A preliminary investigation into staff satisfaction,and staff emotions and attitudes in a unit for men with learning disabilities and serious challenging behaviours

People with learning disabilities who also exhibit challenging behaviour live in a social context that should be considered in order to understand and deal with their behaviours. This context includes the characteristics of staff members, and their satisfaction with the whole culture and environment in which they work. The social context will also affect and be affected by staff emotions and attitudes towards the residents in that living environment. The present paper describes a preliminary investigation into staff satisfaction, and staff emotions and attitudes towards residents in a traditional setting for people with both learning disabilities and serious challenging behaviours and it discusses the implications for future research. The findings indicate that staff satisfaction was low and could be improved considerably in terms of management support. However, the level of satisfaction in working with the residents in the unit was high, as were the perceptions of practical support from immediate colleagues. The results also showed the coexistence of different attitudes and emotions which could be described as positive and negative in individual staff members. To assess this, the present authors used a new, 13‐item analogue measure, the Attitudes to People Who Display Challenging Behaviour questionnaire. The level of such attitudes and feelings in this particular context did not vary noticeably relative to whether staff members felt well supported by the service or not. This new measure may well have applications in future research in this area.     

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) × 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.     

Evaluation of the first Medical Psychiatry Unit in Japan

Abstract The first Medical Psychiatry Unit (MPU) in Japan was established in 1990. The clinical experience during the first 4 years of this unit is presented, and the characteristics of the Unit between its first 2 years and its latter 2 years are compared. The number of patients, the average length of stay, the primary psychiatric disorders, the combined physical diseases and their outcomes are presented. The data suggest that while the experience of the MPU is limited, it plays an important role in Japan as (i) an appropriate clinical setting for patients with combined medical and psychiatric illnesses, (ii) a strategic model for dealing with psychiatric patients in the general hospital, (iii) an educational setting for psychiatric residents to become more familiar with medicine and surgery, and (iv) an opportunity for non-psychiatric residents to become familiar with psychiatric illnesses and treatments.     

Living in hospital and hostel: the pattern of interactions of people with learning difficulties

ABSTRACT. This study compared interactions between the staff and residents living in hospital wards and in community-based hostels. Twenty-four people with moderate to severe learning difficulties participated in this study. Interactions were categorized according to who was the initiator and recipient, their purpose, attitude of the recipient, duration, and place. It was found that the hospital and hotel residents had virtually no interactions with people outwith the establishment in which they lived. The hostel appeared to offer the residents a sociable environment with more interpersonal interactions and more positive attitudes towards the interactants than the hospital. Interactions in both kinds of setting were very short, thus giving residents little chance to develop communicative skills. It is suggested that a more personal approach, such as joint activities between residents and staff, and living in small groups in ordinary housing, should be the first priorities in the effort to improve the pattern of social interactions of people with moderate to severe learning difficulties.     

Activity situations on an Alzheimer's disease special care unit and resident environmental interactions, time use, and affect

Routine activity situations on an Alzheimer's disease (AD) special care unit were examined with respect to residents' social and physical environmental interactions, time use, and apparent affect. Using a computer-assisted observational tool, observers recorded prevailing activity situations and corresponding behaviors and affects of seven residents every 10 minutes, from 8:00 AM to 8:00 PM, across four days. Although meals/snacks and some activity groups were positively associated with use of physical objects and engagement in activities, residents were predominantly environmentally disengaged, inactive, or without positive affects during the most prevalent activity situations of background media, downtime, and television. Findings suggest that routine activity situations may act as potent environmental influences on the quality of life (QOL) of people with AD and mediate the effectiveness of other environmental interventions undertaken on their behalf.     

Effect of design interventions on a dementia care setting

This study examined the effects of particular design interventions in a long-term care facility on residents with dementia and staff perceptions of care delivery. Major renovations were carried out in a care facility in the Midwestern United States. Renovations included a new addition of a dementia care unit designed as a cluster of resident rooms around living and dining areas, and two renovated wings with decentralized dining areas. The research methods used in the study included environmental assessment with the Professional Environmental Assessment Protocol (PEAP), behavioral mapping, and focus-group interviews with staff members. The renovated environment scored higher in PEAP and was perceived by the staff members as a more homelike setting. Although behavioral observations indicate that there was more involvement in programmed activities by the residents, the decentralized neighborhood design did not meet all the behavioral expectations due to a lack of appropriate activities, high staff turnover, and family members' resistance to the relocation of their loved ones. Organizational commitment, advanced planning for appropriate staffing levels, and dementia-related training is crucial for fuller realization of the potential of a household design.     

