Mental Health Professionals' Perceptions of Difficult Psychiatric Situations: A Brief Report on Development of the Psychiatric Situations Scale
G Palmer, A Boykin, K Lythgoe, D Bizzell, D Daiss
attitude of health personnel, interpersonal relations, medical staff, mental health
G Palmer, A Boykin, K Lythgoe, D Bizzell, D Daiss. Mental Health Professionals' Perceptions of Difficult Psychiatric Situations: A Brief Report on Development of the Psychiatric Situations Scale. The Internet Journal of Mental Health. 2005 Volume 3 Number 1.
Mental health professionals are faced with a variety of stressors that occur in the work environment. In mental health settings, most employees encounter situations in their careers that are uncomfortable or distressing. In general, each individual responds in a slightly different manner to each presented situation; and each individual may report a different level of discomfort to similar situations. A variety of factors might influence a professional's response to stressful situations including past work experiences, professional training, and each individual's personality style. The potential for staff turnover and burnout caused by significant discomfort when dealing with coworkers and patients is high (1).
In the mental health setting, appropriate interactions between staff members and their patients, coworkers, and supervisors are important for improved quality of services. However, developing the skills to interact appropriately in the work setting can be challenging. In fact, many educational programs for health care professionals do not provide extensive training and preparation regarding interpersonal interactions in the work environment. Additionally, there is little research available to assess which types of interactions might be perceived as most difficult for persons in mental health professions.
Few inventories have been developed to assess difficult interpersonal situations in a number of areas. One group of researchers developed the Gay and Lesbian Oppressive Situations Inventory- Frequency and Effect (GALOSI-F and GALOSI-E) (2). This inventory was designed to measure negative situations often encountered by gay and lesbian singles and couples. In the area of medical and patient care, the Threatening Medical Situations Inventory (TMSI) was developed to measure cognitive confrontation and avoidance within the area of medical threat (3). Although not specifically designed to measure difficult interpersonal situations, the TMSI was designed to address differences in coping styles in response to medical situations.
Although scales have been developed to assess perceptions regarding difficult interpersonal situations, few human service researchers have attempted to assess staff perceptions of difficult employment situations. Dunn, Umlauf, and Mermis were perhaps the first researchers to address staff perceptions of difficult work situations. The authors developed the Rehabilitation Situations Inventory (RSI), which was designed to measure staff perceptions of difficult behavioral situations in a rehabilitation setting (4). The measure had good internal reliability and later subscale development revealed a six-factor structure (5). Research with the RSI has been conducted with medical students (6), students in health professions (7), and rural versus urban college students preparing for human service professions (8). Findings generally revealed no significant differences between disciplines and scores on the RSI. However, years of employment in disability care produced significant differences between groups on the RSI.
To date, there has been no specific measure developed specifically for mental health professionals to identify which staff-coworker and staff-patient interactions are most difficult. Further, there is no specific outcome-based evaluation that adequately measures a program's ability to modify perceptions of professionals in dealing with difficult interpersonal encounters in psychiatric settings. Outcome-based evaluation is important for many purposes including analysis of a program's effectiveness and cost benefit (9). The purpose of this study is to present development of a scale designed to measure staff perceptions regarding difficult psychiatric situations, the Psychiatric Situations Scale. The authors sought to develop a reliable measure that serves as a preliminary step in developing an outcome measure for the evaluation of staff training.
The first author met with members of several disciplines including psychology (
The Psychiatric Situations Scale then was completed by 115 staff members from 3 major disciplines- medical, mental health, and administrative. Scales were distributed to those who provided inpatient and/or outpatient services in the Midwestern and Eastern regions of the United States. Respondents in all disciplines had significant exposure to persons with mental health needs. Demographic characteristics of the sample according to discipline can be found in Table 1.
The respondents were asked to rate each statement on a Likert scale anchored by “1 = situation was least disturbing or not applicable to a particular position of employment” to “5 = situation was most disturbing.” Items generally pertained to staff- patient interaction (e.g., patient threatens to kill staff), staff- staff interaction (e.g., coworker frequently calls in sick for his/her shift), or staff-supervisor interaction (e.g., psychologist/psychiatrist overrides healthcare workers' recommendations).
Statistical analyses were conducted with SPSS Version 13.0 (10). Interquartile ranges were calculated to assist with item reduction. Once reduction of the number of items was conducted, internal reliability was conducted with split-half reliability and Cronbach's alpha coefficient (11). Finally, a series of one-way analysis of variance (ANOVA) were calculated to assess significant differences between Psychiatric Situations Scale total scores of groups based on occupation (i.e., medical, mental health, and administrative), gender, and years of experience in the mental health profession. In regards to occupation, it was hypothesized that total scores on the Psychiatric Situations Scale might be significantly different between medical, mental health, and administrative groups due to types of experiences/interactions in mental health settings. In the area of gender, the authors predicted that there would be no significant differences based on gender. Finally, it was hypothesized that those individuals with more experience would have significantly less discomfort to items on the scale. Therefore, Psychiatric Situations Scale total scores were expected to be lower for those with more experience in the mental health field.
