Finding time for patients: an exploration of nurses’ time allocation in an acute psychiatric setting

Journal of Psychiatric and Mental Health Nursing, 2000, 7, 259–268

© 2000 Blackwell Science Ltd 259

Finding time for patients: an exploration of nurses’ timeallocation in an acute psychiatric settingD. WHITTINGTON1 ma med tcert afbps s cpsychol & C. McLAUGHLIN2 b sc dphil rmn rgnrcnt rnt cert ed

1Professor of Health Psychology, School of Health Sciences, University of Ulster, Jordanstown, Shore Road,Whiteabbey, Co. Antrim, N. Ireland, BT37 0QB & 2Nurse Lecturer, School of Nursing and Midwifery, Queen’sUniversity Belfast, Multidisciplinary Education Centre, Altnagelvin Area Hospital, Derry, Northern Ireland, BT47 1SB

WHITTINGTON D. & McLAUGHLIN C. (2000) Journal of Psychiatric and MentalHealth Nursing 7, 259–268

Finding time for patients: an exploration of nurses’ time allocation in an acutepsychiatric setting

This article explores the proportion of work time psychiatric nurses spend in potentially

psychotherapeutic one-to-one communication with patients. Twenty staff nurses from three

acute admission wards in a psychiatric hospital in Northern Ireland were observed. The

time spent in a selection of routine activities was recorded using a specially developed obser-

vation system Nurses’ Daily Activity Recording System (NURDARS). The main findings

were: (i) less than half of the working day (42.7%) was spent in patient contact, and (ii)

the proportion of work time which was devoted to potentially psychotherapeutic interac-

tion with patients was very small (6.75%). The implications and limitations of the study

are discussed and suggestions are made for the management and practice of psychiatric

nursing, for the education of psychiatric nurses, and for further research.

Keywords: patient contact time, psychiatric nurses’ roles, skill mix, ward observation

systems

Accepted for publication: 11 February 2000

Correspondence:

D. Whittington

School of Health Sciences

University of Ulster

Jordanstown

Shore Road, Whiteabbey

Co. Antrim, N. Ireland

BT37 0QB

Introduction

Despite advances in psychopharmacology the great major-

ity of in-patient psychiatric care remains premised upon

notionally therapeutic interaction between patients and

health-care professionals. Whether the approach adopted

is psychodynamic, cognitive or behavioural; group or indi-

vidual; it will involve purposive, structured communication

with the patient. Arguably too, the effectiveness of formal

psychotherapeutic sessions can be positively or negatively

influenced by the extent to which less formal interaction

in the ward environment supports it. Even where the

approach is primarily biomedical, there is acceptance of the

value of supportive social environments as a context for

therapy. Put simply, talking to patients is a significant part

of psychiatric care and the amount of time health profes-

sionals in acute psychiatric settings can devote to it is an

important quality indicator.

For psychiatric nurses in particular, it can be argued that

interaction with patients should be the primary focus of

care. Barker et al. (1997), for example, develop Hildegard

Peplau’s idea that nursing should ‘take as its unique focus

the reactions of the patient or client to his illness or health

problem’ (Peplau 1989, p. 28) and suggest a theoretical

construction of psychiatric nursing premised upon ‘inter-

active, developmental human activity more concerned with

the future development of the person than with the origins

or causes of their present mental distress’ (Barker et al.1997, p. 663) and upon ‘collaborative reauthoring of the

person’s life’ (Barker et al. 1997, p. 663).

D. Whittington & C. McLaughlin

260 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 259–268

The aspiration therefore is a psychiatric nursing work-

force that both recognizes the therapeutic significance of

interaction with patients and is able to devote significant

time to it. Regrettably, the evidence from some 25 years of

study suggests that in the NHS at least, the aspiration

remains largely unfulfilled. Thus, Cormack (1976) notes a

marked disjunction between the view of the psychiatric

nurse as actively involved in therapy promoted in training

courses and the largely administrative and monitoring

activities of the nurses in the 18 acute admissions wards

where he collected the data. Much more recently Gijbels

(1995) suggests that while psychiatric nurses possess psy-

chotherapeutic skills they do not use them and that they

devote most of their time to task-oriented administration

and management. He notes that nurses are perceived by

other health professionals as generalists who ‘keep the

place ticking over’ (Gijbels 1995, p. 464) and assist others

by collecting and distributing information but who are not

expected to have much influence on the design and imple-

mentation of therapeutic intervention.

