Ward climate within a high secure forensic psychiatric hospital: Perceptions of patients and nursing staff and the role of patient characteristics
journal contributionposted on 20.03.2017 by Meike Godelieve de Vries, Inti Angelo Brazil, Matthew Tonkin, Berend Hendrik Bulten
Any type of content formally published in an academic journal, usually following a peer-review process.
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. Ward climate is an important factor within the treatment of inpatients in secure settings and has been studied for almost 50 years. Ward climate can be seen as a multifactorial construct including the material, social, and emotional conditions of a given ward and the interaction between these factors (Moos, 1989 and Tonkin, 2015). Ward climate is found to play a role in therapeutic outcomes like drop out-, release-, and re-admission rates (Moos, Shelton, & Petty, 1973), patient satisfaction (Bressington et al., 2011, Middelboe et al., 2001, Nesset et al., 2009 and Røssberg and Friis, 2004), motivation for treatment (van der Helm, Beunk, Stams, & van der Laan, 2014), treatment engagement and therapeutic alliance (Long et al., 2011). Climate can be seen as an aspect of program responsivity that enhances treatment effects (Beech and Hamilton-Giachritsis, 2005, Howells and Day, 2003 and Ward et al., 2004). Ward climate has also found to be a determinant of staff wellbeing, playing a role in staff performance and morale (Moos & Schaefer, 1987), job satisfaction (Bressington et al., 2011, Middelboe et al., 2001 and Røssberg and Friis, 2004), and occupational stress (Kirby & Pollock, 1995). The relationship between ward climate and organizational- and therapeutic outcomes underlines the importance of establishing and maintaining an environment in which therapeutic progress is encouraged and that supports staff ability to deliver responsible high quality care to their patients. However, creating an optimal climate within a high security forensic setting can be very challenging due to the complex patient population, involuntary admission within a closed setting and the balance between security needs and treatment goals (Burrows, 1991, Campling et al., 2004 and Howells et al., 2007). Moreover, patients and staff members working within forensic psychiatric settings seem to evaluate ward climate differently (Caplan, 1993, Day et al., 2011, Dickens et al., 2014, Howells et al., 2009, Livingston et al., 2012, Long et al., 2011, Moos, 1975, Morrison et al., 1997, Røssberg and Friis, 2004 and Schalast et al., 2008). For instance, Howells et al. (2009) found that patients in a high secure hospital service in the United Kingdom (UK) evaluated cohesion among patients more favorably than staff members. Another study found that patients in open, low and medium secure wards of a psychiatric hospital in the UK evaluated the ward climate as safer than staff members (Dickens et al., 2014). In both studies, staff members evaluated the therapeutic hold (how much the environment is supportive of therapy and therapeutic change) more favorably compared to patients. Caplan (1993) found that staff and patient perceptions differed with regard to several scales of the Ward Atmosphere Scale (WAS; Moos and Houts, 1968, Moos, 1989 and Moos, 1974), including order and organization, program clarity and staff control. Possible explanations given in previous research for the divergent perceptions between nursing staff and patients are, the different roles and functions that staff and patients have within a forensic institution (Caplan, 1993, Goffman, 1961 and Røssberg and Friis, 2004), and the restrictions to the liberty and personal freedom of incarcerated patients (Langdon, Cosgrave, & Tranah, 2004). Patients' restricted liberty could also be a potential explanation for the finding that the perception of climate differs as a function of the level of security (Dickens et al., 2014, Long et al., 2011 and Milsom et al., 2014). It follows that gaining insight into patients' and staff's perception of ward climate is highly informative and promotes the discovery of potentially meaningful discrepancies between the groups. Friis (1986) has argued that the patient's perception of the ward milieu can be seen as a most important indicator of how the milieu affects the patient. When striving to keep patients in a responsive therapeutic environment which is designed to address their needs (in order to enhance treatment efficacy), it is important to have insight in how the climate is actually perceived by patients. Forensic nurses could use this information in their daily work, actively discussing the different views on ward climate within their team and with their patient group. Together they could identify different needs, create opportunities for improvement of the treatment milieu