Token economy in a hospital rehabilitation system

A ward-based token economy programme which formed one part of a larger rehabilitative service for long-stay psychiatric patients is described. The clinical effectiveness of the programme is examined by the use of various nursing, psychological and psychiatric assessments before and after the patients' treatment on the ward, and the progress of former patients is followed-up as they move to different parts of the rehabilitation service. Significant clinical gains in patients' psychiatric symptomatology and problem behaviour on the ward are reported, although there were indications that improvement was not fully maintained as the patients moved on to other parts of the service. Comparison of the present clinical programme with the earlier research programmes on the ward indicated that the present regime was superior. The advantages and problems of token economy as a rehabilitative facility are discussed, outlining the various different roles for token economy with psychiatric rehabilitation. Finally, the future of token economy for long-stay patients is considered, questioning whether it might more appropriately be replaced by other structured ward programmes.     

Patient participation: its meaning and significance in the context of caring

The ideal that patients should be participants in their own care has found wide acceptance amongst nurses. Yet within the academic discipline of nursing little has been done to clarify the nature of participation. In this paper, a phenomenology of participation is presented as it applies to the caring work of nursing. Participation requires: (a) attunement to a mutual 'stock of knowledge at hand'; (b) emotional and motivational attunement to the other's concerns; (c) taking for granted (and implicitly assuming the other takes it for granted) that one can contribute worthily; (d) feeling that one's identity is not under threat. Though it is difficult to attain, participation appears to embody many of the ideals central to current thinking in nursing. Moreover, the attempt to build participatory relationships with patients is ethically required of members of a 'caring' profession.     

Staff anxieties about death in residential settings for elderly people

This study examined the relationship between death anxiety, the anxiety surrounding dealing practically with dying, and the level of experience of care assistants in residential settings for the elderly. It also examined the perception of the officer in charge of the establishment of the care assistants' level of anxiety. Age was the best predictor of both death anxiety and practical anxiety, the two being correlated. There was also a difference in perception of staff anxiety as a consequence of ethnic-group membership. The implications of this for training and practice are discussed.     

‘Levels’ of attainment in nursing practice: reality or illusion?

In earlier research based on an analysis of course documentation, it had been found that there was little consensus among nurse educators concerning the parameters which distinguish levels of practice skills, particularly those which differentiate diploma and degree qualifications in the United Kingdom. This result was confirmed and strengthened in the current study. Lecturers in nursing, when presented with a sorting task using 40 statements derived from course documentation selected from the earlier study, were unable to distinguish statements describing diploma level from those describing degree level practice. Possible reasons for the difficulty are discussed. It is concluded that the attempt to represent practice skill in a hierarchy of assessment for degree or diploma qualifications is premature since the parameters of practice remain unreliably specified.     

Development of a behavioural marker system for scrub practitioners' non‐technical skills (SPLINTS system)

Rationale, aims and objectives Adverse events still occur despite ongoing efforts to reduce harm to patients. Contributory factors to adverse events are often due to limitations in clinicians’ non‐technical skills (e.g. communication, situation awareness), rather than deficiencies in technical competence. We developed a behavioural rating system to provide a structured means for teaching and assessing scrub practitioners’ (i.e. nurse, technician, operating department practitioner) non‐technical skills. Method Psychologists facilitated focus groups (n = 4) with experienced scrub practitioners (n = 16; 4 in each group) to develop a preliminary taxonomy. Focus groups reviewed lists of non‐technical‐skill‐related behaviours that were extracted from an interview study. The focus groups labelled skill categories and elements and also provided examples of good and poor behaviours for those skills. An expert panel (n = 2 psychologists; n = 1 expert nurse) then used an iterative process to individually and collaboratively review and refine those data to produce a prototype skills taxonomy. Results A preliminary taxonomy containing eight non‐technical skill categories with 28 underlying elements was produced. The expert panel reduced this to three categories (situation awareness, communication and teamwork, task management), each with three underlying elements. The system was called the Scrub Practitioners’ List of Intraoperative Non‐Technical Skills system. A scoring system and a user handbook were also developed. Conclusion A prototype behavioural rating system for scrub practitioners’ non‐technical skills was developed, to aid in teaching and providing formative assessment. This important aspect of performance is not currently explicitly addressed in any educational route to qualify as a scrub practitioner.