Gijbels (1995) also examines the nurses’ own percep-

tions of their difficulties in working with individual

patients and stresses their consistent report of time-

management problems. Both nurses and non-nurses in his

sample commented on ‘the amount of time that nurses

spent on administrative and clerical duties which kept them

away from patients’ (Gijbels 1995, p. 462) . In a similar

but stronger vein Moore (1998) reports that 20% of the

215 patients interviewed in a study of acute admissions

wards in the English NHS regions thought that nurses were

‘rude, disrespectful or spent too much time in the office’

Moore (1998, p. 57).

This paper reports on an observational study carried out

in Northern Ireland examining the time psychiatric nurses

spend in notionally ‘therapeutic’ one-to-one interaction

with patients as opposed to other nursing duties or roles.

The work described was part of a broader study exa-

mining psychiatric nurses’ attitudes to suicidal patients,

relationships between these attitudes and perceived

communication competence, and response to ward-based

communication training (McLaughlin 1997). The data

reported here is from the baseline study undertaken prior

to provision of the training programme. Suicidal patients

were the primary focus of the work but baseline observa-

tions were undertaken in three acute admissions wards

providing nursing care for a broader range of patients.

Hospital, community health and social services are part

of an integrated service in Northern Ireland, and there is

evidence that the contraction of hospital-based psychiatric

care was less precipitate there than elsewhere in the UK

(Donnelly et al. 1994, 1996, Whittington et al. 1997).

Despite these differences there is little to suggest that

Northern Irish psychiatric nurses are substantially differ-

ent from their colleagues in Great Britain. Carrigan (1994),

for example, reports findings similar to those of Gijbels

(1995) and suggests that nurses in acute psychiatric wards

in Northern Ireland perceive difficulties in delivering

individualized care.

Review of the literature

The role and remit of the psychiatric nurse have been much

debated and their evolution can be seen to mirror both

the development of psychiatric care and the increasing

autonomy of nursing as a profession. Reynolds & Cormack

(1990), for example, suggest that psychiatric nursing has

four components namely: the custodial, the medical sup-

portive, the administrative, and the psychotherapeutic.

They argue that they overlap and impinge on each other but

that the psychotherapeutic component has steadily assumed

primacy. Other authors (Kalkman 1958, Royal College of

Nursing 1970, Altschul 1972, Hessler 1980, Barker et al.1997) also stress the centrality of the psychotherapeutic role

and note the relationship between emphasis on the unique-

ness of this contribution and increasing professionalization

in psychiatric nursing.

Peplau (1994) notes the many and diverse claims on

nurses’ time and speculates on the enhancement of care

quality if every registered psychiatric nurse spent 12 hours

a week in therapeutic interaction with patients. The chal-

lenge for psychiatric nursing she suggests is the creation of

conditions that permit the allocation of such a proportion

of the working week to psychotherapeutic activities. The

observational literature however, suggests that in reality

nurses spend only very limited time in direct contact of any

kind with patients. Altschul (1972), for example, found

that only 8% of psychiatric nurses’ time was spent in one-

to-one interaction with in-patients. Sanson-Fisher et al.(1979, 1980) found that one-to-one therapy accounted for

only 15.9% of nurses’ time. Street (1982) found that some

nurses did not interact with any patients for days on end;

Hodges et al. (1986) found that in-patients in acute wards

received negligible attention from nurses once they had

been in the ward for more than 10 days; and Martin (1992)

found that in-patients spent between 6 and 12% of their

waking time interacting with staff. Other authors suggest

that while nurses recognize the importance of interaction

with in-patients they report difficulties in finding time to

engage in it (Gijbels 1995, Ricketts 1996, Hopton 1998,

Moore 1998, Warren 1998). It might be assumed that an

increase in the nurse–patient ratio would result in nurses

spending more time in direct contact with patients, but

Sandford et al. (1990) found that when the staff–patient

Finding time for patients

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 259–268 261

ratio was increased the percentage of time nurses spent in

direct contact with in-patients did not increase, but the

amount of time that they spent interacting with each other

did.