A qualitative study of the experiences of long-term care for residents with dementia, their relatives and staff

Most older people living in 24-hour care settings have dementia. We employed qualitative interviews to explore positive and negative aspects of the experience of family carers, staff and people with dementia living in 10 homes in London and West Essex, selected to cover the full range of 24-hour long-term care settings. The interview used open semi-structured questions. We interviewed 21 residents, 17 relatives and 30 staff and five main themes were identified: Privacy and choice; relationships (abuse and vulnerability); activities; physical environment; and expectations of a care environment by carers, should they one day live in long-term care themselves. Despite being no longer responsible for the day-to-day care of the residents there was a continuing level of psychological distress among some relatives. We found that residents with a range of severity of dementia were able to participate. The most striking theme from their interviews was the need for choice. All groups talked about improving lines of communication amongst residents, relatives and staff and about the importance of activities. We recommend that homes should set up formal structures for engaging with user and carer views at all levels. This would mean relatives on the board, and regular meetings for residents, relatives, advocates and staff. This should lead to cultural changes where residents are perceived as individuals and care is provided in a more flexible way. There should be a programme of activities in each 24-hour care setting, which all care staff are given time to implement. These activities need to be tailored to the individual resident rather than the whole group.     

Inpatient clinical research: its importance in psychiatry and psychopharmacology

We have outlined the essential components found in an inpatient psychiatry research unit from the point of patient recruitment through discharge. In virtually every phase of a patient's hospitalization on the unit, there is the potential for significant tension between research and clinical goals. We conclude that, as Braff and associates have suggested, clinical and research interests are compatible when both receive appropriate support. We have also discussed the potential advantages of an inpatient research setting for patient care. Because of the washout period, there is greater opportunity for an extended diagnostic assessment and response to the therapeutic milieu alone. The attention and priority patients receive during the research phase can be of significant therapeutic benefit. Findings from research protocols can be used to help with diagnosis and clinical care. Working on an inpatient research unit provides residents and other trainees with special learning experiences. In particular, observational and diagnostic skills are sharpened. Techniques of non-pharmacologic behavioral management are added to the trainees' repertoire of therapeutic interventions. By nature, the research experience promotes creative thinking and problem solving. In this era of fiscal restrictions and cost accountability in medicine, potential advantages for immediate patient care and for staff training are only secondary reasons which justify the existence of inpatient research centers in psychiatry. We must also ask what specific and unique research information an inpatient research setting offers compared to less expensive outpatient research environments. The first factor to be considered is the ability to study individuals whose illness is so severe as to make outpatient management difficult or impossible. It is becoming increasingly clear that for many categories of psychiatric disorders, there is a spectrum of severity of possible behavioral manifestations seen in affected individuals. In depressive illness, for example, the spectrum of expression appears to range from dysthymic disorder to major depressive disorder with psychotic features. Individuals with more severe symptomatology tend to create the greater cost to society because of their correspondingly greater degree of dysfunctional behavior, need for repeated and extended hospitalization, requirement for social services, etc. Such individuals, therefore, need to be studied in a research setting at least as much as patients with milder manifestations of psychiatric illness. This would not be possible without the control, structure, and staffing found in an inpatient setting.(ABSTRACT TRUNCATED AT 400 WORDS)     

Quality and costs of community-based residential supports for people with mental retardation and challenging behavior

A longitudinal matched-groups design was used to examine the quality and costs of community-based residential supports to people with mental retardation and challenging behavior. Two forms of provision were investigated: noncongregate settings, where the minority of residents had challenging behavior, and congregate settings, where the majority of residents had challenging behavior. Data were collected for 25 people in each setting. We collected information through interviewing service personnel in each type of setting on the costs of service provision, the nature of support provided, and the quality of life of residents. We also conducted observations in each setting. Results suggest that noncongregate residential supports may be more cost effective than congregate residential supports.     

Depression in assisted living: results from a four-state study.

