A Health Care Program for Hospital Staff Larry Kirstein, M.D. Department
of Psychiatry,
Mt. Sinai School of Medicine,
Abstract: This paper illustrates the significance of one aspect of psychiatric consultation to questions of general hospital health care delivery. The contractual arrangements, implementation, and evaluation of a health care delivery program for nonprofessional hospital employees are presenfed. Changes in patients’ perception of treatment were evaluated by random surveys of representative clinic and ward populations before and after this program was implemented. The program was evaluated by precourse-postcourse questionnaires completed anonymously by the hospital personnelgroup. The program was found to be successful in generating lists of major health care delivery problems and some possible solutions. The majority of personnel enjoyed and benefited from this program. A conceptual framework and implications of psychiatric consultation for problems of general health care delivery are discussed.
The trend toward rapid assessment and treatment that characterizes inpatient psychiatry of the 1970s has had a major impact on hospital-based consultation programs. Communication and communitybased psychosocial theories, biologic advances in measurements and mechanisms, and naturalistic epidemiologic research are being integrated into hospital-based consultation (1,2). Primary prevention, the concept of reducing the incidence of an illness, has taken on new meaning as diverse areas of clinical research and knowledge are incorporated into general hospital consultation. Postoperative morbidity and mortality have been reduced through prophylactic psychiatric consultation (3-5). Psychiatric consultants play an integral role in the identification and treatment of patients at risk for coronary artery disease (6). Staff of medical care facilities have benefited from psychiatric consultation in terms of improved patient care and diminished interpersonal conflicts (7). While consultation to the nurse-physicianpatient team is frequent in consultation work (8,9), less attention is directed to other hospital em134 ISSN 0163-8343/79/020134-05/$02.25
New York, New York
ployees, even though their interactions with patients can have considerable impact on the patients’ overall experience of health care delivery. This paper describes the development, implementation, and evaluation of a program devised by the psychiatric consultant to improve the mental health needs of “nonprofessional” hospital employees.
Method Contractual
Arrangements
At the request of the medical director and chief administrator of the hospital (consultees), a meeting was arranged to discuss the feasibility of organizing an awareness training course for hospital personnel. The consultees wished to diminish interpersonal stress for the hospital employee group. Although the administration verbally supported such a program, they had no plans for conceptualization, organization, or implementation. The meeting was attended by representatives from various clinical departments, but only the psychiatric representative volunteered to take responsibility for such a course. The contract established between administration and the psychiatric consultant contained the following points: 1. The psychiatric consultant would designate a time, setting, and structure for the health care delivery program. 2. Only hospital personnel whose work duties involved direct patient contact would be invited to participate in the course. 3. Administration would be responsible to free up the personnel to attend the course. agreed to make available two 4. Administration psychiatric nurses to co-lead the course work for a total of ten hours.
General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979
A Health Care Program for Hospital Staff
the patient care experience 5. Data regarding would be collected from outpatient clinic and inpatient wards by hospital administrative staff at the direction of the psychiatric consultant. 6. Data regarding the health care delivery program (HCDP) would be collected from the hospital personnel group by the psychiatric consultant preceding and at the completion of the HCDP. All nonprofessional hospital personnel (excluded were nurses, social workers, and doctors) who had some direct patient care contact were encouraged to sign up for a series of four l-hour sessions dealing with patients and health care offered at three different times during normal working hours 1 day/week. Lists were established so as not to deplete a clinic or ward unit of its paraprofessional or clerical staff. Participants were limited to 33 per class (n = 98). At the beginning and at the completion of the course, the hospital personnel were asked to complete anonymously a four-item questionnaire designed to measure attitude changes toward an HCDP. Each answer on this questionnaire was or don’t know. Difcoded yes, no, somewhat, ferences were tested for significance using Chisquare test for categorized variables and Student’s two-tailed t-test for continuous variables; 0.05% level was accepted as significant.