Simply spending time with patients need not be psy-

chotherapeutic and it is acknowledged in the literature that

distinctions must be made between communication that

has a manifest therapeutic outcome, communication

that is intended as therapeutic but has no such manifest

outcome, and communication that is neutral in intent.

Robinson (1994, 1995), for example, examined the nature

of direct contact with patients and reported that individu-

alized therapeutic interaction occurred less often than task-

centred interaction. In addition, Robinson (1994) reported

that nurses spent only 20% of their time in patient super-

vision, and that much of this time resulted in little, if any,

therapeutic input by nursing staff.

It seems from these findings that most of the psychiatric

nurse’s working time is spent on something other than

giving direct care to patients and that the therapeutic

potential of wards is not being fully exploited. Several of

the studies cited comment that psychiatric nurses are good

at forming therapeutic relationships with their patients and

that the relative continuity of their presence on the ward

should make them particularly sensitive to their patients’

needs and to subtle changes in patients’ symptoms and

general wellbeing. Yet, 20 years after Altschul’s (1972) and

Cormack’s (1976) work, it seems that little has changed

and that, however they perceive their role, psychiatric

nurses still have difficulties in finding time for patients.

If the situation is to change there is a need for further,

more detailed studies of the way psychiatric nurses spend

their time and of the barriers to their devoting increased

amounts of time to potentially psychotherapeutic interac-

tion with patients. There is also a need for the development

of valid, reliable and generally acceptable instruments for

the observation of psychiatric nursing activity.

Aim of the study and research questions

The aim of this study was the quantification of the time

spent by a sample of psychiatric nurses in a range of work-

related activities with particular emphasis on potentially

psychotherapeutic one-to-one interaction with patients.

Three main research questions were posed. They were as

follows.

• How much time do psychiatric nurses in selected acute

admissions wards spend in specified activities during

the course of a working day?

• What proportion of their work time do psychiatric

nurses in selected acute admissions wards spend in

one-to-one interaction with patients?

• What proportion of the time spent by psychiatric

nurses in selected acute admissions wards in one-to-

one interaction with patients can be defined as poten-

tially psychotherapeutic?

Methods

The study instrument

An observation instrument entitled Nurses ‘Daily Activity

Recording System’ (NURDARS) was developed using

standard techniques for the development of ‘category’

observation systems (Medley & Mitzel 1962). Categories

were derived from scrutiny of earlier studies and from

knowledge and informal observation of similar ward set-

tings. Pilot observations were carried out and reliability

and validity were established with the assistance of a small

team comprising three psychiatric nurse tutors and a Direc-

tor of Nurse Education with relevant experience. The final-

ized recording system (see Appendix 1) contained 18

categories for observable psychiatric nursing activities, one

for meal times and one for ‘Other duties’. Eleven categories

represented forms of direct contact with patients and nine

(including ‘Other duties’ and meal times) did not. Category

13 ‘Group therapy’ was defined exclusively as periods of

time spent in formally designated group-therapy sessions.

Categories 14 and 15 (‘Individual therapy’ and ‘Social con-

versation’) were perhaps the most difficult to code. Essen-

tially the observers were attempting to identify occasions

when nurses were consciously intending to be supportive,

to counsel, to listen actively to patients’ accounts of their

feelings or difficulties, or to discuss treatment procedures

and events. These events were coded 14, ‘Individual

therapy’. ‘Social conversation’ activities on the other

hand were defined as occasions on which nurses had

discussions with patients which they might have had with

anyone – about the weather, television programmes, or

other staff (for example). These interactions may well

have been therapeutic for some patients but they were not

purposely so.

The recording sheet was a matrix of the 20 activity

categories by 10 time periods dividing up the working

day, commencing at 7.30 am and ending at 5.50 pm . The

number of minutes each nurse, in each time period, spent

on any of the specified activities was recorded. At the end

of the day, the time spent on each category was calculated.

