Proposed change in service delivery and stress among nursing staff

in examined in a naturalisticand study,which prospec-tively conducted. Results A positiveassociationbetween the organis ational change of the proposed closureand relocation of a psychogeriatric ward and stressamong the nursing staff as measured by the General Health Questionnaire wasdemonstrated. Clinical implications Policy-makers,purchasersand providersneed to consider the Implication of such stress and develop strategies to minimise stressprior to any major policy change. Aims and method A prospective study was undertaken to evaluate the effect of a stamped addressed envelope, as compared to a non-stamped but ad dressed envelope or no envelope, on response to a mailed questionnaire. The correlation between ques tionnaire response and subsequent attendance at the first appointment was also studied. Results The overall response rate was 26% of 176 families offered first appointments at a local child psychiatry service. Families provided with a stamped addressed envelope were more likely to return their questionnaire and those families who returned the ques tionnaire were more likelyto attend their firstappointment. Clinical implications The return of patient question naires has significant clinical and resource implications. Only essential questionnaires should be sent out to referred families as nearly three-quarters will not be returned. The return rate can be enhanced by provid ing a stamped addressed envelope but, if question naires are not returned within 10 days, the likelihood of return is minimal. As more than half of the families who failed to return the questionnaire also failed to attend their first appointment, questionnaires can be used as a measure of motivation and likelihood of attendance as well as a source of clinical information.

the stimulus intensity where necessary to com pensate for effects of medication.
A third way in which supervision of ECT sessions may be beneficial is in helping to make decisions about restimulating patients when doubtful seizures have been achieved, and adjusting dosage settings at subsequent treat ments. It is not easy to do this effectively without being present at the majority of sessions, and observing the response of patients to treatment.
The doctor who supervises ECT also has a more general role in educating medical and other groups of staff about correct use of ECT, and drawing up protocols for use in the ECT clinic. The Royal College of Psychiatrists (1995) recom mend that dedicated time be provided to perform these duties.
I do not doubt the superiority of newer ECT machines such as the Thymatron DGx in allowing ECT to be more flexibly tailored to individual needs, in treating patients with higher convulsive thresh olds and in allowing closer monitoring of treatment. This study shows, however, that it is possible to improve the delivery of ECT substantially by care fully supervising and monitoring the use of existing equipment. Proposed change in service delivery and stress among nursing staff

Ajit Shah and Tamal De
Aimsand method Theimpact of major organisational change in a psychogeriatric service was examined in a naturalistic and opportunistic study, which was prospectively conducted. Results A positiveassociationbetween the organis ational change of the proposed closure and relocation of a psychogeriatric ward and stressamong the nursing staff as measured by the General Health Questionnaire was demonstrated. Clinical implications Policy-makers,purchasers and providers need to consider the Implication of such stress and develop strategies to minimise stressprior to any major policy change.
The provision of health services is constantly evolving to incorporate legislative changes, eco nomic factors and scientific developments. Several recent legislative changes in the National Health Service (NHS), including the NHS and Community Care Act 1990, have resulted in major changes in health service provision. The impact of such changes on NHS staff has been poorly examined. Nursing staff left behind in large psychiatric hospitals during deinstitution-alisation experience burn-out, poor morale and stress (Lamb, 1977;Mendal, 1979). The closure of a continuing care psychogeriatric ward, initiated by the local NHS purchasers, offered a natural experiment to exam ine the effect of impending organisational change on stress among the nursing staff during the course of another study.

The study
Location This study was performed in a 24-bed psychogeriatric continuing care ward at a London district general hospital serving a catchment area of 23 000 elderly. The whole psychogeriatric service included a 16-bed acute admission ward, 10-bed respite ward and two multi-disciplinary community teams.

Measurement of stress
The original study evaluated the efficacy of an educational package in reducing aggressive behaviour among the patients and stress among the nursing staff. Aggressive behaviour was continuously measured over an 18-week period. The educational package, directed at the nursing staff, was implemented during weeks 7 to 12 (inclusive). Stress among the nursing staff was measured using the 30-item General Health Questionnaire (GHQ-30;Goldberg, 1978) at weeks 1, 7, 13 and 19. Using the conventional GHQ scoring method, a GHQ-30 score of five or more indicates a case of psychiatric morbidity (Goldberg &Williams, 1988). Brodaty &Andrews (1983) demonstrated the transience of disorders measured by GHQ-30 when serially adminis tered every two months to general practice attenders. However, in such situations long standing disorders may be missed as respon dents will score zero for chronic symptoms as the answer will be 'same as usual'. A modified scoring system called Chronicity and the General Health Questionnaire (CGHQ) has been devel oped to overcome this difficulty (Goodchild & Duncan-Jones, 1985) and the scores are said to be normally distributed. The nursing staff were first informed of the purchasers plans to close this ward and transfer patients to a private nursing home just before completion of the week 13 GHQ-30. Further details of the purchasers plans emerged in the period between weeks 12 and 18. All agency nurses and one regular nurse on long-term sickness absence were excluded.

