Residents’ Perceptions of Inpatient Psychiatric Care John Racy and Robert H. Goldstein

P

SYCHIATRIC CARE on an inpatient unit entails the exposure of a patient to a multitude of experiences. It is generally intended that these experiences will be of benefit to the patient. A psychiatric clinician who functions in such a setting has a major responsibility for making decisions about the kinds of experiences to which any patient will be subject. He must also try to orchestrate the impact of these experiences in a way that will be of maximum benefit to the patient. This decision-making process must inevitably be influenced by the clinician’s beliefs with respect to how much patients will benefit from these various experiences. These beliefs can be viewed as a set of expectations or as an ideology derived from many sources. In the course of his training, a clinician reads, learns from teachers, and deals with a variety of clinical materials and situations. Out of these emerges that analgam of experience, faith, and knowledge upon which he can draw when a decision is to be made. While reports by Myers and Rosen’ and by Rubenstein and Laswel12 have touched on this issue, relatively little is known about the patterns of beliefs held by psychiatric clinicians. In a previous report3 we described residents’ perceptions of the benefit derived from psychiatric hospitalization. In this study we attempt (1) to assess the beliefs of psychiatric residents regarding what aspects of hospital care benefit patients, (2) to measure these beliefs at the beginning and at the end of a period of clinical training and experience, and (3) to compare these general beliefs or stereotypes against more individualized judgments of what it is that patients actually do benefit from. PROCEDURE The study was conducted

on one of the inpatient

center. This is an acute-treatment a broad spectrum of psychiatric program

entails, when indicated,

exposure to a generally

disorders. The patient-staff psychotherapy,

therapeutic

clinical psychologist proportion patients

(=

floors of a large university

50%)

medical

ratio is low, and the intensive treatment

group experiences,

medication,

are cared for by psychiatric

experience

and who serve a 6-month

of a chief resident and a senior staff clinical director.

are also active participants

of patients

ECT,

milieu. Patients

assigned to the floor as part of their first-year work under the direction

psychiatric

service that has a capacity of 35 patients, with admissions covering

retain

period. Residents

A social worker

in the floor’s clinical and teaching activities.

the services of an attending

are also assigned to psychiatric

activities, and

residents who are

residents.

Psychiatric

psychiatrist,

and

A large

but such private

nurses and nursing assistants play a

major role in patient care, as do closely supervised medical and nursing students and a large cadre of activities therapists. During

their first week on the service, residents were asked to complete

a questionnaire

that in-

volved the rating on a four-point

scale of the degree of benefit derived by patients from each of 20 as-

pects of the hospital experience.

The specific items to be rated included various floor and attending

From the Department of Psychiatry. University of Rochester School of Medicine and Dentistry. Rochester. N. Y. John Racy, M.D.: Associate Professor of Psychiatry and Nursing; Robert H. Goldstein, Ph.D.: Associate Professor of Psychiatry and Psychology; Department of Psychiatry. University of Rochester School of Medicine and Dentistry o 1975 by Grune & Stratton, Inc.

ComPrehensive Psychiatry, Vol. 16. No. 2

(March/April),

1975

17’

172

RACY AND GOLDSTEIN

A

NURSING ASSISTANT

6

PRIVATE PSYCHIATRIST

C

ELECTROSHOCK TREATMENT

D ACTI~ITIE~~NC~UDI~~CHEDU~ED OFF- LIMITS PROGRAM E

STUDENT NURSE

F

FLOOR RULESAND REGULATIONS

G

PATIENT COMMITTEE

H

OTHER PATIENTS

I

BEING ALONE - READING, WRITING, THINKiNG,ETC.

J

GROUP MEETINGS

K

GENERAL FLOOR ATMOSPHERE MEDICATION

1 M

FAMILY OR OTHER VISITORS

N

RESIDENT PSYCHIATRIST

0

GETTING AWAY FROM PROBLEMS BY COMING TO THE HOSPITAL

P

REGISTERED NURSE

Q

TALKING OVER PERSONAL PROBLEMS WITH YOUR DOCTOR

R

STUDENT DOCTOR

S

OTHER STAFF [SOCIAL WORKER, PSYCHOLOGIST, CHIEF RESIDENT, CLINICAL DIRECTOR)

T

REST AND REGULAR MEALS

0 INITIAL STEREOTYPE bp FINAL STEREOTYPE I ACTUAL RATING

1 NOT AT ALL Fig. 1.

Resident initial stereotypea.