and subsequently improve treatment success. Importantly, however, ward climate perception is also dependent on other factors. Recent research by Dickens et al. (2014) revealed associations between patient characteristics and mean evaluation scores of ward climate. They found that female gender positively predicted patient cohesion and perceived safety measured with the Essen Climate Evaluation Scale (EssenCES; Schalast et al., 2008) among patients residing in open, low and medium secure forensic settings. Furthermore, higher perceived risk measured with the Historical, Clinical and Risk Management 20 (HCR-20; Webster, Douglas, Eaves, & Hart, 1997) was associated with lower perceived patient cohesion, a diagnosis of personality disorder or psychosis according to the ICD-10 (WHO, 2010) was related to higher experienced safety, and higher levels of engagement (i.e., the number of programmed therapeutic sessions attended over a two-week period) was associated with greater therapeutic hold. While not accounting for all relationships presented above, the relationship between ward climate and various environmental, social and individual characteristics might reflect the interplay between patients' (security) needs and climate. Hence, individuals at high risk of showing violence or who are suffering from severe psychiatric problems might have higher security needs, leading them to be more exposed to physical, procedural and relational security, ultimately influencing their (perception of) ward climate. Norton (2004) describes how five functional properties of a ward (containment, support, structure, involvement and validation) can also reflect the patient's changing needs, and how the emphasis on these factors can change during a treatment process (and during crisis situations). In contrast to Dickens et al. (2014) there is also research showing that patient characteristics have a small or no impact on ward climate (Moos, 1997 and Pedersen and Karterud, 2007). Pedersen and Karterud (2007) found no substantial associations between patient characteristics (gender, age, level of education, self reported symptom distress, interpersonal problems, diagnosis) and individual ratings of treatment milieu. Data were collected from patients (71% women) suffering mainly from personality, mood and anxiety disorders who had been admitted to day-treatment units. Pedersen and Karterud (2007) argue that since differences between patients' views on ward climate cannot be attributed to patient characteristics they must be largely idiosyncratic. Alternative explanations for the discrepant findings with regard to the role of patient characteristics might be found in differences in methodology (using the EssenCES versus the WAS for assessing climate), and different clinical setting/samples used in the studies of Dickens et al. (2014) and Pedersen and Karterud (2007). Contradictory findings highlight the importance of conducting more research in order to disentangle the possible relationships between patient characteristics and ward climate within secure forensic settings. Gaining more knowledge about these relationships could be beneficial for clinical practice by providing guidance for active management of ward climate. Hence, when striving to keep patients in a therapeutic environment designed to address their needs, taking into account individual patient characteristics is essential. In order to do so, more research is needed, demonstrating whether or not certain personal characteristics are related to the perception of ward climate. When relationships and underlying mechanisms are clearer, this knowledge could be used to guide assessment, evaluation, assignment to specific wards, composing patient groups and staff training. Since there are very few studies of the relationship between ward climate and patient characteristics this study contributes to an under-explored but important area. The aim of this current study is to provide more insight into the relationship between patient characteristics and perceived ward climate. Based on previous findings, the demographic characteristics that might be related to perception of ward climate targeted in the present study were patients' age (Campbell et al., 2014, Middelboe et al., 2001 and Pedersen and Karterud, 2007), length of stay within the facility (van der Helm et al., 2014), and risk of violence (Dickens et al., 2014). With respect to pathological personality features, there are reports that psychopathy may be a key determinant of climate in forensic therapeutic settings (Harkins, Beech, & Thornton, 2012). Psychopathy is a severe condition characterized by a combination of personality characteristics entailing disturbed interpersonal-affective functioning combined with high anti-sociality (Neumann, Hare, & Newman, 2007). Therefore, the impa