to improve cancer patients' psychosocial outcomes?

The psychosocial outcomes of cancer patients may be influenced by individual-level, social and treatment centre predictors. This paper aimed to examine the extent to which individual, social and treatment centre variables have been examined as predictors or targets of intervention for psychosocial outcomes of cancer patients. Medline was searched to find studies in which the psychological outcomes of cancer patient were primary variables. Papers published in English between 1999 and 2009 that reported primary data relevant to psychosocial outcomes for cancer patients were included, with 20% randomly selected for further coding. Descriptive studies were coded for inclusion of individual, social or treatment centre variables. Intervention studies were coded to determine if the unit of intervention was the individual patient, social unit or treatment centre. After random sampling, 412 publications meeting the inclusion criteria were identified, 169 were descriptive and 243 interventions. Of the descriptive papers 95.0% included individual predictors, and 5.0% social predictors. None of the descriptive papers examined treatment centre variables as predictors of psychosocial outcomes. Similarly, none of the interventions evaluated the effectiveness of treatment centre interventions for improving psychosocial outcomes. Potential reasons for the overwhelming dominance of individual predictors and individual-focused interventions in psychosocial literature are discussed.

Psychometric evaluation of the Ward Atmosphere Scale in a Russian psychiatric hospital

AIM

The aim of the study was to evaluate the psychometric properties of the 10 subscales of the Ward Atmosphere Scale (WAS) in a Russian psychiatric hospital.

METHODS

A total of 212 patients and 96 staff members at five wards for acute psychiatric patients completed the WAS. We calculated Cronbach's alpha, the Corrected Item Total Subscale Correlation (CITC), and item-revised subscale intercorrelations.

RESULTS

By removing a total of 32 items, the psychometric properties for all subscales except "Autonomy", reached an acceptable level for the patient scores. Although several of the revised subscales were highly intercorrelated, the specificity of the items of the revised scales appeared acceptable.

CONCLUSIONS

The revised WAS version appeared applicable within this Russian psychiatric hospital context. Several of the items that were dropped appeared inapplicable because of differences between Russian and Western culture and psychiatry.

Associations between ward atmosphere, patient satisfaction and outcome

Previous studies have found important associations between the ward atmosphere and patient satisfaction. However, fewer studies have examined the relationship between ward atmosphere and outcome of treatment. The aim of the study was to examine whether or not differences in ward atmosphere were associated with differences in satisfaction and outcome. Eighty patients at three different ward units responded to a questionnaire at admission and by the time of discharge from the hospital. The questionnaire comprised the ward atmosphere scale, a five-item index of patient satisfaction, the Generalized Self-Efficacy Scale, an index of life satisfaction and the symptom checklist SCL-90R. The results showed that differences in the treatment environment between the ward units were associated with differences in patient satisfaction. There was mixed evidence for associations between ward atmosphere and outcome, while no associations were found between ward atmosphere and self-efficacy and life satisfaction. The results may suggest that the relationship between ward atmosphere and outcomes of treatment may be of a more indirect character than the relationship between ward atmosphere and satisfaction.

The ward atmosphere of single-sex wards in a maximum-security forensic psychiatric hospital in Sweden

This exploratory study investigated the ward atmosphere of single-sex wards in a forensic psychiatric context in the light of Moos' conceptualization of the treatment setting. The wards for female patients bore similarities to Relationship-Oriented and Insight-Oriented programmes and had a generally positive ward atmosphere. On the other hand the wards for male patients did not resemble any treatment programme and had a more mixed diagnosis profile than those for female patients. Comparisons of the two types of wards are made and implications of the findings in terms of the overriding principle of normalization are discussed.

The therapeutic relationship in secondary mental health care: a conceptual review of measures

OBJECTIVE

The study aimed to determine the conceptual basis of measures of the patient-professional relationship used in routine mental health services research by reviewing their face, content and construct validity.

METHOD

A comprehensive literature search identified measures of the relationship used in mental health services research. The conceptual basis of each identified measure was identified by a review of measures' authors assessments of face, content and construct validity plus item analysis of the measures themselves.

RESULTS

The search identified 15 measures. The seven developed in psychotherapy were likely to be better validated conceptually; most were based on therapeutic alliance models. Measures developed specifically for mental health services were based on a wider range of models including global assessments of the relationship.

CONCLUSION

Most of the better validated measures originate in psychotherapy, but there is limited evidence for their validity in general mental health services. Four measures are recommended.