Despite efforts to ensure that categories were discrete, pilot

use of the system indicated that some activities could occur

at the same time, e.g. ‘Social conversation’ (category 15)

and ‘Giving out medications’ (category 10) or ‘Physical

care’ (category 11). In these cases observers made a judge-

ment as to the category that predominated and recorded



it alone. It was possible, for instance, for a period of

administering medications to continue for a period of 10

minutes during which a few social comments might be

made. That would be recorded as 10 minutes of category

10. If, on the other hand, the observer judged that admin-

istration of medications proceeded for 2 minutes, stopped

for 5 minutes of social conversation and recommenced

until completion after a further 3 minutes, that would be

recorded as 5 minutes of category 10 and 5 minutes of

category 15.

The sample

There are 10 acute psychiatric admissions units in North-

ern Ireland, five of which are situated in general hospitals.

The remainder are in five psychiatric hospitals, three of

which are somewhat larger than the others. The three-ward

unit that participated in this study was located in one of

the three larger psychiatric hospitals. Twenty nurses took

part. Observation in more than one unit was originally

intended but some hospital managers considered observa-

tion of work patterns potentially sensitive and access was

refused. Thus, the sample was essentially a convenience

sample. Professional judgement suggested however, that

both the nurses and their patients were substantially

similar to those who could have been found on other

admissions wards. All participant nurses were registered

mental nurses (RMNs) of whom 60% were grade ‘D’ staff

nurses and 40% were grade ‘E’. None were ward man-

agers. Eighty per cent were female and 35% commenced

their preregistration training before 1983. Each in-patient

on each of the wards had been allocated a named primary

nurse and an associate nurse.

Once access to the unit had been obtained, a series of

meetings with potential nurse participants were held to

outline the rationale, methodology and potential benefits

of the study. A separate meeting took place with senior

hospital managers. A few nurses were initially hesitant

but all eventually participated. Reassurances were given

about confidentiality and each participant was given a

code number that was known only to them and to the

researcher. Finally, the researcher held a meeting with in-

patients in each of the three wards and outlined the study

to them. It should be noted that the patients welcomed this

type of research.

The procedure

One nurse was observed at a time. The off-duty roster

for each ward was requested 1 week in advance and

the researcher determined which participant was to be

observed and when. As far as possible this was a ran-

dom selection but practical matters such as illness and

unplanned leave influenced the decision. Observations

took place on all weekdays excluding Sundays. Participants

were not warned in advance of their observation day

(although they clearly knew that they would be observed

at some stage in the study). There were two observers each

of whom was an experienced psychiatric nurse and nurse

tutor. Both acted as minimal-participant observers as

described by Altschul (1972) and Sandford & Elzinga

(1990). In the judgement of the observers the events that

took place on the days selected for observation were fairly

typical of ward life in an acute admissions setting. This

judgement was confirmed by the relevant ward managers.

Results

Patient-contact time

Each nurse was observed for a total of 620 minutes (includ-

ing meal breaks). Taking account of the fact that some

nurses took less time in meal breaks than others the total

time spent in meal breaks was 1720 minutes. This time

is excluded from the analysis leaving a total time of

10 680 minutes for possible nurse–patient interactions.

Table 1 shows that 57.3% of the total time was spent in

non-patient-contact activities and 42.7% of the total time

was spent in patient-contact activities.

Non-patient activities

Table 2 shows the number of minutes spent by nurses

in each non-patient contact activity. It was found that

Table 1Shows the total time (minutes) and percentage time spent in nonpatient-contact activities and in patient-contact activities

Activities Total time (minutes) Time (%)

Non-patient contact 6118 57.3%Patient contact 4562 42.7%

Table 2Shows the total time (minutes) and the percentage time spent innon-patient-contact activities

Observed activity Total time Time (%)

1. Receiving reports 230 2.16%2. Office administration 1541 14.43%3. Talking or reporting to other staff 1970 18.45%4. Unavailable to patients 782 7.32%5. Clinical room duties 291 2.73%6. Time with student nurse 581 5.44%7. Doctor’s rounds 492 4.61%8. Other duties 231 2.16%

Total time 6118 57.30%



18.45% of the working day was spent in talking or report-

ing to other staff; 14.43% was spent in office administra-

tion, 7.32% in being unavailable (includes going errands,

leaving the ward for personal reasons); 5.44% with student

nurses; 4.61% in doctor’s rounds (case conferences);

2.73% in clinical room duties; 2.16% in receiving reports;

and a final 2.16% in other duties (bed making, putting

away laundry or tidying the ward).