OBJECTIVE: Assisted living is a rapidly-growing sector of long-term care, but little research has been done on depression in this setting. Using data from a large sample of assisted-living residents, the authors sought to 1) describe the prevalence of depression and depressive symptoms; 2) identify resident characteristics associated with depression; and 3) examine the relationship between depression and the rate of nursing home placement and mortality. METHODS: A group of 2,078 residents age 65 and older were enrolled from 193 assisted-living facilities across four states (Florida, Maryland, New Jersey, and North Carolina). Residents were classified as depressed if their score on the Cornell Scale for Depression in Dementia (CSDD) exceeded 7. RESULTS: Using this criterion, 13% were depressed, and only 18% of those were on antidepressants. Over one-third of residents had symptoms of depression, such as anxious expression, rumination, or worrying, and 25% displayed sad voice, sad expression, or tearfulness. Depression was significantly associated with medical comorbidity, social withdrawal, psychosis, agitation, and length of residence in the facility. Depressed residents were discharged to nursing homes at 1.5 times the rate of nondepressed residents. Rates of mortality were also higher for depressed residents, but only those with severe depression (CSDD >12) had a statistically significant increased rate of death. CONCLUSION: The mission of assisted living is to help older adults retain autonomy, privacy, and quality of life in a personalized environment. Greater effort should be made to detect and treat depression in this setting, both to reduce suffering and prolong the resident's ability to remain in their preferred environment.     

Influence of experience on major clinical decisions. Training implications.

We studied 779 walk-in psychiatric patients presenting to 32 first- or second-year residents and 772 patients presenting to 25 third-year residents or attending physicians as to the decision to admit to the hospital or to administer medication to those not admitted. There were no significant demographic or clinical differences between patients presenting to the two groups. The more experienced staff admitted half as many patients and treated serious depression with tricyclics twice as frequently. Inexperienced psychiatrists used hospitalization more frequently when these patients suffered from suicidal ideation, hallucinations, delusions, and inability to cope. When the training procedure was modified and second-year residents were introduced into a more structured setting, their decision-making quickly approached that of third-year residents and attending physicians. We suggest that specific training can modify decision-making, where general clinical experience may not. Implications for resident and medical student training are discussed.     

Termination in individual psychotherapy: a survey of residents' experience

This paper describes the result of a survey on one Canadian Psychiatric Residency Program. Fifty-four percent of the residents responded to the questionnaire enquiring about their experience of termination in long-term psychotherapy. The majority of residents (66%), had ended therapy prior to fifty sessions. In only a small number of terminations the resident felt the patient was ready to terminate (16%) and that therapy had come to a "natural termination". Therapy often ended prematurely due to the change of setting of the resident, drop-out and other practical circumstances as well as therapeutic impasses. The paper discusses the factors that influence the premature ending of what the residents undertook as long-term psychotherapy and their implications for their training and the patients' treatment.     

Does admission to a hospital geriatric psychiatry programme improve benzodiazepine and other drug use?

Seventy-five consecutive patients admitted to a hospital geriatric psychiatry unit had their medication reviewed on admission and at discharge. Use of benzodiazepines declined significantly from 40% to 20% of patients, but use of other therapeutic groups showed no significant change. The number of patients taking drug combinations with potentially adverse side-effects decreased significantly between admission (21) and discharge (7). The use of relatively contraindicated drugs also declined. Drug utilization review is a valuable technique for drawing attention to potential problems of prescribing for elderly people.     

Innovative dementia care: functional status over time of persons with Alzheimer disease in a residential care centre compared to special care units.

Residential care centres (RCCs) for persons with Alzheimer disease are increasing worldwide, but there are few studies that compare the functional outcomes of RCC residents to residents of other types of continuing care settings. This study compared residents of the first Canadian RCC on physical, cognitive, behavioural and emotional functioning 6, 12 and 18 months after admission to residents of special care units (SCUs) operated by the same continuing care provider. SCU residents were initially functioning lower than RCC residents on most outcome measures and these differences persisted over time. Resident functioning declined over time regardless of care setting and, when the initial status was controlled for, the rates of decline were similar. However, RCC residents experienced greater independence/freedom of choice, fewer physical or psychotropic medication restraints and were more active, which may have enhanced their quality of life.     