Ward atmosphere - the Scarlet Pimpernel of psychiatric settings?

Patients and staff in a forensic psychiatric setting were requested to name three distinguishing characteristics of the ward atmosphere. The manifest content analysis of the responses revealed the following categories: interpersonal relations and pre-conditions for interpersonal relations; organization; staff; treatment; daily activities; physical environment; and feeling good and secure. The patients appeared to have a peripheral role as contributors to the ward atmosphere in the views of the respondents. The easily administered single question format provided valuable information about an intangible element of psychiatric settings - the ward atmosphere.

Social climate within secure inpatient services for people with intellectual disabilities

BACKGROUND

The social climate of inpatient facilities is thought to be an important contributor to treatment outcome. However, little research has focused on this construct within secure forensic services for people with intellectual disabilities (ID). Therefore, the objective of this study was to investigate the social climate of two different types of secure units ('low' secure vs. 'medium' secure) contained within the same facility for offenders with ID. Two hypotheses were generated: (1) residents would rate the social climate of the whole facility in a more negative direction than staff, and (2) residents and staff would rate the social climate of the 'low' secure unit in a more positive direction than that of the 'medium' secure unit.

METHOD

Using a 2 (factor 'Participant' = Staff or Resident) x 2 (factor 'Unit' = 'Low' or 'Medium' Secure Unit) between-subjects design, 18 residents and 37 staff members were recruited and completed the Correctional Institutions Environment Scale (CIES), a measure of social climate.

RESULTS

Residents tended to rate the units in a more positive direction than staff on some sub-scales. Participants rated the 'low' secure unit in a more positive direction than the 'medium' secure unit on two sub-scales of the CIES. However, on selected sub-scales there were differences. The findings of this study suggest that the CIES may be a valid instrument for use within forensic services for people with ID, and further suggests that residents and staff have different perceptions of the shared social climate, which may have implications for service development.

Presencing: channeling therapeutic effectiveness with the mentally ill in a state psychiatric hospital

Twenty-three nursing staff in a state psychiatric hospital in the eastern United States narrated their experiences in establishing meaningful presence with seriously and persistently mentally ill clients. Interviews were audiotaped, transcribed, and then interpreted using a phenomenological hermeneutic method. The results of interpretation point to clarifying or illustrating that presence is established and maintained in the context of anxiety and uncertainty. Six themes were constructed to describe staff presencing: knowing the uniqueness of individual clients; listening actively with intense focus on the client; engaging several potential channels for change; caring with confidence, creativity, and perceived respect; involving clients optimally; and encountering mutually defined effective change.

A suggested revision of the Ward Atmosphere Scale

OBJECTIVE

In a previous study, we have suggested a revision of the Anger/Aggression and the Spontaneity subscales. The main aim of this study was to re-evaluate the psychometric properties of the other eight subscales of the Ward Atmosphere Scale.

METHOD

A total of 550 patients and 822 staff members on 54 psychiatric wards for psychotic patients completed the WAS and the Good Milieu Index (GMI). We calculated Cronbach's alpha, the Corrected Item Total subscale Correlation, subscale intercorrelations and the correlation between subscales and GMI.

RESULTS

By removing a total of 16 items, the psychometric properties improved. The revised subscales had acceptable psychometrics and gave a clearer picture of the relationship between the perceived level of patient satisfaction and the WAS subscale scores.

CONCLUSION

The revision suggested in this study 'modernized' several of the subscales. We suggest that this revision is implemented in the future use of the WAS.

A comparison of the psychosocial environment of two types of residences for persons with severe mental illness: small congregate community residences and psychiatric inpatient settings

BACKGROUND

Legislation was passed in Sweden to stimulate the development of different housing solutions for persons suffering from severe mental illness. Among these solutions are small congregate residences built in the community to provide suitable housing and support for those not able or willing to live independently.

AIMS

The general aim of the present study was to compare the psychosocial environment of two types of residences for the persons with severe mental illness - congregate community residences and psychiatric inpatient settings. A specific aim was to see if the former provided higher levels of autonomy than the latter.

METHODS

In this cross-sectional study the real version of the Community Oriented Program Environmental Scale (COPES) was administered to residents, patients and staff members.

RESULTS

The study showed that the psychosocial environment differs between the two types of settings. Residents and staff in small congregate residences rated higher levels of Autonomy and lower levels of Practical Orientation, Anger and Aggression and Order and Organisation than patients and staff in inpatient settings.

