The purpose of this independent study is to identify a topic of my choice namely ‘The Cause and Consequence of Boredom: An exploratory study of Patients’ Perceptions within a Psychiatric Inpatient Unit’. A rationale will be given for the chosen topic, a literature review will be carried out and a Research Proposal formulated.
This essay will explore the concept of ‘boredom’ and the factors surrounding this issue, such as the causes, consequences and solutions from a patient’s perspective. These factors will constitute my learning outcomes. On completion of the essay I should be able to demonstrate a better understanding on the topic of boredom and from critically evaluating the literature will gain a more in-depth knowledge of the causal factors, the impact it has on patients and the suggested solutions to the problem identified within the literature. Additionally, on completion of the assignment I will have gained knowledge in writing an academic essay, thoroughly researching a topic utilizing critical analysis of academic literature and completing a research proposal thus achieving the stated outcomes. In completing a learning contract this will improve my incentive to focus on my essay and formulate and develop realistic aims and outcomes. In a study carried out by Wai-chi Chan & Wai-tong (2000) it was found that a learning contract could improve students’ autonomy and control over learning and increased motivation and sharing in learning.
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The rationale for choosing the topic is that as a student within an acute psychiatric admission ward I frequently encounter patients who complain of boredom, and some of the reasons they stated were, ‘having nothing to do’, ‘confinement to the ward’, ‘nothing going on within the ward’, ‘nothing in common with other patients’, amongst other perceived attributable factors. This prompted me to think about the legitimacy of their complaints and consider whether the ward environment was in fact hindering or promoting the patient’s recovery. Craig & Power (2010) highlights the problem of boredom within acute ward settings and the notion that it is bad for the patient’s recovery and that therapeutic intervention tailored to their need should be considered. Similarly, Binnema (2004) suggests that to reduce boredom and enhance the patients’ experience psychological, physical and personal factors which include therapeutic activities, exercise, physical health, financial and housing issues should be addressed during the patient’s hospital stay. Additionally, in consideration of the ward environment I realised that it was rather drab and space was extremely limited. Within the ward there is a large dayroom where social encounters can occur, but it is not conducive to enabling individual or group therapeutic interventions due to the common use of the facilities. Dijkstrak, Pieterse & Pruyn (2006) suggest that there is research to support the notion that the healthcare environment can make a difference to the patient’s recovery. It is therefore important to consider this when supporting patient’s therapy and recovery.
Consequently, it is important for nurses working within an acute environment to consider solution to these problems. Binnema (2004) purports that if nurses had a clear understanding of the concept of boredom, it would support them to enhance their ability to provide a more enhanced therapeutic environment. Therefore, Nurses have a pivotal role to play in improving both the therapeutic relationship with patients whilst ensuring that the environment is conducive to recovery.
From a professional perspective, the Department of Health (2002) published a policy on adult acute inpatient care provision in which they highlighted that high levels of interaction between staff and patients within the ward environment reduce boredom. Furthermore, they stressed that in response to a dearth of research on acute inpatient care there was a need for research in the effectiveness of acute services. Binnema (2004) also highlight that many psychiatric patients experience boredom and lack the opportunity to engage therapeutically within the hospital environment, and indicate therefore that there is a necessity for further research of this concept.
A concept map will be utilized to generate ideas and enable focus and structure within this essay. Concept maps can be used by students to both gain new knowledge and utilize prior knowledge breaking it down into ideas and put the information in order thus making sense of it and the connotations between and among the concepts (Hinck, Sims-Giddens et al, 2006). The central theme within the concept is ‘Boredom’, and this is illustrated along with the sub-themes in (appendix 1). The concept map constructed has particular reference to boredom within an acute psychiatric setting which has been shown to warrant further investigation.