Stress,role and training in carers of the elderly

The measurement of stressful event frequencies among different long-stay settings within a hospital for the elderly showed that staff with higher-ranking roles, regardless of their training, experienced certain stressful events more frequently than other staff members. Stressful event frequencies for a unit with only untrained care staff did not differ from frequencies for wards of trained nurses.     

Seizure detection using scalp‐EEG

Scalp electroencephalography (EEG)–based seizure‐detection algorithms applied in a clinical setting should detect a broad range of different seizures with high sensitivity and selectivity and should be easy to use with identical parameter settings for all patients. Available algorithms provide sensitivities between 75% and 90%. EEG seizure patterns with short duration, low amplitude, circumscribed focal activity, high frequency, and unusual morphology as well as EEG seizure patterns obscured by artifacts are generally difficult to detect. Therefore, detection algorithms generally perform worse on seizures of extratemporal origin as compared to those of temporal lobe origin. Specificity (false‐positive alarms) varies between 0.1 and 5 per hour. Low false‐positive alarm rates are of critical importance for acceptance of algorithms in a clinical setting. Reasons for false‐positive alarms include physiological and pathological interictal EEG activities as well as various artifacts. To achieve a stable, reproducible performance (especially concerning specificity), algorithms need to be tested and validated on a large amount of EEG data comprising a complete temporal assessment of all interictal EEG. Patient‐specific algorithms can further improve sensitivity and specificity but need parameter adjustments and training for individual patients. Seizure alarm systems need to provide on‐line calculation with short detection delays in the order of few seconds. Scalp‐EEG–based seizure detection systems can be helpful in an everyday clinical setting in the epilepsy monitoring unit, but at the current stage cannot replace continuous supervision of patients and complete visual review of the acquired data by specially trained personnel. In an outpatient setting, application of scalp‐EEG–based seizure‐detection systems is limited because patients won't tolerate wearing widespread EEG electrode arrays for long periods in everyday life. Recently developed subcutaneous EEG electrodes may offer a solution in this respect.     

The clinician-investigator interface in psychiatry I--Values and problems

The two following papers describe some of the benefits and problems involved in integrating clinical and investigative work. It is stressed that there are a number of advantages to such integration. Researchers especially benefit from the proximity to patients and clinicians. Education can be significantly enhanced when researchers and clinicians are in one setting and this can benefit residents, medical students and non-medical health personnel. There are a number of problems to such clinical research in psychiatry. These are discussed especially as they relate to senior faculty and their resistances to research. The shortage of clinician scientists in teaching positions means that most residents are not involved with such people as mentors early in their training and do not consider this as a career option after their residency training. Reductionistic thinking on the part of some researchers and when researchers are not first-rate clinicians both contribute to residents not becoming involved in clinical investigation. Funding policies as well as chairmen's hiring policies also play a role here.     

Finding a practical method to increase engagement of residents on a dementia care unit

Previous research has shown that it is possible to increase the engagement of residents with dementia in daily activities by making changes in institutional care practices. However, these changes often require expensive and cumbersome staff training programs that long-term care facilities may be unlikely to adopt and maintain. This study evaluates a simple, inexpensive recording and feedback procedure to increase resident engagement in a way that may be more amenable to adoption by long-term care facilities. Nursing assistants working in a locked dementia care unit were asked to complete a daily activity record on which they recorded the amount and quality of resident engagement. The facility's activity director was asked to read these activity records each day and give immediate, positive feedback to the nursing assistants. This procedure was evaluated by using a control series design. Results revealed baseline engagement observations with a mean of 11 percent, which increased to a mean of 44 percent during observations under treatment conditions. This study suggests that simple, inexpensive changes in institutional practices can make meaningful improvements in the level of engagement of residents with dementia.     

General psychiatry residents' perceptions of specialized training in the field of mental retardation

This study examined the perceptions of general psychiatry residents about the utility of specialized training that they received on an inpatient unit for patients with mental retardation and co-occurring psychiatric disorders. An anonymous questionnaire was sent to 58 former and current residents, and 43 questionnaires were returned. Views about the educational components of the training program were rated by Likert scale. A total of 98 percent of respondents strongly agreed or agreed that training was useful. Most respondents (56 percent) rated the training as sufficient preparation to treat patients with mental retardation; 84 percent reported that the training should be required during psychiatric residencies. Psychiatry residents were very satisfied with their specialized educational experience and found it to be a valuable component of their training.