Real ward atmosphere

Pedersena and Karterudbc (2007) described the inventory for determining the patient’s perception of the ward (form-R – Real Ward) and ideal notions (form-I – Ideal Ward) about it based on the Ward Atmosphere Scale (WAS). The first hypothesis was geared to discover if there was a significant difference among the perceptions of nurses, patients, and relatives across the different Jordanian hospitals in terms of the form-R of the WAS instrument.

In this section, the real perception of the participants will be discussed according to their actual experiences and realistic familiarity regarding the ward atmosphere and not based on what they have pre-conceived notions about what a ward atmosphere should be like. Based on the results, the findings show that patients from different Jordanian hospitals had lower level ratings in terms of their ward perception for involvement, support, autonomy, practical orientation, order and organisation, and programme clarity.

The patients were discovered to have low levels of perception in the subscales that were related their experiences of restriction in the ward. The perception of the patients, through subscales such as involvement and autonomy, were regarded to be lower from the other participants because they were the ones that directly experienced the restrictions of the hospital rules, as implemented by the nursing staff. On the other hand, the nurses’ roles of the healthcare providers entailed needed to anticipate the relative needs of the patients, which could have made the patients feel as such.

This could have resulted in the patients’ perception of lesser involvement and autonomy. This could be the same explanation for why the patients also gave low rates for spontaneity, personal problem orientation, anger and aggression. The nurses also had a higher level of anger and aggression perception, meaning they viewed the patients to have a higher degree of freedom to argue with the ward staff and express aggression. From the nurses’ perspective, this could be because they have been on the other end of the aggression wherein they experience it from the aggressor that they perceived it to be high.

Nurses also have rated the lowest level for the staff control subscale. This was attributed to the fact that as employees of the hospital, they recognize that they have little control over the rules and regulations of the facilities, as they were not in the administrative roles. Other studies, along with this one, could use the perceptions of the patients and the patients’ relatives as means of receiving feedback (James et al. , 1990). However, from the perspective of the nursing staff members it reflected the quality that they associate with their work and for their organisation.

Furthermore, the viewpoint of the staff members was viewed to affect the quality of care given to the patients (James et al. , 1990). In this case, if the staff member viewed the patients to have low autonomy and involvement, it could translate in the necessity for them to exert more effort to be vigilant and sensitive to their needs. A one-way ANOVA was performed in order to analyse the differences of perceptions across the different participants in this study in order to test the significant differences in the mean scores of the participants groups.

The analysis revealed that there was a significant difference between all participant groups in all the dimensions of the Real ward atmosphere, with the exception of Spontaneity and Personal Problem Orientation. A post hoc analysis was done to pinpoint when the nurses had lower scores and it revealed that it was in their perceptions of Involvement, Autonomy, Practical Orientation, Order and Organisation subscales.

Furthermore, the patients and the relatives were viewed to display in significant differences in their perception of the subscales Involvement, Autonomy, Practical Orientation and Order and Organisation, which could be widely due to the relationships and the similar personal interests between them. The most significant differences were found in the subscales of Staff Control and Anger and Aggression for the patients and the nurses. The patients, as aggressors, and nurses as the recipients of aggression were bound to have different perspectives of this subscale.

While patients viewed nurses to have exerted significant control over them, the nursing staff viewed the opposite according to the rules of the healthcare facility. This revealed that nurses viewed the wards to be an avenue wherein open arguments and displays of anger were allowed from patients and their relatives, while the latter perceived the nurses to be strict in terms of implementing the behavioural rules and regulations of the ward.

Thus, there was no significant difference between the patients and the patients’ relatives alone, however this difference existed between these two participant groups and the nurses. The NCMH stood out among the groups because they rated their hospital to be lower in eight subscales, in comparison to the other hospitals. However, they rated their real ward higher in terms of Anger and Aggression and Staff Control. The hospital experienced low ratings from their nurses with regards to the patients’ involvement and spontaneity.

The hospital was also noted to have poor order and organisation, as well as programme clarity. When the patients and their relatives’ perceptions were compared across the hospitals, it showed that there were no significant differences that were discovered, even for NCMH, except for the subscale of Spontaneity, which showed that the hospital was perceived to be more tolerant of all personality types and the need for the patients to express themselves. The patients and their relatives’ perception could be viewed to significantly deviate from the nurses’ perception, especially from the NCMH.

