A pilot study on the use of the telephone in an acute psychiatric service

Greater care in the community will lead to the geographic dispersal of psychiatric services and the role of communications technology will become increasingly important. McLaren et al (1991) described the potential role for new communications technology, such as interactive television, in the provision of psychiatric services but before resorting to new communications technology it will be import ant to ensure that full use is being made of existing technology such as the telephone. The telephone is widely used in the UK health service but poorly understood, in contrast to the USA where it has been recognised as an important medium for care delivery (Hallam, 1989). This pilot study was designed to gather information on the current role of the telephone in an acute psychiatric service and to aid the planning of the use of more advanced communications technology such as interactive television.

Greater care in the community will lead to the geographic dispersal of psychiatric services and the role of communications technology will become increasingly important. McLaren et al (1991) described the potential role for new communications technology, such as interactive television, in the provision of psychiatric services but before resorting to new communications technology it will be import ant to ensure that full use is being made of existing technology such as the telephone. The telephone is widely used in the UK health service but poorly understood, in contrast to the USA where it has been recognised as an important medium for care delivery (Hallam, 1989). This pilot study was designed to gather information on the current role of the telephone in an acute psychiatric service and to aid the planning of the use of more advanced communications technology such as interactive television.

The study
A naturalistic observational approach was used. Two acute psychiatric wards in the same unit were chosen for study. The unit was sited in a large general hospital and served a deprived inner city catchment area. The telecommunications system in the general hospital had recently been updated. The obser vations were recorded by two psychiatrists, each allo cated one of the wards. They observed in four hour blocks, one block per day, to ensure that each period between 09.00 and 21.00 was observed once on each ward. They were both asked to record the time each telephone call was made. The observer on ward A was asked to record the nature of the call and if possible other communication occurring in the ward office. The observer on ward B was asked to concen trate on face-to-face communication and if possible record the nature of the calls. While recording, the observer sat in the ward office positioned to minimise disruption to staff.

General observations
Both observers recorded a rich flow of communi cation within the nursing offices suggestive of a preference for face-to-face contact. On ward B much useful clinical information on current patient status was exchanged informally between members of the nursing staff. On ward A the medical staff appeared on the ward at several unexpected times and dis cussed patients with nursing staff in an informal manner. Such exchange of information between staff appeared to take place much more fluently than during the formal nursing shift handovers or ward rounds. During the observation period no emergencies arose on either ward.

Telephone use
The mean number of incoming calls per 12 hour period for the two wards equalled the mean number of outgoing calls (33.5), giving an average cell rate of 2.8 per hour for both. The temporal patterns of the calls differed depending on whether they were out going or incoming. The incoming calls showed an initial peak of 7 (09.00-10.00) followed by a steady rate of between 0.5 and 4 per hour (mean 2.3) over the 12 hour period studied. Outgoing calls also showed an initial peak, 9 (0900-10.00), 8.5 (10.00-11.00) but fell offduring the afternoon and evening (range 0-4; mean 1.6)

Parties and reasons for calling
These results are reported in detail for ward A. The most frequent calling dyad, combining calls in and out, was nurses calling nurses within the hospital (27%). Thirteen per cent were nurses speaking to ancillary staff such as porters. Twenty per cent were nurses making administrative contacts, for example to order agency nursing staff. Of the incoming calls, the highest number were of nurses contacting nurses (36%) followed by personal calls for nurses (18%) and calls from patients (15%). Nurse-doctor contact was only 4% of the total. The results for ward B were incomplete as a consequence of the study design but similar trends were observed on inspection.

Comment
The quantitative results should be interpreted with caution as there are several possible sources of bias. The presence of a psychiatrist in the ward office may have influenced the calling out behaviour but should not have influenced the calling in. Differences in the face-to-face communication between doctors and nurses were noted between the two wards and this may have resulted in differences in the reasons for calling on ward B not detected with this study design. Hallam (1989) distinguished administrative and consultation calls in primary care and these results support that distinction. They suggest that in this service the telephone is used primarily for simple administrative tasks with a low but significant rate of consultation calls, patients calling to seek advice from nursing staff. The absence of calls from relatives may reflect the low level of family support available to this inner city patient group.
Both observers reported the impression that clinical information was often exchanged informally in the ward office.This may have been a consequence of the personal styles of the staff involved; however similar observations have been made concerning communication in industry and it has been reported that "real" decisions are made during informal chats outside official meeting rooms.
Despite its small scale, this study illustrates the complexity of the communications network centered on the acute psychiatric ward and the importance of gaining an overall picture of the different channels of communication used. If the informal clinical communication observed is substantiated by further study it will present a considerable challenge for the future use of communications technology in a dispersed service. It is unlikely that such communi cation will be effectively reproduced over interactive television as this is likely to require scheduled contact. More regular and more formal contact may have to take place through such communications technology to compensate. Such communication, intermediate between the formal ward round and in formal appearances on the ward, has been described by Kennedy & Hird (1980) in their study of a shortstay admission ward. To improve the efficiency of communication they arranged for the consultant to attend an extended "Kardex meeting" at the beginning of each day. Egido (1988), discussing the disappointing impact advanced communications technology has made in industry, emphasised the need to understand the culture of the organisation where the technology is to be used. The study design reported above offers one possible way of gaining such understanding in an acute psychiatric service. In particular, the relation ship between the use of the telephone, informal face-to-face communication and formal face-to-face contact such as handovers needs clarification. If the restricted administrative role of the telephone is confirmed by further study it may be that an extended role for the telephone should be explored before more advanced communications technology, such as interactive television, is introduced.