Literature Review
The literature review was performed taking cognizance of the research topic chosen. Cormack (2000) highlights the importance of carrying out a ‘critical review’ of what has been known previously within the literature in order to prepare the ground for new research. A literature search was carried utilizing keywords such as ‘boredom’, ‘acute care’, ‘psychiatric inpatients’, ‘acute mental health’, ‘therapeutic environment’, ‘acute mental health nursing’. A systematic review was carried out within academic journals relating to the topic by accessing databases such as EBSCOhost, CINAHL Plus with Full Tex, Ovid, Science Direct, Wiley InterScience, IngentaConnect, to uncover relevant literature pertaining to the subject and to retrieve up-to-date studies to elucidate what research had already been carried and the value of carrying out further research.
To understand the concept of ‘boredom’ it will be of benefit to review the definition within the literature. Kass et al (2001) support the view that boredom proneness as a multidimensional concept and point out that the literature lacks differentiation between boredom as a ‘trait’ or a ‘state’, but that numerous writers suggest a distinction between ‘situational’ and ‘dispositional’ boredom. This would therefore pose a dilemma for researchers in proposing a solution to the problem. It is of no surprise therefore that concept of boredom has been studied from different perspectives and by diverse factions. Dahlenthe, Martin, Ragan et al (2004) state that boredom has generated a great deal of research in education, psychology, organizational behaviour, accident prevention and medicine.
Anderson (2005) defines boredom as ‘the death of meaning’. Fahlman et al (2009) support this belief but are more conservative in their view suggesting it is a ‘lack of meaning and purpose’. Barbalet (1999, p.637) further describes boredom as ‘a type or form of anxiety about the lack of meaningfulness of an activity, a condition, and (possibly) a life. These beliefs would suggest that boredom has a significant dispositional component. In contrast, Todman (2003, p.147) describes ‘boredom’ as ‘an unpleasant state that is invariably accompanied by attributions of environmental sameness’, which would imply that it may be attributed to situational factors. As already stated boredom is a multidimensional concept many of which are too complex to address within this essay but those already described can offer a clearer understanding of the concept, that there may be both psychological and environmental components to boredom.
Martin, Sadlo & Stew (2006) state that ‘modern philosophers’ are of the opinion that boredom may arise from ‘over-stimulation’ rather than ‘monotony’ which originated from ‘ancient times’ and attribute this to ‘trivia’ in the modern world. Whereas some studies have suggested that boredom is a result of ‘enforced idleness’ (Meehan, McIntosh & Bergen, 2006). These beliefs would advocate that the origins of boredom may be attributed to environmental factors. Fahlaman et al (2009) have described the relationship between the experience of boredom and negative affect which denotes a psychological phenomenon. It is therefore valid to consider that these could have a significant impact on the behaviour of a patient within an acute inpatient ward. It will be of interest to compare these concepts with the findings from the experiences of the patient’s within an acute inpatient setting.
It is important to consider the impact of boredom within an inpatient setting regardless of the cause. There are significant similarities described within the literature. Beer et al (2001) purport that the negative consequences of overstimulation within acute psychiatric ward settings are violence and aggression. In contrast Stein & Wilkinson (2007) attribute these behaviours to under stimulation. However, Khan et al (1987) suggests that low stimulus within the environment is known to decrease psychotic symptoms in the individual. Bracke (2004) associates the provision of rewarding activities with the reduction of boredom. This would imply that involvement in activities of interest to the individual is a significant factor in reducing boredom. In contemplating these views the consequences are varied and complex and could pose a dilemma within an acute ward setting. Consequently it would appear that individual factors would require to be taken account of when considering the solutions to the problem.
On searching the literature it was found that there was a dearth of studies on the effects of ‘boredom’ within a healthcare setting. However, three studies were found where the researchers carried out research within an acute care psychiatric environment, a high-secure forensic setting and a day activity program in rehabilitation centres in which boredom emerged as a concept of both environmental and individual characteristics of participants in the first two studies, and in the third the determinants of boredom were primarily studied which showed that both environmental and individual factors played a part. These will be discussed respectively taking account of Polit et al (2001) method of critiquing research articles namely, methodological, ethical and interpretive dimensions, and will take account of their relevance to the Research Proposal.