Results Format Introduction to sysWeek 1: Conceptualization. tems theory was considered a launching point for the study. Within the hospital setting, multiple systems of stratification exist, but the one chosen for this course was based on a patient service model: input, throughput, and output. People were asked to consider whether their job duties best fit into any one or a combination of these components. Input was defined as the involvement with a patient from the time the patient decided he needed an appointment until he presented to the clinic, emergency room, and so on. Throughput consisted of the direct patient care tasks. Output was defined as patient contacts from the time the patient left the doctor’s office or hospital ward until the next appointment was arranged. The purpose of structuring the initial program in this way was twofold. First, it provided a simple model in which numerous strangers working in different settings and in physically distinct parts of the hospital complex could identify shared or overlapping areas of pa-
tient care involvement. Second, and more important, it provided the focus for the first small group discussion: What are the nonpatient (organizational) factors that enter into the health care delivery system as potential problems or areas of conflict? A hypothetical example was given: the case of the clinic that must schedule its patients’ follow-up appointments 2-3 months in the future because of limited staffing. Each group was then divided into three small groups of 8-12 people who were instructed first to identify how their jobs fit into the model. Then, with the help of the facilitator (either one of the two nurses or the sole psychiatrist), each group began the task of identifying organizational impediments and dilemmas to patient care. People were asked to identify problems in their work areas and solutions or coping mechanisms utilized to contain the problems. Each facilitator was instructed to organize the data into a coherent list. After 3040 minutes of discussion the three small groups disbanded and the three facilitators integrated their lists into a single list. Although some of the problems identified could be considered unique to the particular hospital, many of the issues and solutions seemed to have applicability to other institutions as well (Table 1).
Table 1. Nonpatient
factors
PROBLEMS 1. Excessive paper work 2. Problems with the physical layout 3. Insufficient personal space and time 4. Insufficient information about intradepartmental procedures 5. “Dead wood“ among the staff 6. Shift rotation 7. Communication problems between the hospital and local agencies 8. Overflow of patients for several of the outpatient clinics SUGGESTIONS 1. Provision of maps and clearer labeling of directions
within the hospital 2. More stringent control between capacity for service delivery and nature and number of patients seen in clinics
3. Orientation
program for hospital personnel with particular emphasis on intrahospital consultation and referral procedures 4. Meetings to help facilitate communication between the hospital and its major referral agencies 5. Paying attention to morale issues among the staff
135
L. Kirstein
Week 2: Patients’ problems. Introduction to this aspect of the course consisted of a diagram of the transactional analysis model of parent, adult, and child. Presented material described how various stresses (e.g., pain and/or toxicity from the illness, fear of bodily harm, anxiety about the unknown, and previous medical trauma) can influence a patient to move out of the adult role. Similarly, pressures and stresses (social, economical, personal, physical, and so on) that can influence the hospital employee’s capacity to function in an adult role were mentioned. The manner in which hospital employees’ specific information, advice, procedures, and so on were conveyed to patients formed a framework in which they should interact professionally with patients (in the adult role). When the large group was organized into three smaller discussion groups, it was pointed out that conflicts and problems occur when patients succeed in moving the hospital employee out of the adult role. The groups were asked to consider two questions: (a) How do patients do this and (b) what do they do to contend with the patients? After a 3040 minute discussion, the small groups were disbanded and the three facilitators compiled their list (Table 2). Week 3: Coping with stress. For the third session, the small group component was begun almost immediately. The only instruction was that people should not limit themselves to professional coping mechanisms but rather use the group experience to mention anything that helps relieve the tensions and pressures of hospital work. Table 3 presents a synthesis of the suggestions shared by the group members. Toward the end of the group meetings, a Table 2. Patient problems 1. The demanding patient 2. The manipulative patient (a) Inappropriate use of hospital facilities (b) Purposeful lying (c) Medication abuse 3. The dependent patient (a) “Nobody told me” 4. The omniscient patient (a) “My way” 5. The rule-breaking patient (a) Doesn’t call to cancel (b) Doesn’t listen to advice 6. The offensive patient (a) Condescending, patronizing, or prejudiced (b) Socially embarrassing
136
Table 3. Coping with stress A. What works professionally? 1. Anticipating the problem 2. Delaying a response when angry 3. Asking patients to be responsible 4. Stating things in an adult manner 5. Reality testing (a) About the rules and guidelinesin thissituation (b) About the consequences of the patient’s actions or lack of actions 6. Professional backup 7. Firmness (limit setting) 8. Knowing your job B. What works personally? 1. To be able to discharge your frustrations in an area where the patient cannot see it 2. To have free time during the day 3. To be able to share your problems with your peers 4. To develop a sense of humor and a philosophical perspective about the job 5. To be involved in a variety of extracurricular interests so that the job is only one component of your life 6. To have channels for aggression such as sports, etc.