2 SOMEWHAT final steraotypas,

4

3 QUITE A BIT

EXTREMELY

and actual ratings of benefit.

staff personnel, treatment procedures, and components of the floor milieu (see Fig. 1). Residents were instructed to fill out this initial questionnaire in terms of their impression of the benefit derived by “patients in general.” At the conclusion of their 6-month assignment, residents again completed this same questionnaire in terms of patients in general. These two ratings were considered to represent the residents’ prevailing beliefs or stereotypes at these two times. The same questionnaire was also used to obtain residents’ judgments as to the benefit actually derived by individual patients under their care during their 6-month assignment to the floor. These ratings of actual benefit were made at the time of each patient’s discharge from the hospital. Thus, ratings of benefit to patients were available for each of the 20 questionnaire items reflecting (1) the residents’ initial stereotype, (2) the residents’ final stereotype, and (3) the residents’ actual ratings for each of their patients. Questionnaires were collected from 23 residents, representing four 6-month rotations. The residents made actual ratings for 346 patients (128 males, 218 females). The ages of the patients ranged from 13 to 76 years with a mean of 40.3 years (i 16.2). The diagnostic distribution included 30% schizophrenics, 28% affective psychoses, 32% neurotics and character disorders, and 10% organic and other disorders. Patients hospitalized for less than 7 days were excluded from the study. For each item, three mean scores were calculated: The mean of the residents’ initial stereotype ratings, the mean of the residents’ final stereotype ratings, and the mean of the actual ratings given by

RESIDENTS’

residents

113

PERCEPTIONS

for their own patients.

These actual ratings were computed

on the basis of differing N’s for

the various items, since certain items were relevant to and could be rated for all patients (e.g., nurse, general floor atmosphere),

while other items applied only to some patients (e.g., private psychiatrist.

ECT).

RESULTS

Table 1 presents the mean scores and rank order of items for each of the three sets of ratings, i.e., initial stereotypes, final stereotypes, and actual ratings. The results of the stereotype data indicate that highest benefit scores are found for the items dealing with somatic therapies (ECT, medication). Items relating to individual psychotherapy, milieu factors, and group experiences received lower scores, and it would appear that the residents viewed these aspects of the hospital experience as being of somewhat lesser benefit for patients in general. The residents’ belief was that they themselves were the staff person from whom patients in general derived the greatest benefit, with nurses, private psychiatrists, and the remainder of the floor staff being viewed as exercising a somewhat lesser beneficial influence. Among milieu variables, residents believed general atmosphere factors were more beneficial than were specific structured activities or group meetings. It can be seen that the rank orders of items in the two sets of stereotype data are quite similar. Indeed, the rank-order correlation coefficient between the initial and the final stereotypes yielded a value of + 0.9 1. Thus, after a 6-month clinical experience, residents held essentially the same beliefs regarding the relative benefit derived by patients from various aspects of hospitalization that they held at the beginning of the experience. Table 1. Mean Values of Residents’ Stereotvoe Initial Stereotype

Itern

Rank

and Actual

Ratings of Benefit

Final Stereotype Mean

Rank

I tern

Actual Mean

Ratings

I tern

Rank

Mean

1.

ECT

3.55

1.

ECT

3.78

1.

ECT

3.51

2.

Medication

3.39

2.

Medication

3.57

2.

Priv. psychiat.

2.95

3.

Resident

3.30

3.

Resident

3.35

3.

Resident

2.91

4.

Regist. nurse*

3.17

4.

Talk with doctor

3.17

4.

Medication

5.

Talk with doctor*

3.17

5.

Priv. psychiat.*

3.04

5.

Getting

6.

Priv. psychiat.

3.00

6.

Floor atmosph.*

3.04

6.

Floor atmosph.*

2.72

7.

Floor atmosph.

2.96

7.

Activities

2.96

7.

Talk with doctor’

2.72

8.

Activities*

2.87

8.

Getting away

2.91

8.

Activities

2.68

9.

Getting

2.87

9.

Regist. nurse

2.83

9.

Regist. nurse

2.53

Stud. doctor

2.74

10.

Rest & meals

2.43 2.42

Away*

away

2.82 2.78

10.

Group meetings

2.68

10.

11.

Stud. doctor

2.65

1 I.

Other pts.

2.70

11.

Floor rules*

12.

Other pts.*

2.61

12.

Floor rules

2.51

12.

Other pts.*

2.42

13.

Other staff *

2.61

13.

Nurs. assist.

2.48

13.

Stud. doctor

2.39 2.37

14.

Family

2.48

14.

Group meetings

2.43

14.

Family

15.

Floor rules*

&visit.

2.43

15.

Family

2.35

15.

Group

16.

Rest & meals*

2.43

16.

Stud. nurse

2.30

16.

Nurs. assist.

2.06

&visit.

&visit. meetings

2.22

17.

Nurs. assist.

2.39

17.