Study One
Shattell, Andes & Thomas (2008) carried out a study which was specifically to ask inpatients within a 30 bedded ward, ‘what stands out to them within the hospital environment’. A phenomenological approach was utilized in order to acquire direct experiences from patients. 10 patients and 9 nurses took part. Patients’ diagnosis varied namely personality disorder, depression, substance abuse, bipolar, anxiety disorder and post traumatic stress disorder. Their ethnic background was also varied. Acutely psychotic patients were excluded. There were also various therapeutic activities available within the ward environment. Nurse participants were all female also from various ethnic backgrounds. Ethical factors were considered and informed consent was sought and approved by the sponsoring university.
Phenomenological interviews were carried out to ‘gain rich experiences of the participants’, and participants were encouraged to elaborate if they wished on the topic. The interviews were audio-taped and transcribed verbatim. Themes were generated from ‘meaning units’. The vigour of the study was enhanced by presenting the data to the research group who interpreted the data and finalized the thematic structure.
Findings showed that experiences of both nurses and patients were similar. Both felt the effects of confinement to the ward and nurses agreed with patients that there was a lack of nurse/patient communication. Rules appeared restrictive to both and intimidating. Participants also highlighted the lack of interaction between nurses and patients. There were general feelings of powerlessness, mistrust which resulted in feelings of panic and agitation. Both nurses and patients questioned the ability of the hospital to help patients namely not addressing their illness effectively and patients being assigned to inappropriate groups. Workload was also a factor for nursing staff.
One of the main themes which emerged was ‘boredom’ and many attributed this to the locked door environment. The main outcome of the study was the lack of meaningful closeness between nurses and patients and the environment hindered the therapeutic relationship. The authors stated that this echoed previous studies.
Study 2
Meehan et al (2006) carried out a study within a high security inpatient forensic setting. This study focussed on the reasons for aggressive behaviour of patients. Two wards took part 23 bedded high intensity and 23 bedded low intensity long term unit. 22 male and 5 female inpatients took part and 85% had a diagnosis of schizophrenia. 5 focus groups were conducted by an independent researcher and semi-structured interviews were carried out with a list of questions. Spontaneous feedback was encouraged. The sample was chosen by inviting people to participate through advertisements within wards. Inpatients of less than 3 months or those with acute symptoms were excluded. The study was approved by the Human Research Ethics Committee within the organization. Data was transcribed and checked by a group moderator to ensure accuracy and authentication. Content analysis was utilized to transcribe the data and they were reviewed several times to generate units of information, produce a set of preliminary categories and cluster these into themes. These were carried out by two members of the research team who compared and discussed these before reaching an agreement on the final set of these.
The main themes generated were; the environment, empty days, staff interactions, medication issues and personal characteristics of the patient themselves. Lack of space and prolonged confinement and ignorance of these factors by the staff were main issues. All participants highlighted that boredom was a source of frustration and cancellation of patient activities was a factor. The environment was seen as controlling rather than therapeutic. A lack of understanding and empathy was also identified. The main solutions identified to resolve these was to ensure early intervention to incidents that occurred, change in staff attitudes and provision of therapeutic activities to relieve boredom which was perceived to be the biggest problem within the unit.
Study 3
Bracke et al (2006) carried out a study within Rehabilitation Centres and it focused on the conceptualization of boredom exploring some of its determinants. The study tested some hypotheses, and multilevel analysis was utilized to elucidate the ‘contextual and individual determinants of boredom’. The participants comprised of a random sample of 646 clients and an average sample of each was chosen. Clients were excluded due to lack of information of key variables. 63% were men with varying levels of educational attainment with a mean age of 44 years. Other demographic information i.e. age, marital status, housing and previous receipt of residential psychiatric care was considered. A survey utilizing a structured questionnaire was carried out and clients’ experiences of boredom were measured utilizing a Likert scale. Reliability was measured by questioning respondents outside the centre. Variances were analyzed using exploratory factor analysis. Independent variables were also measured e.g. degree or routinization, complexity, closeness of supervision and the intrinsic and extrinsic value of task was coded on a Likert-type scale. Other tools were utilized to measure mental health status (Global severity Index), the Brief Symptom Index and finally age; gender and education were used as control variables.