series of guidelines was offered by the leader for coping with some job-related stresses: Identify the problem. Articulate the problem in an adult role and try to address the patients’ adult role requirements and responsibilities. Attempt to resolve the dilemma (current conflict) or identify what else the patient can do to resolve the problem.
Week 4: Experiential exercise. For the final sessions, all participants were asked to report to the auditorium for a large group exercise. It was explained that the specific details of the exercise would be described at that time. The fourth session was, however, to be an experiential one in which the hospital personnel would have the opportunity to wait for a doctor. In addition, the two nurse facilitators who understood the purpose of the exercise chose alternate roleS for the 20-minute exercise. One nurse assumed a disinterested posture, reading the newspaper after announcing that the doctor would be detained a few minutes and insisting that people not leave the room while she herself left to get a cup of coffee. The other nurse suggested how people could occupy their time,
A Health Care Program for Hospital Staff
tried to find out when the doctor would be arriving, and circulated among the participants. After 20 minutes, the doctor arrived and asked the participants to form six small groups of 15-20 people each to share with each other their thoughts and feelings about the exercise they had just been through. The three facilitators circulated and attempted to help people consider how they felt about the differing behaviors of the two nurses and their attitudes toward the doctor. A rich variety of reactions was elicited. In the final 10 minutes of the course people were asked to respond anonymously to the same series of questions as before (Table 4). The course was experienced as a positive constructive exercise by the large majority of hospital personnel; (P < 0.001) for all four precourse-postcourse questions. Retrospectively, the absentee rates of the nonprofessional staff at four outpatient clinics were collected for two l-month intervals, one preceding and one following the HCDP. During the prepro-
Table 4. Hospital
care delivery
program
gram period, 10 of 60 staff members were absent compared with only 3 of 60 during the postprogram sampling period (P < 0.001, Chi-square analysis for shift in binomial proportions).
Discussion In this paper the author has described the contractual arrangements, implementation, and evaluation of an HCDP for nonprofessional hospital employees. Application of administrative consultations by hospital-based psychiatrists and the implications of this specific program are discussed.
Administrative Consultation Of the four types of consultation models outlined by Caplan (7), the HCDP best fits the programcentered administrative consultation. The fundamental principle in this type of consultation is that a consultant will advise and recommend the plan-
evaluation
PRECOURSE QUESTIONS Do you feel that a 4-week course designed to discuss and examine problems and solutions of working with medical patients will be: Informative to you (provide new information) Of practical use to you A tense experience because you will be expected to share your own observations and solutions with others A pleasurable or enjoyable experience because you will be able to share your own observations and solutions with others POSTCOURSE QUESTIONS Did you find this 4-week course: 1. Informative (provide new information)” 2. Practically useful” 3. Anxiety provoking” 4. Enjoyable” 5. Should have monthly follow-up meetings 6. Should be repeated for new personnel 7. Other comments (miscellaneous): (a) Physicians should attend (n = 13) (b) The course should run longer than 4 weeks (iz = 16) (c) The sessions should run longer than 1 hour (n = 3)
Yes
Somewhat
No
Don’t know
19 (20%) 15 (16%) 23 (24%)
40 (43%) 21 (22%) 21 (22%)
12 (13%) 10 (11%) 30 (31%)
22 (24%) 48 (51%) 22 (23%)
13 (14%)
29 (31%)
17 (18%)
34 (37%)
64 53 4 57 53 65
26 24 72 22
2 6 16 8 16 2
(70%) (59%) (5%) (63%) (58%) (74%)
(28%) (27%) (78%) (24%) -
(2%) (7%) (17%) (9%) (17%) (2%)
0 7 : (4%) 23 (25%) 21 (24%)
“P < 0.001, Chi-square analysis.