The views were also compared with the recommended levels for non-psychosis programmes, which were considered as the optimal ward atmosphere. It showed that the only same levels of perception between real and optimal ward atmosphere perception was on the Anger and Aggression subscale. This was considered to be slightly higher than the recommended level, however, it is still considered intermediate level based on Friis’s recommendations and Eklund & Hansson definitions of the values of the boundaries for each WAS subscale.

This meant that the remaining subscales were lower than the recommended levels, which did not translate to a good evaluation of the perception because as supported in the literature the non- psychotic wards ought to have a high level of Involvement, Spontaneity, Autonomy Practical Orientation, Personal Problem Orientation and Programme Clarity. The Literature also indicated that the non-psychotic patients preferred a high level of Support and Order and Organisations, whereas they only wanted an intermediate level of Anger and Aggression.

They also seemed to prefer a low level of Staff Control (Friis, 1986b). There are no recommended levels for relatives, since this was the first time the patients’ relatives’ perceptions were studied, hence there can be no point of comparison. Since the different sets of tests used to analyze the results revealed that there were significant difference in the Real WAS scores between the nurses, patients and relatives, H1 is rejected.

In terms of interpreting this rejection, it showed that the differential roles of the patient and staff could provide a differential effect in the perceptions of the different participant groups. According to the literature reviewed, the policies that the hospitals adhered to could impact the roles that the staff took on for the patient. It also influenced the amount of freedom that was given to the patients, the visitors (which were often the relatives of the patients) and the staff. This was also found to have a significant impact in the patients’ recovery.

The differential rules between the hospitals could explain the differential perspective of the nurses. It was the nurses, not the patients and the patients’ relatives that were held accountable for following the rules and regulations of the healthcare facility. Thus, they would be the ones perceived to be strict enforcers of the rules. On the other hand, Timko and Moos (1996) revealed that it was important for patients to experience more freedom in the ward because a more self-directive and self-understanding treatment could allow for overall governance.

Since the nursing staffs was highly concerned with the order and organisation, staff control, as well as the programme clarification, studies revealed that greater levels of autonomy and spontaneity could have positive effects on the structural efficiency of the ward (Timko & Moos, 1996). According to Rossberg and Friis (2004), the ward was a place that prioritised patient satisfaction, rather than staff satisfaction. The findings of the study, however, found revealed that patients’ satisfaction was not prioritised in a real ward perception because they reported the lowest perception of autonomy, involvement and spontaneity.

This could be properly attributed to the fact that the psychiatric wards were more restrictive and concerned with the adherence to safety rules and regulations. The significant differences in the perceptions of the nurses, patients and staff members were normal due to the different roles and reasons as to why these individuals were in the ward, which affected the differential viewpoints of the patients (Rossberg & Friis, 2004). Hypothesis 2: There are no differences in the perceptions of Ideal ward atmosphere between nurses, patients and relatives.

The study also analysed if there was a significant difference between perceptions of the nurses, patients and relatives about the Ideal ward atmosphere. As mentioned the Ideal ward atmosphere referred to the ward atmosphere that would be perfect or what should serve as a standard for what ward atmospheres should be like. This did not refer to the perception of the actual ward atmosphere; instead it referred to the idyllic notion of what a perfect ward would be like. It was also measured using the Ideal WAS instrument.

The nurses and the relatives had high rates for subscales Involvement, Support, Spontaneity, Practical Orientation, Personal Problem Orientation, Anger and Aggression and Programme Clarity subscales. This meant their perception of an Ideal ward were relatively higher in favour of these subscales, in comparison to the patients. Relatives did not agree that patient autonomy should be high for ideal wards. They rated Order and Organisation to be lower than nurses and patients. For the relatives and the nurses, Staff Control was rated lower than the patients did.

This meant that relatives and nurses did not think the staff should have that much control in determining the rules and the strictness in the ward. The ANOVA statistical analysis revealed that there were significant differences in the way the participant groups viewed the Ideal ward atmosphere, except for Involvement and Staff Control. Patients had lower scores for Support, Spontaneity, Practical Orientation, Personal Problem Orientation, Anger and Aggression and Programme Clarity than relatives and nurses, in their perception of the Ideal ward.