CONCLUSIONS

The psychosocial environment profiles for psychiatric settings in different phases of the care process may vary in terms of the aforementioned subscales.

Perceptions of the real and the ideal ward atmosphere among trainees and staff before and after the introduction of a new work rehabilitation model

Changes in the ward atmosphere of a psychiatric work rehabilitation unit were investigated. Both trainees and staff filled in the Community-Oriented Programs Environment Scale (COPES) before and after a new rehabilitation model was implemented. It was hypothesised that the levels of autonomy and practical orientation would increase from both the trainees' and staff's perspective concerning the real ward atmosphere and that the staff's perceptions of an ideal ward atmosphere would change in the same way. The staff perceived an increased level of autonomy with respect to both the real ward atmosphere and to what constitutes an ideal ward atmosphere, which partly confirmed the hypotheses, but the level of practical orientation was stable. Concerning the staff's estimate of an ideal ward atmosphere, further changes were an increased level of involvement and a decrease in spontaneity, which was not hypothesised, but was not in conflict with the philosophy behind the new model. From the trainee's perspective there was no change of either autonomy or practical orientation. Instead, there was a decrease in personal problem orientation. Compared to an optimal profile, the ward atmosphere was beneficial, before as well as after implementation of the new programme. Differences were found between the staff and the trainees, but they were not large enough to separate the groups according to what is considered an optimal profile. The few changes found support earlier conclusions that the ward atmosphere is a stable phenomenon over time.

Ward atmosphere, client satisfaction, and client motivation in a psychiatric work rehabilitation unit

This study investigated the ward atmosphere of a psychiatric work rehabilitation unit and its relationships to clients' satisfaction with the unit and client motivation, operationalised as proneness to set personal goals for their rehabilitation. The Community-oriented Programs Environment Scale was used and 52 clients participated. Their report of the ward atmosphere was in accordance with recommended levels on 5 sub-scales out of 10. A regression analysis revealed that optimal levels of order-and-organization and support were of importance for satisfaction with the unit. An optimal level of support was associated with a high rating of personal goals. This study added two therapeutically interesting factors-satisfaction and motivation-to the flora of factors that have been related to perceptions of the ward atmosphere.

Ward atmosphere in acute psychiatric in-patient care: patients' perceptions, ideals and satisfaction

OBJECTIVE

To investigate the relationship between patients' perception of the real and ideal ward atmosphere and their satisfaction.

METHOD

Patients filled in the Ward Atmosphere Scale (WAS, Real and Ideal Form) and a satisfaction questionnaire. Patient characteristics were derived from clinical assessments.

RESULTS

WAS ratings were almost independent of patient characteristics. Patients in locked wards perceived more anger and aggression and patients subjected to coercive measures perceived less autonomy and practical orientation. Patient satisfaction was predicted by higher scores on the WAS Relationship- and System Maintenance dimensions, explaining 41% of the variance. In particular support, order and organization predicted satisfaction. Except from the areas of anger/aggression and staff control, patients gave the 'ideal' ward higher ratings on all subscales. The perceived gap between the 'ideal' and 'real' ward explained 45% of variance in satisfaction.

CONCLUSION

Patients' perception of ward atmosphere is a clinically meaningful measure appearing to be a strong predictor of satisfaction.

Relationships between characteristics of the ward atmosphere and treatment outcome in a psychiatric day-care unit based on occupational therapy

The relationships between characteristics of the ward atmosphere and treatment outcome in a psychiatric day-care unit were investigated. The treatment programme was based on occupational group therapy and included long-term mentally ill patients, equally distributed with regard to psychosis and non-psychosis diagnoses. The ward atmosphere was rated on the Community-Oriented Programs Environment Scale (COPES), and outcome variables concerned symptoms, global mental health, quality of life, and functioning in daily life. The COPES ratings were re-coded in order to control for the fact that different levels of ward atmosphere factors are recommended for psychotic and non-psychotic patients. The results revealed that an optimal initial level of anger and aggression in treatment was significantly associated with improvement in global mental health and functioning in everyday life. Initial optimal levels of staff control and practical orientation were significantly associated with improvement in psychiatric symptoms. The characteristics of the ward atmosphere at the end of the treatment period were significantly correlated with various aspects of functioning in daily life. The study demonstrated associations with outcome variables not previously linked with ward atmosphere characteristics, e.g. functioning in daily life and quality of life.