137
L. Kirstein
ning, handling, and implementing of a specific organizational problem. The HCDP is not remarkably different from the usual hospital psychiatric consultations. Frequently, what is identified as a patient problem is viewed by the psychiatric consultant as an intrastaff problem, a staff-patient problem, or a hospital policy-patient problem (4). In a recent report of consultation service activities, after mental status evaluation, the two most frequent consultant activities were advising staff about patient management and being supportive of staff (5). Although in the HCDP the consultee is an organizational system rather than a physician, the goal of attempting to facilitate and improve patient care is common to all three situations. Two differences between the program-centered administrative consultation and HCDP are noteworthy. In Caplan’s scheme, implementation of the program remains the organization’s responsibility and the consultant is usually an outsider to the organization. In the HCDP, the psychiatrist can be a member of the hospital staff. Although this approach would provide an individual with more detailed knowledge of the stresses and strains within the organization, the socioeconomic ties that bind the psychiatrist to the institution could compromise his consultative objectivity. A discussion with the administrative consultee about the psychiatrist’s potential role conflicts and contractually derived powers and authority would be useful in diminishing the consultant’s dilemma. As a member of the organization, it might be easier for the consultant initially to implement the HCDP and later step aside and serve as a resource person on the project.
Health Cure Delivery Program The hospital setting, with its primary goal of providing quality patient care, provides an environment in which people with varied medical backgrounds (the nonprofessional staff) are confronted with people experiencing a variety of physical and emotional discomforts. Clearly defined job descriptions and a personal sense of job-related competence helps nonprofessional staff to lessen patients’ suffering; yet the frustrations, anxieties, and fears of these personnel can influence their own job performance, in terms of absenteeism, decreased work output, increased errors, increased interpersonal friction, or some other form of manpower wastage. Two
138
separate measures suggest that the HCDP may be a worthwhile experience in diminishing job-related dissatisfaction. First, absenteeism dropped significantly during the 1 month following the study (May) compared with the month preceding the study (March). Although other factors certainly could influence this finding (such as school vacations and medical illness), these data do lend support to the value of the HCDP. Second, the precourse-postcourse program questionnaire and the lists generated by the employees during the first three exercises are evidence that this program was taken seriously and was experienced positively. In addition, no group casualties were noted. In summary, this study demonstrated the significance of psychiatric consultation to questions of general hospital health care delivery. It underscored the role of the psychiatrist in promoting staff morale through educational group-oriented experiences.
