Professional Documents
Culture Documents
010363
(Laudet 2004), in substance misuse more generally Rachel Steele is a clinical librarian
Summary with Tees, Esk and Wear Valleys
(Corvinelli 2005) and in absconding from
Many psychiatric in-patients report boredom. Such NHS Foundation Trust. Her main
psychiatric hospitals (Bowers 1999). Although interests include the emerging
complaints may appear trivial, but this literature
the possible association between boredom and role of the clinical librarian/
review by a clinical librarian suggests that boredom
psychiatric disorders is complex, Newell et al informationist in leading and
is more complex than may initially appear and relates facilitating access to the evidence
to wider areas of importance for in-patient psychi (2012) found a correlation between depression
base in all aspects of mental health
atric teams. Boredom may relate to the internal and boredom, and Todman (2003) argues that services, as well as educational/
experience of meaning, which itself encompasses boredom may be a prodromal marker in psychosis. CPD interventions to develop
meaningful relationships and roles and a sense of The experience of boredom therefore has much health professionals’ skills in
using evidence in their practice.
control. Although meaningful therapeutic activities wider implications than may initially appear.
Paul Henderson is a consultant
are vital, mental health professionals should focus psychiatrist, Frances Lennon
on the internal as well as the external dimensions Why ask a clinical librarian? is an occupational therapist and
of boredom. Medications, particularly dopamine Donna Swinden is a modern
antagonist antipsychotics, may be a contributing As this article is one of many outputs from the matron, all based at the time of
factor. This article highlights the benefits of the TEWV Clinical Librarian Project, it is appropriate writing in an adult acute in-patient
to highlight briefly the rationale for the initiative. service of Tees, Esk and Wear
clinical librarian role in synthesising research
Valleys NHS Foundation Trust.
in mental health. Research can illuminate psy Clinical librarians have been in existence for
Correspondence Rachel Steele,
chiatric practice in a more holistic way than purely around 40 years. They provide research summaries Library and Information Service,
by applying ‘scientific’ evidence in the practice of to support clinical decision-making and to inform Education Centre, Lanchester Road
‘biological’ psychiatry. strategy and changes. Hospital, Durham DH1 5RD, UK.
Email: rachelsteele@nhs.net
Declaration of interest There have been very few clinical librarian
None. projects in mental health. A notable exception is
a study by Gorring et al (2010), which concluded
that the clinical librarian role can be effective in
This critical literature review on boredom arose out implementing evidence-based psychiatric practice
of a pilot clinical librarian/informationist project in clinical teams.
in Tees, Esk and Wear Valleys (TEWV) NHS Davidoff & Florance (2000) acknowledge the
Foundation Trust. At the time of writing, the lead contributions that clinical librarians can make in
author (R.S.) was clinical librarian/informationist stimulating access to the evidence base, pointing
for four pilot teams in the trust. One of these out that many now read the literature and write
teams includes a consultant psychiatrist (P.H.), brief synopses of papers to present on ward rounds
a modern matron (D.S.) and an occupational and at conferences.
therapist (F.L.) in an adult acute in-patient service. During the TEWV Clinical Librarian Project,
The consultant psychiatrist suggested that R.S. it soon became apparent that clinicians valued
consult the research evidence base to illuminate the role of an information specialist/librarian
in-patients’ reports of ‘boredom’. The body of this who could critically appraise and synthesise
article, including the conclusions, has been written research, as well as the more traditional role of the
by R.S., with commentaries by P.H., F.L. and D.S. healthcare librarian, which focuses on information
searching.
Is in-patient boredom important?
Boredom is a topic that has received little
Benefits and uses of evidence syntheses
empirical attention in clinical settings (Goldberg in mental health
2011). Although patients’ complaints that they are This article is an instructive example to consul
‘bored’ may sound trivial, there is some (although tant psychiatrists of the benefits of the clinical
limited) evidence that boredom is associated with a librarian’s evidence-synthesising role, and
range of illnesses and dysfunctional behaviour, for consequently of research evidence synthesis, to
example as a trigger for relapse in dual diagnosis mental healthcare.