On the other hand, patients’ relatives and nurses were more optimistic in terms of having a positive ward, valuing subscales such as Involvement, Support, Spontaneity, Practical Orientation, Personal Problem Orientation, Anger and Aggression and Programme Clarity than patients did. These subscales reflected the view that an Ideal ward had active patients, structured programs and were open to the voice and the opinions of the patients. The points wherein relatives and nurses did not have similar Ideal ward perceptions were on the points for Autonomy, Practical Orientation, Anger and Aggression and Order and Organisation.

Since half of the patients that were participants in the study were admitted involuntarily, Autonomy was understandable included in their ideal perception of wards. However, the nature of psychiatric wards did not allow improving the psychosocial aspects of the ward, which included autonomy (Brunt & Hansson, 2002). Moos (1974) noted that autonomy was also inversely correlated to disturbed behaviour. In the ideal ward atmosphere, autonomy was highly perceived as a factor because it also came with the absence of disturbed behaviour.

Furthermore, it was also observed that the patient’s relatives noted low rates for Order and Organisation than nurses. This was attributed to the fact that nurses were also perceived to have this in the real ward setting and that patients already know what to expect of their daily routine. The relatives also noted a higher rating for Anger and Aggression, in comparison to nurses and patients. This was indicative of the perception of the relatives that there was an insufficient allowance for the patients to display Anger and Aggression in the ward and that this could still be increased.

It was also revealed that patients felt that nurses should be stricter in order to control them because they indicated higher ratings for Staff Control. In the ideal setting, nurses did not want to be strict enforcers, which could be attributed to the absence of disturbance or resistance in the ward that would need them to be stricter. These findings supported what previous studies presented that ward atmosphere was affected by patient’s satisfaction (Druss et al. , 1999, Shipley et al. , 2000) and the level of intervention, in terms of control increased the levels Order and Organisation (Melle et al. , 1996).

In order to analyse the levels of the ward atmosphere, so as to give an indication of ‘clinical’ or ‘practical’ significance of these different ratings, Friis’ (1984) recommendations in conjunction with Eklund and Hansson’s boundaries were used. Using Eklund and Hansson’s (1996) boundaries it appears the nurses from all hospitals describe their Ideal ward atmosphere as high on the following subscales: Support, Order and Organisation and Programme Clarity. Therefore, the results of this study indicated that all participants at all hospitals rated high levels on nine subscales of Ideal ward atmosphere scale ranging from 3.

85 for Autonomy as the lowest mean score and 7. 68 for Order and Organisation as the highest mean score (Eklund & Hansson, 1984). There was no significant difference in the perceptions of nurses, patients and their relatives when it came to the rate of involvement, which was at an intermediate level. This reflected that participant groups already feel that there was a moderate level of engagement and involvement for the patients in the ward. Nurses and patient’s relatives also viewed their Ideal ward setting to have more levels of Support and Spontaneity than patients did.

This revealed that the nurses and relatives needed the atmosphere to become more supportive for staff members and the relatives, as well as for the hospital to become more tolerant for different kinds of people and differential needs. They viewed an ideal ward to promote expressions of emotions and individuality. This reflected what Brunt and Rask (2007) called as the internal characteristics of ward atmosphere, wherein non-physical and non-tangible properties were discussed. It reflected that the nurses and the relatives of the patients valued the patients’ expression of feelings towards other patients and staff in the hospital (Moos, 2007).

Brunt and Rask (2007) described attributed such as interpersonal relationships to be reflected through empathy, sensitivity, the ability to listen and patience. There were also significant differences in the subscales for ideal Practical Orientation and Personal Problem Orientation. They were viewed to be rated on an intermediate level by patients and nurses, and can be interpreted positively in this study since the patients had typically shorter periods of stay in the ward and the acute nature of the patient’s problems.

This could be viewed as the hospital’s efforts to equip the patients to deal with practical matters, as well as with emotional ones. They viewed this to stabilize the patients and to prepare them for discharge. However, the patients’ relatives viewed these subscales to be different from the patients and the nurses. This showed that the relatives were already satisfied with what the hospital was doing to teach practical skills and to guarantee appropriate discharge conditions.

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