The Milieu Enhancement Model: a nursing practice model, Part I

The Milieu Enhancement Nursing Practice Model (MEM) served as the conceptual framework for implementing a 3-year project funded by the Department of Health and Human Services through the Division of Nursing as a demonstration grant (No. 1 D10 NU 600013) from October 1987 through September 1990. The MEM is described and examples of its use in developing health care forms, conducting research, guiding practice, and categorizing enhancements are presented.

The ward atmosphere of a child psychosomatic unit: a ten-year follow-up

Using the Ward Atmosphere Scale, we reassessed the ward atmosphere of a psychosomatic unit for children and adolescents that has been operating successfully for 10 years. There was remarkable stability in essential treatment program characteristics despite the complete turnover in patients and a 60% turnover in staff. There was substantial correlation between patient and staff perceptions in 1988 and across time (Spearman's rho: 0.951-0.660, all p values less than 0.05). Patients and staff subgroups differed somewhat in their relative emphases on certain program dimensions but, overall, the program still correlated highly with the therapeutic community cluster described by Moos (Spearman's rho: 0.660-0.809, all p values less than 0.05). This stability was achieved despite multiple health care changes, most notably shortened length of stay. Stability was probably due to high staff/patient ratio, continuity of the medical direction, and focus on milieu maintenance in staff meetings.

Staff and patients: divergent views of treatment

A patient-staff survey, focusing on the efficacy of treatment and aftercare, showed inconsistencies in the way staff perceived treatment given patients at a large municipal acute care hospital. Primary therapists, psychiatrists, and psychologists saw treatment in a routine, standardized fashion, whereas nurses, social workers, activity therapists, and others viewed treatment in more elaborate, individualized terms. The survey also showed disparities between what staff intended to do and what patients perceived was happening to them. Implications of these findings and recommendations for coordinating staff efforts and clarifying patient understanding of treatment are presented.

Measuring the treatment environment of a psychiatric ward and a community mental health center after the Italian reform

In 1978 a major psychiatric reform drastically changed the Italian psychiatric system by the closing of admissions to mental hospitals and the development of psychiatric units in general hospitals and of alternative services in the community. The paper presents the results of a study in which two treatment environments set up according to the reform, i.e. a psychiatric unit in a general hospital and a community mental health center run by the same staff, were examined using the Ward Atmosphere Scale (WAS) and the Community Oriented Programs Environment Scale (COPES). In addition, validity studies of the Italian versions of the WAS and COPES are presented. Both instruments were found to be feasible and useful, easily understood, easy to administer and relatively well accepted by the psychiatric staff. The quality of the two scales has been confirmed by psychometric analysis, with the exception of the independence of scales. No major differences between the two environments emerged, both showing characteristics consistent with the new treatment philosophy.

Expressed emotion and nursing the schizophrenic patient

The findings from the family studies of schizophrenic family members' readmission (which coined the term 'expressed emotion' to explain why some families have members who need readmission more often than others) are related to a variety of areas of psychiatric nursing research, including nurses' attitudes, nurses' behaviour, ward atmosphere, institutionalization, social therapy, and patient outcome. This follows the Berkowitz & Heinel report that psychiatric nurses at one hospital behave like the families that have lower readmission rates. A strategy for further research of psychiatric nurses 'expressed emotion' is proposed, in relation to the course and outcome of schizophrenic patients' hospitalization.

Effects of consultation on the ward atmosphere in a state psychiatric hospital

The Ward Atmosphere Scale was used to assess the development of a therapeutic milieu in a clinical ward converted to a research unit at a state psychiatric hospital. The designated ward had been considered a “problem ward” with low staff moral, a high incidence of violence by patients, and high incidence of injuries to patients and staff. The scale was administered to patients and staff on two occasions. The results of the first administration were presented to staff, and from these consultation sessions, a therapeutic milieu developed. The scale was readministered 3 mo. after the implementation of the therapeutic milieu. Significant improvements were seen in staff's perception of the ward environment, incidence of patients' assaults, and staff use of seclusion and restraints.