259
https://doi.org/10.1192/apt.bp.112.010363 Published online by Cambridge University Press
Steele et al
260 Advances in psychiatric treatment (2013), vol. 19, 259–267 doi: 10.1192/apt.bp.112.010363
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Boredom among psychiatric in-patients
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Steele et al
treatment offers advantages over individual Caddy et al (2011) reported that participation in
therapy for voice-hearers. Place et al ’s successful creative activity groups positively correlated with
therapeutic partnership approach could therefore improved mental health in an acute in-patient
be replicated in ‘hearing-voices groups’ which psychiatric hospital in Australia. However, they
could address in-patients’ needs for meaningful pointed out that not everyone finds such groups
relationships with staff and other patients. meaningful or beneficial, so group allocation
should reflect the needs of individual patients
Having meaningful roles (p. 331).
There may also be a role for partner organis
Binnema (2004: p. 839) argues that offering
ations who could ‘in-reach’ to meet patients’
psychiatric patients the opportunity to take on
needs for meaningful activities while in hospital
meaningful roles while in hospital may give them
and provide continuity of therapeutic input after
a sense of meaning and therefore empowerment.
discharge. There are limited examples of partner/
Such roles could be provided through purposeful
voluntary organisations working in this way, but
activities. Indeed, NICE stresses that psychiatric
Thomas et al (2012) report a successful voluntary
in-patients should have access to ‘meaningful
activities programme that complements statutory
and culturally appropriate’ activities (National
child and adolescent mental health services. The
Institute for Health and Clinical Excellence 2011:
service user whose experiences are described in
p. 118). Antoniou’s (2007) experience as a service
Box 2 also highlights the benefits of continuing
user supports Binnema’s assertion that boredom
therapeutic activities pre- and post-discharge.
may be linked to the absence of meaningful roles
or roles that patients are used to when not in
Having a sense of control
hospital. She writes:
The need of patients to have a say in the activities
‘There are two sorts of “boring” on the ward. One
and occupations offered on the wards has been
is caused by having lots of hours to fill and not
having the things one usually has to fill them up recognised by NICE (National Institute for
with because one is not at home […] It is possible to Health and Clinical Excellence 2011). Binnema
be bored on the ward even when there are activities (2004) likewise argues that ‘Loss of control […]
planned every hour, and not to be bored when doing is related to decreased mental health. Conversely,
nothing’ (Antoniou 2007: p. 33).
empowerment […] and thus decreased boredom,
This argument is potentially relevant to ward- is related to increased mental health’ (p. 836). He
based group activities. Simpson et al (2005) acknowledges that loss of control is intrinsically
reported that some nurses, ward managers and related to the nature of psychiatric illnesses, but
psychiatrists saw the occupational therapist’s also argues that authoritarian psychiatric nursing
role as largely focused on group activities: ‘Often may encourage patient dependency. The challenge
these were seen as predominantly diversionary is to empower patients by harnessing the potential
or time-filling activities, with the more explicitly of the hospital therapeutic environment.
therapeutic functions […] rarely acknowledged’ Farnworth et al (2004) cite the example of
(p. 547–8). Newell (2009: p. 26) believes that a service user who was dissatisfied with ward
organised group activities deal only with external occupations but felt that he had learnt how to gain
components of boredom, so the provision of more control over his time. Interestingly, they note that
activities does not necessarily reduce complaints he was the only participant interviewed who said
of boredom. that he was ‘quite happy with [his] life’ (p. 435).
If activities do not provide opportunities to If a lack of control is related to boredom, we
experience meaningful roles, then it is unlikely might expect there to be an association between
that they will exert their full therapeutic effect. autonomous activities and reduced boredom.
Farnworth et al (2004), in a naturalistic inquiry Indeed, Newell et al (2012) reported that, although
study involving eight patients in an Australian there was an association between in-patients’
secure forensic psychiatric unit, found that engagement in autonomous activity and decreased
popular groups offered ‘a specific purpose and self-reports of boredom, ‘There was no evidence of
outcome’ or encompassed ‘novelty, creativity or any relationship between boredom proneness and
nonverbal components to performance’ (p. 435). organised activities’ (p. 6).
For example, the ‘cook your own meal’ group had Given the importance of autonomy, Newell
a waiting list. However, many of the activities et al (2012) hypothesised that involuntary in-
on offer seemed to lack ‘novelty, challenge and patients would be more prone to boredom.