References 1. Lipowski ZJ: Psychosomatic medicine in the seventies: an overview. Am J Psychiatry 134:233-244, 1977 2. Friedman M: Pathogenesis of Coronary Artery Disease. New York, McGraw-Hill, 1969 3. Weisman AD, Hackett TP: Psychosis after eye surgery: Establishment of specific doctor-patient relationship in prevention and treatment of block patch delirium. N Engl J Med 258:1284, 1958 4. Meyer E, Mendelson M: Psychiatric consultation with patients on medical and surgical wards: patterns and processes. Psychiatry 24: 197-220, 1961 5. Karasu T, et al: Hosp Community Psychiatry 28:29194, 1977 6. Kennedy JA, Bakst H: The influence of emotion on the outcome of cardiac surgery. A predictive study. Bull NY Acad Med 42:811, 1966 7. Caplan G: The Theory and Practice of Mental Health Consultation. New York, Basic Books Inc., 1970 8. Simmons RG et al: Donors and non-donors: The role of the family and the physician in kidney transplantation. Semin Psychiatry 3:102, 1971 9. Witherstly D: Sexual attitudes of hospitalized personnel: A model of continuing education. Am J Psychiatry 573-576, 1976
Direct reprint requests to: Larry Kirstein, M.D. Department of Psychiatry Mt. Sinai Hospital 1 Gustave Levy Plaza New York, NY 10029
of Psychiatry,
Mt. Sinai School of Medicine,
Abstract: This paper illustrates the significance of one aspect of psychiatric consultation to questions of general hospital health care delivery. The contractual arrangements, implementation, and evaluation of a health care delivery program for nonprofessional hospital employees are presenfed. Changes in patients’ perception of treatment were evaluated by random surveys of representative clinic and ward populations before and after this program was implemented. The program was evaluated by precourse-postcourse questionnaires completed anonymously by the hospital personnelgroup. The program was found to be successful in generating lists of major health care delivery problems and some possible solutions. The majority of personnel enjoyed and benefited from this program. A conceptual framework and implications of psychiatric consultation for problems of general health care delivery are discussed.
The trend toward rapid assessment and treatment that characterizes inpatient psychiatry of the 1970s has had a major impact on hospital-based consultation programs. Communication and communitybased psychosocial theories, biologic advances in measurements and mechanisms, and naturalistic epidemiologic research are being integrated into hospital-based consultation (1,2). Primary prevention, the concept of reducing the incidence of an illness, has taken on new meaning as diverse areas of clinical research and knowledge are incorporated into general hospital consultation. Postoperative morbidity and mortality have been reduced through prophylactic psychiatric consultation (3-5). Psychiatric consultants play an integral role in the identification and treatment of patients at risk for coronary artery disease (6). Staff of medical care facilities have benefited from psychiatric consultation in terms of improved patient care and diminished interpersonal conflicts (7). While consultation to the nurse-physicianpatient team is frequent in consultation work (8,9), less attention is directed to other hospital em134 ISSN 0163-8343/79/020134-05/$02.25
New York, New York
ployees, even though their interactions with patients can have considerable impact on the patients’ overall experience of health care delivery. This paper describes the development, implementation, and evaluation of a program devised by the psychiatric consultant to improve the mental health needs of “nonprofessional” hospital employees.
Method Contractual
Arrangements
At the request of the medical director and chief administrator of the hospital (consultees), a meeting was arranged to discuss the feasibility of organizing an awareness training course for hospital personnel. The consultees wished to diminish interpersonal stress for the hospital employee group. Although the administration verbally supported such a program, they had no plans for conceptualization, organization, or implementation. The meeting was attended by representatives from various clinical departments, but only the psychiatric representative volunteered to take responsibility for such a course. The contract established between administration and the psychiatric consultant contained the following points: 1. The psychiatric consultant would designate a time, setting, and structure for the health care delivery program. 2. Only hospital personnel whose work duties involved direct patient contact would be invited to participate in the course. 3. Administration would be responsible to free up the personnel to attend the course. agreed to make available two 4. Administration psychiatric nurses to co-lead the course work for a total of ten hours.