Ward atmosphere changes during restructuring of an alcoholism treatment center. A quasi-experimental study

At an Alcoholism Treatment Center which was under restructuring, the Ward Atmosphere Scale (WAS) was used to study the effect of changes on the climate of two wards. Before implementation, after the first phase of changes one year later, and after the second phase changes a year later, patients (n1 = 19, n2 = 16, n3 = 23) and staff members (n1 = 21, n2 = 24, n3 = 25) filled out WAS forms. The patients were divided into two groups according to a quasi-experimental design. In a Short-term intensive inpatient unit all of the restructuring was implemented, whereas only some were in a Half-way house. The Short-term intensive patients reported significant improvements between the second and the third assessment (p less than .05) and between the first and the third year (p less than .02), but not from the first to the second year. The Half-way house patients showed no significant improvements. The patients altogether reported significant improvements in six subvariables of the eight hypothesized. The total WAS score of the staff increased significantly each year (p less than .01), and there was a clear improvement between the first and third assessment (p less than .001). The staff reported significant improvements from the first to the third assessment in seven subvariables of the eight hypothesized.

Characteristics of a good ward atmosphere

Thirty-five short term wards were evaluated with the WAS and a good milieu index. The results indicated that psychotic and non-psychotic patients need different types of atmosphere. Psychotic patients seem to benefit primarily from a milieu with a high level of Support, Practical orientation and Order and organization, and a low level of Anger and aggression, whereas non-psychotic patients seem to benefit mostly from a milieu with a high level of all subscales except for two: the level of Staff control ought to be low and the level of Anger and aggression ought probably to be intermediate.

Research assessing consumer satisfaction with mental health treatment: a review of findings

This article reviews the findings of studies examining consumer satisfaction with mental health treatment. Typically, published studies find the vast majority of patients satisfied with treatment. Despite the numerous methodological problems in this research, it remains highly probable that the majority of consumers are satisfied with the services received. More specific findings in this literature remain less well demonstrated; there generally are few studies relevant to each specific question and the methodology of these studies often has been weak. However, trends point to weak relationships between patient demographic variables and satisfaction; significant relationships between patient diagnosis, treatment history, and psychological status and satisfaction; strong relationships between length of treatment and manner of termination and satisfaction; a strong relationship between satisfaction and patient global report of outcome; and a weak relationship between satisfaction and therapist rating of outcome. Satisfaction also appears to be multidimensional, although a large general factor is evident in most studies. A number of additional findings are catalogued; and research lying outside the formal domain of satisfaction research, but relevant to this body of research, is reviewed.

Current status of milieu psychiatry

Appreciation of the role of milieu in psychiatry has waxed and waned in response to various scientific, ideologic, and social pressures. In this review, historical trends in the use of environment in treatment of mental illness are integrated with social science and empirical research studies of milieu. While the insights of social scientists of the prepsychotropic drug era helped sensitize psychiatry to deleterious effects of hospitalization, the 1960s saw development of a schism between an antipsychiatry movement and a defensive medical reaction, now critical of the excesses and claims of proponents of milieu treatment methods. Recent research studies, however, have begun to document significant effects of milieu upon treatment outcomes, suggesting an opportunity for renewed collaboration between social scientists and hospital psychiatrists. The importance of directing future research efforts toward more specific parameters of milieu in interaction with different diagnoses or patient populations is discussed.

Person-environment relationships in adulthood: implications for human factors engineering

Environments for aging and the aged are best designed if human factors engineers incorporate a developmental view of adulthood in their planning. Accordingly, environments for living should be designed to accommodate the transitions between stages of adult life as well as the periods of stability. The optimal human factors interventions involve both psychosocial and physical aspects of the environment and include changing people through psychological intervention. Examples of human factors engineering for aging in perception, learning, and memory, as well as work, leisure, and health, illustrate areas that require successively more complicated plans for intervention.

Task force report: the social climate of mental health

This paper focuses on the contributions the field of social ecology can make to understanding and assessing the social environment, with special reference to the prevention of mental illness. Intervention in the social environment for mental illness prevention calls for an adequate concept of the environmental effects of mental health; a classification method for measuring and comparing different environments; a knowledge of the relationships between environmental variables and behavioral or psychological outcomes; and a way of determining the most effective interventions.

The alcoholic's perception of the ward as a predictor of aftercare attendance

The present study attempted to determine whether attendance in aftercare services could be predicted from the alcoholic's perception of the inpatient ward environment. Thirty-five Ss who completed inpatient treatment and were eligible for outpatient group therapy were followed up 3 months after discharge. One factor of the Ward Atmosphere Scale, autonomy, significantly differentiated attenders (N = 13) from nonattenders (N = 22); attenders perceived more autonomy on the ward than did nonattenders. Two additional factors, aggression and insight, also differentiated the groups, although not to a statistically significant degree. Attenders were found to perceive more encouragement by the staff to express openly their angry feelings and to share their personal selves with others than were nonattenders.