Patient-contact activities

Table 3 shows the breakdown of the time nurses spent in

patient-contact activities. It was found that nurses spent

9.39% of their time in giving medications; 7.56% in pro-

viding individual therapy; 5.81% in supervising mealtimes;

4.98% in social conversation with in-patients; 3.62% in

providing group therapy; 3.21% assisting with Electro

Convulsive Therapy (ECT); 2.43% in escort duties to other

hospitals or wards; 1.36% in clinical-room duties with in-

patients (e.g. taking blood samples, applying dressings);

1.97% in non-interactive close observation; 1.84% in

physical care activities (washing, feeding, ‘toileting’); and

0.53% in interactive close observation.

Analysis of time spent in ‘Close observation’

During the course of the study 20% of nurses were

observed while they were undertaking ‘Close observation’

(Kingdon & Bakewell 1988, Dennis 1997). Table 3 shows

that a total of 210 minutes was spent in non-interactive

‘Close observation’ (involving no verbal nurse–patient

interaction). Fifty-seven minutes, during a total of 30

verbal interactions, was spent in interactive ‘Close obser-

vation’. Further scrutiny showed that these interactions

were of short duration (from 1 to 8 minutes), and that their

verbal content involved mainly ‘Social conversation’,

rather than potentially psychotherapeutic discussion or

reference to the reasons for ‘Close observation’.

Mean time spent in ‘Social conversation’ compared

with mean time spent in ‘Individual therapy’

Table 3 showed that 7.56% of the participants’ time was

spent in ‘Individual therapy’. It should be noted, however,

that 0.81% of the time was spent in taking patients for a

walk outside the ward. These periods were initially

included as ‘Individual therapy’ time but were difficult to

observe. They have accordingly been omitted from the

analysis that follows leaving 6.75% of the time quite

clearly spent in ‘Individual therapy’ as defined. As shown

in Table 3 this compares with 4.98% of time spent in

‘Social conversation’. Table 4 compares the distribution

of time spent in ‘Social conversation’ (see p. 3 for defini-

tion) for each nurse (m = 26.6, s.d. = 21.2) with the dis-

tribution of time spent in ‘Individual therapy’ for each

nurse (m = 36.05, s.d. = 31.0). This difference was not sta-

tistically significant (t-test).

The number of ‘Social conversation’ sessions

compared with the number of ‘Individual therapy’

sessions

The number of occasions on which each nurse engaged in

‘Social conversation’ and in ‘Individual therapy’ was exam-

ined, as shown in Table 5. For 90% of the participants

the number of ‘Social conversation’ sessions exceeded the

number of ‘Individual therapy’ sessions. There was a total

of 215 ‘Social conversation’ sessions and for each nurse the

number of ‘Social conversation’ sessions ranged from three

to 30 (m = 10.75, s.d. = 6.41). This compared with 68

‘Individual therapy’ sessions with a range for each nurse

from zero to 11 (m = 3.40, s.d. = 2.72). The t-test analy-

sis showed that the difference between the number of

‘Social conversation’ sessions and the number of ‘Indi-

vidual therapy’ sessions was statistically significant (t =-4.86, P < 0.001).