General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979
A Health Care Program for Hospital Staff
the patient care experience 5. Data regarding would be collected from outpatient clinic and inpatient wards by hospital administrative staff at the direction of the psychiatric consultant. 6. Data regarding the health care delivery program (HCDP) would be collected from the hospital personnel group by the psychiatric consultant preceding and at the completion of the HCDP. All nonprofessional hospital personnel (excluded were nurses, social workers, and doctors) who had some direct patient care contact were encouraged to sign up for a series of four l-hour sessions dealing with patients and health care offered at three different times during normal working hours 1 day/week. Lists were established so as not to deplete a clinic or ward unit of its paraprofessional or clerical staff. Participants were limited to 33 per class (n = 98). At the beginning and at the completion of the course, the hospital personnel were asked to complete anonymously a four-item questionnaire designed to measure attitude changes toward an HCDP. Each answer on this questionnaire was or don’t know. Difcoded yes, no, somewhat, ferences were tested for significance using Chisquare test for categorized variables and Student’s two-tailed t-test for continuous variables; 0.05% level was accepted as significant.
Results Format Introduction to sysWeek 1: Conceptualization. tems theory was considered a launching point for the study. Within the hospital setting, multiple systems of stratification exist, but the one chosen for this course was based on a patient service model: input, throughput, and output. People were asked to consider whether their job duties best fit into any one or a combination of these components. Input was defined as the involvement with a patient from the time the patient decided he needed an appointment until he presented to the clinic, emergency room, and so on. Throughput consisted of the direct patient care tasks. Output was defined as patient contacts from the time the patient left the doctor’s office or hospital ward until the next appointment was arranged. The purpose of structuring the initial program in this way was twofold. First, it provided a simple model in which numerous strangers working in different settings and in physically distinct parts of the hospital complex could identify shared or overlapping areas of pa-
tient care involvement. Second, and more important, it provided the focus for the first small group discussion: What are the nonpatient (organizational) factors that enter into the health care delivery system as potential problems or areas of conflict? A hypothetical example was given: the case of the clinic that must schedule its patients’ follow-up appointments 2-3 months in the future because of limited staffing. Each group was then divided into three small groups of 8-12 people who were instructed first to identify how their jobs fit into the model. Then, with the help of the facilitator (either one of the two nurses or the sole psychiatrist), each group began the task of identifying organizational impediments and dilemmas to patient care. People were asked to identify problems in their work areas and solutions or coping mechanisms utilized to contain the problems. Each facilitator was instructed to organize the data into a coherent list. After 3040 minutes of discussion the three small groups disbanded and the three facilitators integrated their lists into a single list. Although some of the problems identified could be considered unique to the particular hospital, many of the issues and solutions seemed to have applicability to other institutions as well (Table 1).
Table 1. Nonpatient
factors
PROBLEMS 1. Excessive paper work 2. Problems with the physical layout 3. Insufficient personal space and time 4. Insufficient information about intradepartmental procedures 5. “Dead wood“ among the staff 6. Shift rotation 7. Communication problems between the hospital and local agencies 8. Overflow of patients for several of the outpatient clinics SUGGESTIONS 1. Provision of maps and clearer labeling of directions
within the hospital 2. More stringent control between capacity for service delivery and nature and number of patients seen in clinics
3. Orientation
program for hospital personnel with particular emphasis on intrahospital consultation and referral procedures 4. Meetings to help facilitate communication between the hospital and its major referral agencies 5. Paying attention to morale issues among the staff
135
L. Kirstein