Reduction of the original 69 items was accomplished by examining the interquartile ranges of each item. Items were eliminated if the item had an interquartile range of less than two between the 25th and 75th percentile. Items with interquartile ranges greater than or equal to two were chosen because they were considered to have sufficient variation to allow for discrimination between groups of respondents. Of the 69 original items, 42 items met this criterion. Remaining analyses were conducted only on the 42 items. The 42-item version of the Psychiatric Situations Scale is provided as an Appendix.
Internal reliability was calculated by two different methods. First internal reliability was calculated using Cronbach's coefficient alpha (α = .93). Then, the split-half correlation coefficient between first and last half of the items of the scale were calculated (
A series of one-way analyses of variance (ANOVA's) were conducted; and Bonferroni adjustments were calculated for multiple comparisons (
The Levene's test was used to confirm the assumption of homogeneity of variances between male (
A series of a priori two-tailed
Table 3 lists items perceived to be the top three most difficult situations by medical, mental health, and administrative disciplines. For medical and mental health professions, the top two items pertained to patient threats of harm to the professionals, other staff, or their families. For the administrative sample, only one of the top two items pertained to threats by patients to harm the employee or their family.
This paper presents preliminary findings regarding development of an instrument designed to assess the perception of difficult psychiatric situations by mental health professionals. The Psychiatric Situations Scale was developed and tested among members of three mental health disciplines (i.e., medical staff and professionals, mental health professionals, and administrative staff who deal directly with persons who have mental health needs).
One important finding regarding analysis of the instrument was that mean scores on the Psychiatric Situations Scale were significantly lower for the Administrative group when compared to the Medical and Mental Health groups. This finding suggests that of the 42-items comprising the instrument, the Administrative group found the items less distressing/uncomfortable than the other groups. One explanation for this finding is that Administrative professionals were less likely to encounter the psychiatric situations described in the Psychiatric Situations Scale.
There were several limitations of the study. One limitation of the study was that the sample was one of convenience. Additional reliability and validity studies will be necessary in order to determine usefulness of the tool for medical, mental health, and administrative professionals. The Psychiatric Situations Scale could be potentially applicable as an evaluation tool in both inpatient and outpatient psychiatric settings. Also, a professional's perception of a variety of psychiatric situations does not necessarily translate into lack of skill in dealing with a difficult situation. As pointed out in previous research, a professional's skill level or competence at performing job duties improves at a faster rate than perceived comfort with difficult interpersonal situations encountered in the job setting (4,12,13).
Another limitation of the study was with the scaling of the original 42-item instrument (i.e., scaling of 1 = situation as least disturbing or not applicable to particular position of employment). This might have presented a measurement problem by artificially inflating the variance of the scale. Therefore, the scale is presented in the Appendix with a “not applicable (N/A)” scaling option. Future research is necessary to assess the utility of the new scale with the “not applicable (N/A)” scaling option.
Due to the small sample size, exploratory factor analysis was not conducted to determine what type of factor structure exists. Content of the Psychiatric Situations Scale suggests items pertain to one of three factors including staff-patient interaction, staff-staff interaction, and staff-supervisor interaction. However, exploratory analysis with a large sample is necessary to determine the exact type of factor structure. If different subscales are found, the subscales might provide specific areas of focus for staff training; and the Psychiatric Situations Scale might prove useful in order to further assist with evaluating staff training programs. Furthermore, subscale development could provide important information regarding perceptions of different mental health disciplines.
Future research is necessary to assess whether mental health professionals who go through training to increase competence and reduce discomfort in difficult psychiatric situations will have lower scores on the Psychiatric Situations Scale. Preliminary analysis suggests that the Psychiatric Situations Scale may prove to be useful in the measurement of challenging psychiatric situations, in the face of the mental health professional's comfort.
In conclusion, this study presents the preliminary construction and analysis of reliability for a scale measuring discomfort with situations often encountered in mental health care. The study also provides an important first step in the construction of a scale to assess staff's level of comfort in difficult interpersonal situations. The ultimate objective for the development of this particular scale is to eventually produce an outcome measure for staff training, as well as to identify which situations should be emphasized in staff training.
Glen A. Palmer, Ph.D. Lanning Center for Behavioral Services Mary Lanning Memorial Hospital 715 North St. Joseph Avenue Hastings, NE 68901 E-mail: firstname.lastname@example.org