personal meaning’ and patients thought them However, their study indicated the opposite. A
boring or ‘old hat’ (p. 435). potential confounder was that more voluntary
262 Advances in psychiatric treatment (2013), vol. 19, 259–267 doi: 10.1192/apt.bp.112.010363
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Boredom among psychiatric in-patients
than involuntary patients were diagnosed with may contribute to a lack of drive, and consequently
depression and ‘depression is highly correlated boredom, in people with schizophrenia because
with proneness to boredom’. We return to the of the nature of the negative symptoms of the
complex relationship between depression and disorder. However, studies of healthy volunteers
boredom in ‘Associations between boredom and offer indications. Artaloytia et al (2006) reported
psychiatric diagnoses’, below. that single doses of haloperidol, and particularly
As numerous authors (e.g. Simpson 2005; Hitch of risperidone, produced negative symptoms in
2009) argue, occupational therapists are often healthy volunteers. Park et al (2012) likewise found
dismayed to receive referrals of patients who that a single dose of risperidone induced negative
are ‘bored’, believing that this shows a limited symptoms (including increased avolition), although
understanding of their role. Shattell (2007) also they concluded that haloperidol, amisulpride and
notes that many nurses react negatively to patients’ aripiprazole did not.
boredom, saying that their role is not ‘to entertain It is therefore worth considering medication as
patients’. However, Newell (2009: p. 27) believes a possible contributor to boredom when reviewing
that ultimately ‘we should be helping our service drug choice and dosage.
users to address boredom for themselves’.
Associations between boredom and psychiatric
Medication and boredom diagnoses
In examining boredom, it is difficult to disentangle Newell et al (2012) investigated proneness to
the effects of medication from those of psychiatric boredom in a cross-sectional sample of 55
illness, but there is some evidence that medication psychiatric in-patients. The study should be
could be a contributing factor independent of psy regarded as preliminary because of its design
chiatric disorder. Healey (2009) notes that almost and small sample, but as far as we know it is the
all antidepressants ‘can be somewhat sedative’ and only study that has investigated the prevalence
that with selective serotonin reuptake inhibitors of boredom in adult psychiatric in-patients. The
(SSRIs) ‘there may be a paradoxical coexistence of authors concluded that the three variables most
feeling drowsy or fatigued’ (p. 70). He also points predictive of boredom were having depression,
out that the sedative effect of all benzodiazepines anxiety or perhaps a personality disorder.
except clobazam is well documented (p. 154). If The possible association/relationship between
we consider theories of situation-dependent bore boredom and psychiatric disorders is complex.
dom, which stress the centrality of environmental Clinicians may mistake boredom for depression
conditions, then the sedative/attention-impairing or negative symptoms of schizophrenia, but
effects of these medications could contribute to boredom does seem to be a distinct phenomenon.
patients’ experiences of environmental sameness Goldberg et al (2011), in a cross-sectional sample
and thus feelings of boredom. Internally driven of underg raduates, reported higher correlations
theories positing a link between boredom and between boredom and depression than between
inattention may also be significant (Eastwood boredom and apathy or anhedonia, but found that
2012; Malkovsky 2012). If medications induce depression and boredom were empirically distinct.
sedation, and consequently impair attention or Todman (2003) argues, on the basis of clinical
concentration, this may also be a contributor to and non-clinical empirical studies and case studies
boredom. of out-patients with psychosis, that boredom may
The antipsychotics are also a potentially be a prodromal marker in psychosis but that this
significant contributor because of their blocking may work in a heterogeneous and sometimes
of the D2 dopamine receptor. The mesolimbic non-intuitive manner. He argues against the
dopamine pathway is important for motivation, implicit assumption of the vulnerability–stress–
pleasure and reward, as well as the positive coping model of schizophrenia, i.e. that external
symptoms of psychosis (Stahl 2008: p. 272). Wise stimulation should be reduced. His reasoning is
(2004) concludes that ‘brain dopamine seems to that, although some patients may be motivated
“stamp-in” response–reward and stimulus–reward to avoid excessive stimulation, others (especially
associations that are essential for the control of in partially or fully remitted states) may be as
motivated behaviour by past experience’ (p. motivated to avoid unstimulating environments
10). Flaherty (2011) also argues that ‘Creativity as non-psychotic individuals. However, as this
depends on goal-driven approach motivation from theoretical assertion is based on single cases
midbrain dopaminergic systems’ (p. 132). (albeit with reference to prior research), further
It is difficult to determine the extent to which investigation is needed about the potential value
the dopamine antagonist effects of antipsychotics of boredom as a prodromal marker in psychosis.
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Steele et al
Implications for practice in adult acute questions that arise during MDT discussions. The
in-patient services exploration of boredom is a particular example of
this, as we have an extensive activity programme
Specialist commentary by Paul Henderson, for our acute wards, with a variety of group and
consultant psychiatrist individual sessions, plus an on-site gymnasium.