Week 2: Patients’ problems. Introduction to this aspect of the course consisted of a diagram of the transactional analysis model of parent, adult, and child. Presented material described how various stresses (e.g., pain and/or toxicity from the illness, fear of bodily harm, anxiety about the unknown, and previous medical trauma) can influence a patient to move out of the adult role. Similarly, pressures and stresses (social, economical, personal, physical, and so on) that can influence the hospital employee’s capacity to function in an adult role were mentioned. The manner in which hospital employees’ specific information, advice, procedures, and so on were conveyed to patients formed a framework in which they should interact professionally with patients (in the adult role). When the large group was organized into three smaller discussion groups, it was pointed out that conflicts and problems occur when patients succeed in moving the hospital employee out of the adult role. The groups were asked to consider two questions: (a) How do patients do this and (b) what do they do to contend with the patients? After a 3040 minute discussion, the small groups were disbanded and the three facilitators compiled their list (Table 2). Week 3: Coping with stress. For the third session, the small group component was begun almost immediately. The only instruction was that people should not limit themselves to professional coping mechanisms but rather use the group experience to mention anything that helps relieve the tensions and pressures of hospital work. Table 3 presents a synthesis of the suggestions shared by the group members. Toward the end of the group meetings, a Table 2. Patient problems 1. The demanding patient 2. The manipulative patient (a) Inappropriate use of hospital facilities (b) Purposeful lying (c) Medication abuse 3. The dependent patient (a) “Nobody told me” 4. The omniscient patient (a) “My way” 5. The rule-breaking patient (a) Doesn’t call to cancel (b) Doesn’t listen to advice 6. The offensive patient (a) Condescending, patronizing, or prejudiced (b) Socially embarrassing
136
Table 3. Coping with stress A. What works professionally? 1. Anticipating the problem 2. Delaying a response when angry 3. Asking patients to be responsible 4. Stating things in an adult manner 5. Reality testing (a) About the rules and guidelinesin thissituation (b) About the consequences of the patient’s actions or lack of actions 6. Professional backup 7. Firmness (limit setting) 8. Knowing your job B. What works personally? 1. To be able to discharge your frustrations in an area where the patient cannot see it 2. To have free time during the day 3. To be able to share your problems with your peers 4. To develop a sense of humor and a philosophical perspective about the job 5. To be involved in a variety of extracurricular interests so that the job is only one component of your life 6. To have channels for aggression such as sports, etc.
series of guidelines was offered by the leader for coping with some job-related stresses: Identify the problem. Articulate the problem in an adult role and try to address the patients’ adult role requirements and responsibilities. Attempt to resolve the dilemma (current conflict) or identify what else the patient can do to resolve the problem.
Week 4: Experiential exercise. For the final sessions, all participants were asked to report to the auditorium for a large group exercise. It was explained that the specific details of the exercise would be described at that time. The fourth session was, however, to be an experiential one in which the hospital personnel would have the opportunity to wait for a doctor. In addition, the two nurse facilitators who understood the purpose of the exercise chose alternate roleS for the 20-minute exercise. One nurse assumed a disinterested posture, reading the newspaper after announcing that the doctor would be detained a few minutes and insisting that people not leave the room while she herself left to get a cup of coffee. The other nurse suggested how people could occupy their time,
A Health Care Program for Hospital Staff
tried to find out when the doctor would be arriving, and circulated among the participants. After 20 minutes, the doctor arrived and asked the participants to form six small groups of 15-20 people each to share with each other their thoughts and feelings about the exercise they had just been through. The three facilitators circulated and attempted to help people consider how they felt about the differing behaviors of the two nurses and their attitudes toward the doctor. A rich variety of reactions was elicited. In the final 10 minutes of the course people were asked to respond anonymously to the same series of questions as before (Table 4). The course was experienced as a positive constructive exercise by the large majority of hospital personnel; (P < 0.001) for all four precourse-postcourse questions. Retrospectively, the absentee rates of the nonprofessional staff at four outpatient clinics were collected for two l-month intervals, one preceding and one following the HCDP. During the prepro-
Table 4. Hospital
care delivery
program
gram period, 10 of 60 staff members were absent compared with only 3 of 60 during the postprogram sampling period (P < 0.001, Chi-square analysis for shift in binomial proportions).
Discussion In this paper the author has described the contractual arrangements, implementation, and evaluation of an HCDP for nonprofessional hospital employees. Application of administrative consultations by hospital-based psychiatrists and the implications of this specific program are discussed.