Table 3Shows the total time (minutes) and the percentage time spent inpatient-contact activities

Observed activity Total time Time (%)

1. Clinical duties with patients 145 1.36%2. Giving medications 1003 9.39%3. Physical care 197 1.84%4. Supervising meals 621 5.81%5. Group therapy 387 3.62%6. Individual therapy 808 7.56%7. Social conversation 532 4.98%8. Interactive close observation 57 0.53%9. Non-interactive close observation 210 1.97%

10. Electro Convulsive Therapy (ECT) 343 3.21%11. Escort duties (to other 259 2.43%

hospitals/wards)

Total time 4562 42.7%

Table 4Compares the time spent in social conversation sessions with the time spent in individual therapy sessions

Activity Time spent in sessions Mean Standard deviation (s.d.) Significance (t-test) P-value

Social conversation 532 26.6 21.2 0.27Individual therapy 721 36.05 31.0



‘Individual therapy’ sessions

The length of each ‘Individual therapy’ session was also

examined. Nurses spent 0.64% of their time in ‘Individual

therapy’ sessions of less than 5 minutes duration. There

were 31 of these sessions which averaged 3.4 minutes in

length (s.d. = 5.2). Most of these short sessions involved

explaining procedures or future events to patients. ‘Indi-

vidual therapy’ sessions of 5 minutes or more accounted

for 6.11% of nurses’ time and there were 37 of these longer

sessions (mean length, 32.6 minutes; s.d., 31.3). In these,

nurses talked to patients about their progress or psy-

chosocial difficulties. As is clear from the standard devia-

tion there was considerable variation in the length of these

sessions, the range being from 5 to 45 minutes. There was

a similarly large variation in the total time each nurse spent

in ‘Individual therapy’ in the course of the day, the range

being from 0 to 118 minutes. While the small number of

nurses in the sample precludes systematic exploration of

the relationship between these variations and the partici-

pants’ professional biographies there were no immediately

evident relationships with gender, grade or date of train-

ing. The nurse who spent most time in ‘Individual therapy’

and whose ‘Individual therapy’ sessions were longest

however, was the one nurse in the unit whose preregistra-

tion education had focused heavily on acquiring and using

nurse–patient communication skills.

Discussion

This study had a number of limitations. First, it was based

on a small convenience sample of psychiatric nurses

working in one Northern Irish setting. Secondly, like all

observational studies, it is subject to the possibility that the

nurses’ knowledge of being observed had an effect upon

the way they behaved. Neither the researchers nor the

relevant ward managers felt that the observed behaviour

was atypical but the possibility remains. Thirdly, while the

NURDARS suited the aims of this present study and

proved both practical and reliable, it requires validation

in other facilities. Fourthly, each participant nurse was

observed for only one shift. This shift may have been atypi-

cal. Replication of the study over longer periods of work

time is required. Finally, observation took place during a

period when non-participant staff took sick leave which

resulted in some participants taking on additional duties.

Considerable caution must therefore be exercised in

relating this study to other settings or groups of staff.

Given the paucity of observational studies in the literature

however, it can be argued that even an exploratory study

of this kind is worthwhile.

The main finding from this study is that the observed

nurses spent only a very small proportion of their time

(6.75%) in potentially psychotherapeutic one-to-one inter-

action with their patients. Furthermore, substantially less

than half of their time (42.7%) was spent in any kind of

contact with their patients. It is evident that ‘talking and

reporting to other staff’ and ‘office administration’ taken

together had high priority, occupying (see Table 2) almost

33% of the available time. This confirms earlier research

which also suggests that psychiatric nurses do not allo-

cate much time to psychotherapy (Sandford et al. 1990,

Robinson 1994), that most of their working time is spent

in activities which do not involve patient contact (Martin

1992), and that they could readily be perceived as ‘par-

rots in the office’ (Gijbels 1995) devoting large amounts

of time to receiving, recording, organizing and conveying

information.

It would have been useful to have discovered what

the observed nurses talked to each other about and what

their administrative duties involved, but this was not

recorded. Detailed observation of doctors’ rounds (which

were really case conferences) and of student-nurse as-

sessments was also not possible and observers only

recorded the time spent in these activities (4.61% on

doctors’ rounds and 6% on student nurse assessments).

Checking drugs and equipment, and tidying the clinical

room accounted for 2.73% of nurses’ time, and tidying

the ward, making beds, and putting away and checking

laundry accounted for 2.16% of it. A proportion of the out

of ward time coded as ‘unavailable’ was spent on running

errands on patients’ behalf but by far the greatest part of

this time was spent in either personal or administrative

activities.

When actually in contact with patients much of the

nurses’ time was spent in care which did not involve talking

to them. Even fairly obvious opportunities for potentially

psychotherapeutic interaction did not seem to be exploited.