Findings
The demographic characteristics of the 15 reg ular nurses studied are given in Table 1. GHQ-30 scores for all 15 nurses were available for weeks 1, 7 and 13. However, by week 19, two nurses had left the ward to work elsewhere; thus, only 13 GHQ-SOs were available for week 19. The predominant thrust of the proposed changes occurred between weeks 12 and 19. Thus, weeks 1 (2/15 cases), 7 (0/15 cases) and 13 (3/15 cases) GHQ-SOs were individually compared with week 19 (7/13 cases) GHQ-30 using Fish er's exact test. There was a significant increase in GHQ-30 caseness when week 19 was compared with week 1 (P=0.029) and week 7 (P=0.0014). Comparison between weeks 13 and 19 ap proached significance (P=0.07). The latter may be explained by the nurses becoming aware of the changes just before week 13 GHQ-30 and so stress levels may have increased to narrow the difference with week 19. One of the two nurses at week 1 and all three nurses at week 13 with GHQ-30 caseness were also GHQ-30 cases at week 19. There was a significant increase in CGHQ scores when week 19 was compared with week 1 (P=0.032), week 7 (P=0.008) and week 13 (P=0.006). There was no association between GHQ-30 caseness or CGHQscore at week 19 and any of the demographic factors.

Comment
This study clearly demonstrates that major changes in service delivery are associated with stress among the nursing staff. The educational package is unlikely to have influenced the GHQ-30 scores as there was no difference between week 7 and week 13 GHQ-30 scores (the educational package was offered in that period). This is consistent with reports of burn out, poor morale and stress among nursing staff during the process of deinstitutionalisation (Lamb, 1977;Mendal, 1979). Such effects can be minimised by considering the views and needs of the staff to avoid resistance and misunderstanding (Greenblatt & Budson, 1976;Towell & McAusland, 1984). Managers within this provider unit were involved in regular discussions and counselling sessions with the nursing staff for these reasons. Also, the nursing staff were given an opportunity to Proposed change in service delivery and stress among nursing staff move to the nursing home or consider other work in the provider unit. However, this may not be sufficient as the nurses perceived that their livelihood was threatened. Unless policy makers, purchasers and providers give serious consideration to the impact of such organis ation changes on provider unit staff, not only will staff experience stress but they may leave the NHS. Recruitment of staff is already a problem and such careful consideration may help retain staff.

Kate Newton, Samuel M. Stein and Clare Lucey
Aims and method A prospective study was undertaken to evaluate the effect of a stamped addressed envelope, as compared to a non-stamped but ad dressed envelope or no envelope, on response to a mailed questionnaire. The correlation between ques tionnaire response and subsequent attendance at the first appointment was also studied. Results The overall response rate was 26% of 176 families offered first appointments at a local child psychiatry service. Families provided with a stamped addressed envelope were more likely to return their questionnaire and those families who returned the ques tionnaire were more likely to attend their first appointment. Clinical implications The return of patient question naires has significant clinical and resource implications. Only essential questionnaires should be sent out to referred families as nearly three-quarters will not be returned. The return rate can be enhanced by provid ing a stamped addressed envelope but, if question naires are not returned within 10 days, the likelihood of return is minimal. As more than half of the families who failed to return the questionnaire also failed to attend their first appointment, questionnaires can be used as a measure of motivation and likelihood of attendance as well as a source of clinical information.
Questionnaires are routinely sent to all families prior to their first attendance at the Child and Family Consultation service in Baling, West Lon don. Previous studies have demonstrated an increased response rate to postal surveys if a stamped addressed envelope was included (Erdos, 1957;Veiga. 1974: Leitner et al 1979: Choi et al 1990. Mathai & Markantonakis (1990), found that sending a questionnaire might ensure better attendance of a family to a child psychiatric unit.
The hypothesis tested was that the enclosure of a stamped addressed envelope would improve both the response to a preliminary questionnaire and subsequent attendance at the first appointment.