Other staff

2.26

17.

Stud. nurse

1.97

18.

Stud. nurse

2.26

18.

Rest & meals

2.09

18.

Being alone

1.91

19.

Being alone

2.17

19.

Pt. comm.

1.87

19.

Other staff

1.83

20.

Pt. comm.

2.09

20.

Being alone

1.83

20.

Pt. comm.

1.60

*Denotes

tie.

174

RACY AND GOLDSTEIN

We next examined the absolute level of perceived benefit for each item and compared the mean initial stereotypes with the mean final stereotypes. There was no significant difference (by t test) between mean initial stereotype scores and mean final stereotype scores on any of the 20 items. So the consistency of belief in regard to relative benefit (as reflected in the high rank-order correlation) was also evident with regard to absolute benefit. We wondered whether the apparent stability of these general impressions of benefit might be related to the residents’ levels of clinical experience. An opportunity for examining this question further was made possible by the fact that our resident group was not homogeneous with regard to the matter of prior clinical experience. Half of the residents came to the floor and gave their initial stereotype responses during the very first week of their psychiatric residency (the “naive” group). The other half of the residents came after having already served a 6-month stint on another psychiatric floor of the department (the “experienced” group). A comparison of the responses of these two groups of residents showed that residents’ naive vs. experienced status made little difference and that the patterns of response in these two subgroups were quite similar. The initial stereotypes of naive and experienced residents showed a rank-order correlation of 0.93. Both the naive and experienced groups showed similarly high initialstereotype-final-stereotype correlations (+ 0.87 for the naive and + 0.91 for the experienced). We also compared the initial and final mean stereotype scores separately for the naive and experienced groups. Among the naive residents, only one item of the 20 (ECT) showed a significant (p < 0.05) initial--final difference. There was no significant initial-final difference for any item among the experienced group. It would appear then that essentially the same high level of consistency of residents’ impressions was present, independent of the length of the residents’ experience in this program. We next examined the relationship between the residents’ stereotypes and the actual ratings they gave for their individual patients. Actual rating means yielded a rank-order correlation of 0.86 with initial stereotypes and 0.90 with final stereotypes. These high rank-order correlations would suggest that the residents’ views of the relative value of various aspects of the hospital experience for individual patients were quite similar to their views in this regard for patients in general. In order to determine whether this consistency in views concerning relative benefit of various components of hospitalization was also apparent in terms of absolute ratings of derived benefit, analysis-of-variance methods were then ap plied. For each of the 20 items, a separate simple one-way analysis of variance was applied to the three scores representing the mean initial stereotype, the mean final stereotype, and the mean of actual ratings, Significant differences among the three sets of scores were found for 10 of the 20 items (items A, E, G, J, K, L, N, P, Q, and S). Those items that yielded a significant overall F were then further examined by means of t tests. This revealed that there were differences between the stereotypes and the actual ratings, but not between the two sets of stereotypes (see Fig. 1). In none of the 10 overall significant items was there a significant difference by t test between initial and final stereotypes. The t tests did indicate, however, that in 9 of the 10 items the mean of actual ratings was

RESIDENTS’

175

PERCEPTIONS

significantly lower (p < 0.05) than the mean of initial stereotypes. Furthermore, the mean of actual ratings was also significantly lower (p < 0.05) than the mean of final stereotypes in 6 of these items. Thus it would appear that residents’ overall impressions regarding the relative degree of benefit resulting from various aspects of the hospital experience were not significantly altered as a function of the residents’ experiences on the floor. For many of the items, however, evaluations of actual benefit derived by patients were significantly lower than the general impressionistic view of the benefit these factors could produce. DISCUSSION

Some of the findings on this study are relatively easy to understand, while others are not. It stands to reason that the stereotypes regarding the degree of benefit to be derived from a particular factor would exceed perceived actual benefit. The stereotype judgment was, after all, made on the basis of a hypothetical patient who presumably might stand to profit from a particular modality. Very likely these ratings reflect residents’ views of the potential benefit associated with each factor. Actual ratings, on the other hand, reflected the real variation among individual patients in the degree to which they benefited from a factor. Since few patients are likely to experience the full degree of potential benefit associated with some aspect of the hospital, it is no surprise that the actual ratings are lower than the stereotype ratings. The high rank-order correlation between actual means and the final stereotypes is also a finding that could have been predicted. Residents’ final judgments or stereotypes might reasonably be expected to reflect the degree of benefit they had been attributing to the various items in their ratings for individual patients during their 6-month rotation. Less comprehensible, however, was the high degree of correspondence between initial and final stereotypes. These two sets of stereotypes were much closer to each other (both in terms of rank-order correlation and in terms of absolute means) than either of them was to actual ratings. Taken at face value, these results may indicate that residents enter this rotation with a particular attitudinal set and leave it with that set unaltered. If that were true, it would suggest that the educational process involved in residency training simply serves, in some respects, to confirm preexisting attitudes and beliefs. There are, however, other possibilities that might explain our findings: 1. It will be recalled that our residents could be subdivided into naive and experienced groups. Those residents who had already served a 6-month stint on one of the other inpatient services of the department might be expected to have had considerable experience with the factors to be rated. By the time their initial stereotypes were obtained, their beliefs might well have become firmly fixed and were not likely to be altered by 6 further months of similar experience. But what of the newly arrived naive group? They had been on the service for but 1 week when they gave initial stereotype ratings. A comparison of their responses with those of the experienced group showed an almost identical pattern. It is quite possible that these naive residents had indeed learned much during this first week