Giving medications, for example, accounted for 9.39% of

nurses’ total working time but most of this time was spent

waiting for patients to take medicines, physically adminis-

tering them and recording their administration. Very little

Table 5Compares the number of social conversation sessions with the number of individual therapy sessions

Activity Number of sessions Mean Standard deviation Significance P-value

Social conversation 215 10.75 6.41 0.001Individual therapy 68 3.40 2.72



of all this also included verbal interaction, although some

nurses did ask how patients were or made arrangements

to discuss their concerns at a later time. Similarly while

5.81% of nurses’ time was spent supervising patients at

mealtimes, conversation was limited and usually social.

Accompanying patients to ECT accounted for 3.21% of

working time, but again, while this has the potential for

psychotherapeutic encounters, most observed conversation

was social in content. After patients had recovered from

ECT, nurses, doctors and patients had tea together but

yet again any discussion with patients reflected social,

rather than psychotherapeutic, issues. Finally, although

close observation offers an ideal opportunity for discussion

of relevant issues only 21% of the time was spent in con-

versation and again this was mainly social.

Formal group therapy was regularly scheduled for each

ward but it accounted for only 3.62% of nurses’ time. In

fact it was frequently cancelled owing to staff shortages,

unforeseen events, or, on occasion, because patients did not

want to attend.

Potentially psychotherapeutic one-to-one interaction did

of course take place and nurses spent 6.75% of their

working time engaging in it. This proportion is consider-

ably lower than that recorded by Sanson-Fisher et al.(1979, 1980), who report 15.9% but corresponds with

Altschul (1972) and Martin (1992) who give 8% and

‘between 6 and 12%’, respectively.

There are several possible reasons why the nurses

observed in this study spent so little time in this activity.

First, as Tables 2 and 3 show, they were very busy doing

other things. Data from interviews with these nurses

reported elsewhere (McLaughlin 1999) suggest that they

recognized the importance of communication with their

patients and were frustrated by having so little time avail-

able for it. Comments included the following;

‘I had a lot of things planned and didn’t get a chance to

do them – it happens a lot’,

‘The more time we have in some jobs the less time we

have for patients’ and

‘We are constantly working with different staff and

you have to catch up with what has happened’.

This impression of good intentions overtaken by events

is confirmed by the fact that the observers frequently over-

heard nurses and patients making arrangements regarding

one-to-one psychotherapy which then collapsed owing to

staff shortages or other unforeseen occurrences.

Secondly, some nurses were more proactive in creating

opportunities for one-to-one psychotherapy than others.

Time recorded in ‘Individual therapy’ ranged between 0

and 118 minutes. The nurses who spent either zero or very

little recorded time in ‘Individual therapy’, spent much

of their time in the nursing office apparently writing up

nursing records and answering the telephone. Reasons for

why this is the case were unclear. However, it has been sug-

gested elsewhere that nurses’ preregistration training does

not prepare them adequately for one-to-one psychotherapy

with in-patients (Minghella 1989, Long & Reid 1996) and

as noted above the one nurse in this sample who seemed

to find more time than others had had specific training.

It is possible therefore that some nurses find it difficult to

talk to patients and feel safer within the confines of the

ward’s nursing office. When asked to rate themselves for

communication competence on a simple 10-point scale

(McLaughlin 1999) only five of the 20 nurses observed in

this study regarded themselves as 70% competent. Such

lack of confidence in personal competence could impinge

on both the quantity and quality of psychotherapeutic care.

Conclusions

There is a substantial and growing literature confirming the

notion that psychiatric nurses have a key role to play in

the creation of psychotherapeutic ward environments and

in the provision of formal psychotherapy. Fulfilment of

such a role requires a system of ward management, a skill

mix and a nursing resource that allows nurses to ‘find time

for patients’. The study reported here adds to the literature

which suggests that in fact psychiatric nurses have diffi-

culties in doing so (Altschul 1972, Cormack 1976, 1983,

Martin 1992, Robinson 1994, Lepola & Vanhanen 1997,

Moore 1998). The nurses observed in this study spent less

than half of their time in direct contact with patients and

less than 10% of it engaged in interaction that was even

potentially psychotherapeutic. On the other hand, they

spent about a third of their time either talking to each other

or carrying out administrative tasks.