Data was analysed by looking at associations between the experience of boredom and features of the rehabilitation centre. The findings led to the hypothesis that several characteristics of the day activity programs cause boredom, mainly task characteristics and reward structures. Findings showed that clients were significantly less bored during participation in rehabilitation programs. However programs that led to highly routinized tasks led more easily to experiences of boredom. Tasks with high intrinsic rewards reduced boredom. Clients with particular characteristics were found to be more easily bored i.e. older clients, educated persons experience more feelings of boredom and boredom is more prevalent among people reporting more intense psychiatric complaints.
Study Comparisons
These three studies were considered from various perspectives and utilizing different research methods. Each was robust in terms of validity and reliability utilizing quantitative and qualitative methodologies. There were commonalities within each of the research studies namely, the interests of patients within their respective healthcare environments and how experiences such as space, surroundings, activity levels, relationships, health state, interactions, and individual characteristics all played a part in precipitating boredom. Ethical dimensions was considered in the first two studies but absent within the third which is a weakness as there was no indication of client informed consent or that it was subject to scrutiny from an ethics committee to ensure that it caused no harm to the client. Each study either highlighted limitations or generalizability which would indicate that the findings may not be truly representative in respect of populations within other healthcare setting. The research proposal submitted within this independent study will potentially add to the body of research already available within the literature.
Research Proposal
The overall aim of the study is to identify the meaning of boredom within an acute mental health inpatient setting, and clarify the effects boredom on patients during their inpatient stay. This will help critically evaluate the consequences of boredom on patient behaviour and assist in making recommendations on how to alleviate boredom from patients’ perspective. Therefore, primary research will be utilized to facilitate the critical evaluation of boredom against the literature review and make recommendations on facilitating change within an acute inpatient environment that will improve patient outcomes in relation to alleviating boredom. An in-depth study of the literature has been undertaken which will support the analysis of data utilizing a case study approach.
Within the context of the Cause and Effect of Boredom within a Psychiatric Inpatient Unit this research study aims to focus on a number of objectives:
Define the term ‘Boredom.
Explore patients’ perceptions of the cause and effects of boredom during their inpatient stay.
Critically evaluate the consequences of boredom on patient behaviour.
Make recommendations on alleviating boredom from a patient’s perspective.
Research Approach
Primary empirical data will be collected utilizing a case study approach. This will allow the researcher to carry out an in-depth study and gain knowledge of patients’ experiences of boredom and the effect this has on their day to day functioning within the ward. Polit & Beck (2010) suggest that case studies provide a wealth of information to enable the researcher to examine relationships between different phenomena. This will afford the researcher the opportunity to examine the relationship between boredom, its causes and consequences. It will also allow the opportunity for patients to express their views on the impact of boredom on them as individuals and provide valuable insights into this phenomenon
Research Strategy
This study will be carried out using qualitative data collection techniques and analysis. The case study approach adopted will allow the researcher to look ‘real life situations’ (Descombe 2007). The collection of data from patients will contribute to the ‘real-world’ views about boredom from an individual perspective.
The case study will be approached from a phenomenological perspective. Schwandt (2001) informs that phenomenology affords the respondents the opportunity to voice their day to day experiences. This can be done by using these experiences to elicit data from the transcripts which may have been tape-recorded, and by formulating meaning from the words transcribed, add to the understanding of the experience (Morse, 1994).
Sample Selection
Sampling is important because it reproduces the characteristics of the defined population (Porter & Carter, 2000).
A purposeful sample will be utilized for this study as participants will be obtained from a cohort of patients within an acute psychiatric ward. Purposeful sampling is best used for this type of study as it enables the researcher to gain direct expert knowledge and experience of the topic being studied (Rehm, 2010). The patients within the acute ward will be able to provide first-hand knowledge of their experiences of boredom.