RACY AND

176

GOLDSTEIN

of their residency, even though their clinical experience and exposure to patient material were of limited duration. It is a common observation to find that residents learn extremely rapidly in the early weeks of their residency. Such learning could already be reflected in responses to the questionnaire, which was administered 1 week after the residents’ arrival on the service. 2. Most of the residents accepted into our program were interviewed extensively before they were appointed, and most of them had occasion to spend at least 1 day visiting various parts of the department and meeting with staff members. It is possible that they learned something of the values and standards of the department during these visits, and their decision to accept an appointment here could indicate their agreement with and acceptance of the values they had observed at that time. Thus the residency selection process might operate in such a manner as to generate a group of residents whose beliefs match those of the department they choose to join. 3. It may also be that there is more uniformity in psychiatric undergraduate medical education than we are sometimes inclined to believe. Perhaps the medical schools from which most of our residents come have curricula similar to ours. If so, then our residents may, while medical students, have learned certain values and principles of psychiatric treatment that were substantially the same as those taught in this medical center. 4. The relative benefit derived from the aspects of hospital experience that we enumerated may be widely known-in other words, the responses of our residents may simply reflect the actual state of psychiatric knowledge. Although we offer these suggestions, we do not believe that the list is exhaustive. Other possibilities could be entertained. Furthermore, objections can be raised to each of the explanations offered. When similar studies have been conducted elsewhere, different results have been elicited. In particular we call attention to the study conducted in 1965 at the Yale Psychiatric Institute by Rubenstein and Laswe112,in which residents’ opinions of various therapeutic modalities reflected the prevailing attitudes at that center. Those authors found that psychotherapies were far more valued than somatic therapies. SUMMARY

AND

CONCLUSION

Twenty-three first-year residents on the inpatient service of a department of psychiatry were asked to evaluate on a four-point scale the degree of benefit derived by patients from 20 aspects of the hospital experience affecting psychiatric inpatients. At the time of their entry to the service, the residents were asked to express an initial impression of the benefit derived from these 20 items by patients in genera1 (initial stereotype). Similar information was collected at the end of the residents’ 6-month rotation (final stereotype). In between these two inquiries, the residents submitted individual evaluations of the benefit derived by 346 patients under their care during the study period (actual ratings). Analysis of the data showed a high degree of congruence among the three sets of scores-initial stereotypes, final stereotypes, and actual patient data. This was particularly reflected in the rank-order correlation of the items. Differences among the means were noted for the most part between the stereotypes and the

RESIDENTS’

177

PERCEPTIONS

actual ratings. Stereotype ratings of benefit were generally higher than ratings of benefit for actual patients. The study resulted in two major findings: (1) residents’ initial and final stereotypes and actual ratings regarding relative benefit accruing to patients from various aspects of the hospital were all highly consistent, and (2) actual benefit ratings were lower for almost all aspects of the hospital than the stereotypes of benefit expected from these aspects. The similarity between the actual ratings and final stereotype can be readily explained. Some questions are raised, however, by the similarity of these two sets of data to the initial stereotype. Various hypotheses were offered to explain these findings. REFERENCES 1. Myers JM, Rosen HB: Psychiatrists’ current attitudes about psychiatric treatment. Compr Psychiatry 7:232-239, 1966 2. Rubenstein R, Laswell H: The Sharing of Power

in a Psychiatric

Hospital.

New

Haven,

Yale University Press, 1966 3. Goldstein What benefits

RH, Racy J, Dressier DM, et al: patients? An inquiry into the

opinion of psychiatric in-patients and their residents. Psychiatr Q 46:49-80, 1972

Residents' perceptions of inpatient psychiatric care.

Residents’ Perceptions of Inpatient Psychiatric Care John Racy and Robert H. Goldstein P SYCHIATRIC CARE on an inpatient unit entails the exposure o...
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