The study was based on a small sample in one setting

and thus requires replication. Despite these limitations it

can be argued that it has implications for the management

and practice of psychiatric nursing, for the education of

psychiatric nurses, and for further research in the area.

Implications for the management and practice of

psychiatric nursing

The shift from hospital to community care has revolution-

ized acute psychiatric admissions wards. The proportion of

admissions likely to lead to long hospital stays has been

radically reduced and the aim for most patients is provi-

sion of support and respite while doing everything pos-

sible to facilitate a return to home, family and autonomous

community life. Both patient needs and resource impera-

tives suggest that this should be effected as quickly as

symptoms and circumstances permit. This in turn requires



that the professional skills of psychiatric nurses be fully uti-

lized and that they should be proactive in providing one-

to-one psychotherapy. The study reported here confirms

previous findings that this does not currently happen.

The findings from this study suggest that managers

might profitably audit the amount of time their nursing

staff spend with patients and compare it with the amount

of time they spend in other activities. It could be useful to

use or adapt the observation instrument developed in this

study, thereby permitting comparison between settings or

over time. Psychiatric nurses themselves may need to

re-examine the importance of one-to-one contact with

patients in their delivery of care, to limit the time they

spend in routine duties, and to argue for a skill mix that

allows them to delegate tasks to less qualified colleagues.

Implications for the education of psychiatric nurses

The nurses who took part in this study accepted that com-

munication with patients was an important part of their

work but some felt more confident about providing one-

to-one psychotherapy than others. They may have con-

sidered it beyond their remit or may simply have had

difficulties in talking to patients effectively. Either way

there is a clear argument for improved pre- and postregis-

tration education in this area.

Implications for further research

As has already been noted replication of this study in a

range of settings would be useful. The observation instru-

ment employed requires further validation and it would be

interesting to compare this study with analyses of time

spent in settings with different skill mixes, or where there

had been particular initiatives designed to enhance nurses’

communication skills. It would also be illuminating to

explore patients’ perceptions of nurses’ interventions.

Finally, this study concentrated on the time nurses find for

patients but it can of course be argued that the really

important investigation will focus on what they do with

that time. Detailed observation (possibly using the tools

of linguistic discourse analysis) of Barker et al.’s (1997,

p. 663) ‘collaborative reauthoring of the patient’s life’ is

needed before we can begin to develop that ‘theoretical

construction of psychiatric nursing’ Barker et al. (1997,

p. 663) which would illuminate practice, research and edu-

cation in the area.

Acknowledgments

The work reported here was part of a Doctor of Philoso-

phy thesis submitted by the second author under the super-

vision of the first in August 1997. Both authors wish to

record their gratitude for support provided by Professor

Patrick Darcy, Mr Patrick Henry, Mr Robert Godfrey, and

the staff of the former Western Area College of Nursing,

Altnagelvin Hospital, Derry, N. Ireland. The participation

and support of patients, nurses and managers in the wards

under study are also very much appreciated.

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Appendix I NURSES’ DAILY ACTIVITY RECORDING SHEET DATE:

NURSE’S CODE:

ACTIVITY TIME � 7.30–9AM 9–10AM 10–11AM 11–12MD 12–1PM 1–2PM 2–3PM 3–4PM 4–5PM 5–5.50PM TOTAL

�

1. Receiving Reports:

2. Office Administration:

3. Talk to other Staff:

4. Unavailable to Patients:

5. Clinical Room Duties:

6. Time with Student Nurse:

7. Doctor’s Rounds:

8. Other Duties:

9. Clinical Duties:

10. Giving Medications:

11. Physical Care:

12. Supervising Meals:

13. Group Therapy:

14. Individual Therapy (1/1):

15. Social Conversation:

16 Interactive Close Observation.:

17. Non-Interactive Close Obs.:

18. E.C.T.:

19. Escort Duties:

20. Meal Breaks

Documents

Finding time for patients: an exploration of nurses’ time allocation in an acute psychiatric setting