Acute wards: problems and solutions. A participant observation study of life on an acute psychiatric ward

The College Research Unit is undertaking an ethnographic study to describe life on acute psychiatric wards from the point of view of patients. The project is funded by a generous donation from Jim Birley, former President of the Royal College of Psychiatrists. It aims to bring a new perspective to our understanding of the current state of acute wards. The underlying premise is that solutions to current problems must be informed by a good understanding of what actually happens on the wards and what it feels like to be a patient there.

What is participant observation and why apply it to acute wards?

Participant observation, also known as ethnography, is a style of research that examines real life situations from the ‘inside’. The researcher becomes involved in the daily life of the social group or organisation that is being studied. He or she does this by establishing relationships with the people in the study setting, participating in what they do and talking to them about the events that have been observed. The focus is on the ordinary situations that people encounter and how they behave in them. Observations, and transcripts of conversations and formal interviews, are recorded as ‘fieldnotes’. This typed text is the raw data that are analysed in a systematic way, typically with the help of computer programs developed for the purpose. Rather than being the starting point of the research, hypotheses are generated and tested as part of a cyclical process of sampling, data collection and analysis (Hammersley & Atkinson, 1983). The rationale for using this approach is simply that the researcher's participation in the very web of the social interaction that is being observed, analysed and reported on offers the potential for a deeper understanding of people's experiences than is likely to be captured by other less ‘immersive’ research methods.

A modern acute psychiatric ward is a highly complex social setting. The scarcity of beds means that the patient group includes people of all ages and backgrounds and with very different types of problems. It is an unstable community in that its membership constantly changes as patients are admitted or discharged, or when staff change shifts. Even when doors are locked it remains ‘open’ in the sense that a proportion of patients is likely to be on leave. It is also permeable as patients continue to interact with family, friends and care workers from outside of the hospital and with patients on other wards. Also, workers who are not members of the core staff group, such as psychiatrists and social workers, may have an influence on the community that is out of proportion to the amount of time they spend within it.

Various research strategies have been used to investigate activity and conditions in modern psychiatric wards in the UK (summarised in Quirk & Lelliott, 2001). Surveys, and other quantitative studies, have shown that wards are busy and often crowded places, that the patient group includes many people who are detained under mental health legislation, that violent incidents and episodes of sexual harassment are common and that nurses spend less time in face-to-face contact with patients than they did 10 years ago. Questionnaire surveys of, and semi-structured interviews with, patients and staff have told us something about the subjective experience of ‘living’ on a psychiatric ward. In particular, patients often report feeling both bored and unsafe. Recent work, involving an element of non-participant observation, has described the physical environment of in-patient units and given at least a flavour of the social activity that goes on within it and the ‘acute ward experience’ (Sainsbury Centre for Mental Health, 1998).

Participant observation research has the potential to explore the causes and consequences of some of these problems in depth. For example, it could identify connections between staff behaviour and aggression among patients and unravel questions of cause and effect. One particular issue is about the nature and use of coercion, how these powers are used by staff, and how they are perceived and responded to by patients. The study could also, for the first time, describe the nature of the social relationships between members of the heterogeneous patient group. For example, do patients on wards see themselves as being part of a hospital or ward ‘community’, and are there any remnants of the old-style ‘closed’ or ‘total’ institution as described by Goffman (1961), who conducted a participant observation study in a large psychiatric institution more than 40 years ago? Also, what are patients' strategies for coping in such a charged environment and do these aid recovery? Other questions concern the permeability of the ward in relation to the outside world. For example, if the patient group includes people with drug problems, do they maintain their connections with their suppliers during an in-patient stay and how is this achieved?

Recent research paints a picture of life on psychiatric wards that is unremittingly bleak. This has succeeded in raising the profile of in-patient care in the eyes of policy makers, but is it the whole story? Many patients agree to repeated informal admissions, some even request hospitalisation at times of crisis, while others are more than happy to remain on the ward. Some discharged patients happily return to pay social visits to staff and patients on ‘their ward’ or use the ward as their first point of contact when they need advice or support. Ethnographic research can both identify and document such ‘anomalous’ behaviours and explore the meanings behind them.

The study

The current study started in January 2000 and will last for 3 years. The participant observation, which is now complete, consisted of three separate 3-month periods on three different wards: two in psychiatric units in London hospitals and one in a unit in the south-east. The researcher (A. Q.) immersed himself in life on each ward as much as was possible. He attended the range of ‘events’ which constitute in-patient treatment, such as wardrounds and occupational therapy sessions, and ‘hung around’ in television rooms, dining rooms and corridors in order to observe events and talk to people. The fieldwork has generated a large body of qualitative data about how patients interact with one another and with staff, and about their views on their experiences on the ward. The analysis and write up are expected to be completed in December 2002.

Problems with conducting such a study

Participant observation is a demanding and time-consuming way of gathering data. The researcher may encounter difficulties in being accepted by people on the ward and in sustaining the role long enough to observe the full range of events. The practical problems of gaining access to the wards should not be underestimated either. Research ethics committees and NHS trusts are likely to be resistant, the former due to difficulties in eliciting true informed consent and the latter due to wariness about possible criticism. Further, there are difficulties in gaining acceptance of this type of research among an academic community brought up on quantitative research and, consequently, in getting the results published. That noted, position papers recently published in the BMJ (e.g. Mays & Pope, 2000), the Lancet (e.g. Malterud, 2001) and the British Journal of Psychiatry (Buston et al, 1998) have argued the value of such research and might help to counter scepticism, in part by stressing the need to judge qualitative and quantitative research by different criteria.

Future output

The present research will explore in some depth what happens on acute wards and the meaning of in-patient care to patients, and it will hopefully identify some of the factors that hinder and facilitate patients' access to quality care. Findings will be disseminated via a book describing all of the major themes and implications for policy and practice, plus articles in peer-reviewed journals. A summary of relevant findings will be sent to all those who participated in the study as well as to local and national service user organisations and all relevant professional bodies. In the meantime, emergent findings will be fed into ongoing College initiatives to improve the quality of acute in-patient care.

Declaration of interest

None.