Administrative Consultation Of the four types of consultation models outlined by Caplan (7), the HCDP best fits the programcentered administrative consultation. The fundamental principle in this type of consultation is that a consultant will advise and recommend the plan-
evaluation
PRECOURSE QUESTIONS Do you feel that a 4-week course designed to discuss and examine problems and solutions of working with medical patients will be: Informative to you (provide new information) Of practical use to you A tense experience because you will be expected to share your own observations and solutions with others A pleasurable or enjoyable experience because you will be able to share your own observations and solutions with others POSTCOURSE QUESTIONS Did you find this 4-week course: 1. Informative (provide new information)” 2. Practically useful” 3. Anxiety provoking” 4. Enjoyable” 5. Should have monthly follow-up meetings 6. Should be repeated for new personnel 7. Other comments (miscellaneous): (a) Physicians should attend (n = 13) (b) The course should run longer than 4 weeks (iz = 16) (c) The sessions should run longer than 1 hour (n = 3)
Yes
Somewhat
No
Don’t know
19 (20%) 15 (16%) 23 (24%)
40 (43%) 21 (22%) 21 (22%)
12 (13%) 10 (11%) 30 (31%)
22 (24%) 48 (51%) 22 (23%)
13 (14%)
29 (31%)
17 (18%)
34 (37%)
64 53 4 57 53 65
26 24 72 22
2 6 16 8 16 2
(70%) (59%) (5%) (63%) (58%) (74%)
(28%) (27%) (78%) (24%) -
(2%) (7%) (17%) (9%) (17%) (2%)
0 7 : (4%) 23 (25%) 21 (24%)
“P < 0.001, Chi-square analysis.
137
L. Kirstein
ning, handling, and implementing of a specific organizational problem. The HCDP is not remarkably different from the usual hospital psychiatric consultations. Frequently, what is identified as a patient problem is viewed by the psychiatric consultant as an intrastaff problem, a staff-patient problem, or a hospital policy-patient problem (4). In a recent report of consultation service activities, after mental status evaluation, the two most frequent consultant activities were advising staff about patient management and being supportive of staff (5). Although in the HCDP the consultee is an organizational system rather than a physician, the goal of attempting to facilitate and improve patient care is common to all three situations. Two differences between the program-centered administrative consultation and HCDP are noteworthy. In Caplan’s scheme, implementation of the program remains the organization’s responsibility and the consultant is usually an outsider to the organization. In the HCDP, the psychiatrist can be a member of the hospital staff. Although this approach would provide an individual with more detailed knowledge of the stresses and strains within the organization, the socioeconomic ties that bind the psychiatrist to the institution could compromise his consultative objectivity. A discussion with the administrative consultee about the psychiatrist’s potential role conflicts and contractually derived powers and authority would be useful in diminishing the consultant’s dilemma. As a member of the organization, it might be easier for the consultant initially to implement the HCDP and later step aside and serve as a resource person on the project.
Health Cure Delivery Program The hospital setting, with its primary goal of providing quality patient care, provides an environment in which people with varied medical backgrounds (the nonprofessional staff) are confronted with people experiencing a variety of physical and emotional discomforts. Clearly defined job descriptions and a personal sense of job-related competence helps nonprofessional staff to lessen patients’ suffering; yet the frustrations, anxieties, and fears of these personnel can influence their own job performance, in terms of absenteeism, decreased work output, increased errors, increased interpersonal friction, or some other form of manpower wastage. Two
138
separate measures suggest that the HCDP may be a worthwhile experience in diminishing job-related dissatisfaction. First, absenteeism dropped significantly during the 1 month following the study (May) compared with the month preceding the study (March). Although other factors certainly could influence this finding (such as school vacations and medical illness), these data do lend support to the value of the HCDP. Second, the precourse-postcourse program questionnaire and the lists generated by the employees during the first three exercises are evidence that this program was taken seriously and was experienced positively. In addition, no group casualties were noted. In summary, this study demonstrated the significance of psychiatric consultation to questions of general hospital health care delivery. It underscored the role of the psychiatrist in promoting staff morale through educational group-oriented experiences.
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Direct reprint requests to: Larry Kirstein, M.D. Department of Psychiatry Mt. Sinai Hospital 1 Gustave Levy Plaza New York, NY 10029