Before commenting on the clinical content of the Our intensive support team also access community
article, I think it is important to highlight the facilities, so we were rather puzzled when we often
TEWV Clinical Librarian Project in general. As received negative feedback citing lack of activities.
a newly qualified consultant working in a busy We regularly ask during patient ward meetings
general adult ward, the variety of presentations whether there are any other activities that patients
I see, the rapidity with which they present, and would like to participate in, but we receive very
the multitude of pressures on my time mean that few suggestions. This led us to consider a number
it has simply not been feasible to be as up to of explanations – for example, lack of usual
date across as wide a variety of topics as I would routine, that illness may prevent patients engaging
like. This has probably been the greatest source in activities, or that some people will be bored
of professional and personal discomfort in my whatever activities are on offer.
short consultant career thus far. As an addition The evidence base produced by the clinical
to the multidisciplinary team (MDT), the clinical librarian confirms to some degree our suspicions
librarian has made a significant impact in this and led to some useful discussions of how we
area, both for myself and the wider team, with might address the problem of boredom. It has
junior colleagues, nursing staff, occupational prompted the team to make more use of the
therapists and psychologists all making use of patient workbook so that patients can state their
the service she provides. When compared with all own interests and ideas of what would help them.
the other aspects of clinical governance the MDT We have also implemented a handover between
practises, I have no doubt that the addition of the nursing staff and intensive support staff every
clinical librarian to the team has made the single morning making use of the patient’s workbook,
largest improvement. so that intensive support staff are better informed
My motivation to ask the clinical librarian as to what activities/interventions might be best
to provide an evidence summary on boredom for the individual on that particular day. Our
was that I had become increasingly aware of the intensive support team also monitor the uptake
apparent dichotomy that ward staff appear to be of activities, recording when patients have been
constantly rushing, but many patients complain of offered an activity and have declined it. We are
being bored; and that, because of time pressures, waiting to see whether our patient experience
my own practice was becoming more and more surveys will reflect these changes. We have also
focused on the biological aspects of treatment. In introduced more formalised protected therapeutic
the context of constant pressure to promote a more time so that patients can have more one-to-one
therapeutic environment, with a view to shorter time with the nursing team. We managed this by
hospital stays, it appeared to me that a broader limiting MDT meetings to specific times of the
perspective would be helpful. day. This was introduced at the start of 2012 and
While I am not suggesting that a sole focus on is working well.
reducing patients’ boredom is sufficient, or indeed A further benefit of the TEWV Clinical Librarian
necessary, the richness and nuances of the con Project is that the whole team, from nursing
cepts in this article have certainly provided fresh assistant through to consultant psychiatrist,
and interesting ideas for the whole in-patient MDT become involved in discussions and generate ideas.
to work on together. The insights into internal This has enabled staff who do not traditionally
and external factors, as well as the probable access research, or who do not have the time to do
superiority of autonomously driven activities, as so, to become familiar with literature reviews and
opposed to generic group activities, have certainly experience their usefulness.
significantly informed the ceaseless process of
change that we are engaged in. Specialist commentary by Frances Lennon,
occupational therapist
Specialist commentary by Donna Swinden, We would not usually see our own activities as
modern matron simply ‘occupying’ or ‘filling in’ time. We can be
The TEWV Clinical Librarian Project has been just as ‘bored’ when doing an activity that has no
very beneficial to the clinical ward teams as it has meaning or purpose to us as doing nothing at all.
enabled us to quickly access the evidence base for Occupational therapists aim to empower people
264 Advances in psychiatric treatment (2013), vol. 19, 259–267 doi: 10.1192/apt.bp.112.010363
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Steele et al
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Acknowledgements staff perceptions. International Medical Journal 18: 163–6.
R.S. would like to thank Catherine Ebenezer and Laudet AB, Magura S, Vogel HS, et al (2004) Perceived reasons for
Bryan O’Leary for their support and encourage substance misuse among persons with a psychiatric disorder. American
Journal of Orthopsychiatry 74: 365–75.
ment in the writing of this article. All four authors
Malkovsky E, Merrifield C, Goldberg Y, et al (2012) Exploring the
thank the service user who kindly provided a relationship between boredom and sustained attention. Experimental
patient perspective in Box 2, and Advances peer Brain Research 221: 59–67.
reviewers for their valuable comments. Martin M (2008) The phenomenon of boredom and its relationship to
mindfulness. British Journal of Occupational Therapy 71: 154.
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