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The study participants will comprise of representatives from an acute inpatient psychiatric ward. All patients who are willing and psychologically able will have the opportunity to take part. There will be no exclusions as all experiences from all patients are relevant. It is anticipated that those patients who are acutely unwell are unlikely to volunteer. The study will be advertised on the ward notice board. The ward population comprises of approximately 24 patients. These participants represent inpatients’ that have variable psychiatric diagnosis and all should be representative of the population of other acute psychiatric inpatient wards. The sample has been chosen to provide quality of data from knowledgeable patients who are able to articulate their feelings about boredom. Burns & Grove (2007) express that it requires few participants in a qualitative study in order to achieve saturation of data which is rich in content.
Data Collection Techniques
Empirical data will be gathered to explore the concept of ‘boredom’ and critically analyse its causes and consequences in relation to patients within an acute psychiatric ward. Recommendations on how to alleviate boredom from the patient’s perspective will also be generated from the data. The most suitable data collection technique will therefore be Focus Group interviews. These will be carried out in groups of 6 and the number of Focus Groups will be dependent on the number of volunteers participating. An open-ended interviewing technique will be utilized to enable the patients to freely articulate their views.
Moule & Goodman (2008) highlight that using focus groups to acquire this type of data have the benefit of being less time consuming and participants may contribute more within a group situation. In addition Focus Groups are of benefit when dealing with sensitive information, however they can lead to ‘group think’ where the more vocal members of the group exert more influence over what is said (Speziale & Carpenter 2007). The groups will therefore require an expert facilitator to ensure that all participants have the opportunity to take part. The sessions will be audio-taped to provide a more comprehensive account of the patients’ individual views, as well as a collective description (Bryman & Bell, 2003). This avoids writing field notes and allows the researcher to observe the groups non-verbal communication, as well as concentrate on the subject matter.
Data Analysis
The researcher will code the data to find patterns and extract and formulate themes that emerge from the transcript. This is a form of thematic analysis described by Holloway & Wheeler (2002). Speziale & Carpenter (2007) purport that to gain knowledge of the data an in-depth structured analysis is necessary.
Ethical Issues
Ethical issues such as harm to participants, lack of informed consent, privacy and deception should be considered when carrying out a study (Bryman & Bell, 2003). The benefits of utilising themes will be that the researcher can analyse the data to eliminate bias, to ensure that it is factual, open and honest. To further eliminate bias two researchers will analyse the data, negotiate the narrative and generate themes which emerge. Furthermore, this will enhance the validity and reliability of the data. To reduce the possibility of disclosure of data the information will be kept in a locked cabinet. To ensure confidentiality is respected as much as possible, participants should be reminded not to disclose information from the group in other settings (Holloway & Wheeler, 2002). Adequate information will be given to participants about the study and they should be informed that they can withdraw from the study at any time if they wish (Newll & Burnard, 2006). All participants will require signing an informed consent form in order to participate. An information leaflet will be given to each participant highlighting the purpose of the study. Creswell (1998) suggests that this protects against deception of the purpose and nature of the study. The researcher will seek approval prior to commencement of the study through the Research Ethics committee to ensure that a strict ethical code of conduct is adhered to. This is important when patients are included within a study (Newell & Burnard, 2006).
Conclusion
In conclusion, the topic of boredom was successfully explored within this the literature and valuable learning of the causes and consequences of boredom have been gained. I have learned from carrying out this independent study and by reviewing the literature that nurses have a vital role to play in alleviating boredom within acute settings and the benefits of building on research that has already been done. I now have a better understanding of those clients who have voiced that they are bored within the ward and the many different reasons for this. In addition I have learned how to think critically about a topic, and it has raised my awareness of the underlying principles of research and the benefits and limitations of different approaches. Furthermore, I am able to understand how to utilise various methods of research to study a phenomena, and the differences between quantitative and qualitative data. The knowledge I have acquired from critiquing literature and formulating a Research Proposal has extended my knowledge base about the topic chosen by improving my knowledge of research, will enable me to improve nursing practice and patient outcomes. By working in collaboration with my lecturer I have been able to build my confidence in carrying out this independent study due to the support and encouragement I have received during consultations. My time-management and organisational skills have improved by carrying out this research and I have become more structured in undertaking academic work. Although I have had much support, I have learned to work more independently which has enabled me to gain more confidence in carrying out further research in the future as a mental health nurse and educator.
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