Policy Recommendations for Interventions Against the Lack of Activities & Boredom in Psych Wards

Policy Recommendations for Interventions Against the Lack of Activities & Boredom in Psych Wards
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Abstract
Boredom is a major challenge in many psychiatry wards. This dullness occasioned by the lack of group activities are significant problems in (HMC) and many other psychiatric units. According to HMC hospital’s management, the local problem of boredom and lack of activity was raised by the patients' satisfaction survey they complete during their discharge process. A review of evidence from various databases confirm the gravity of the problem. Consequences of this lack of activities are dire and include self-harm, aggression, fighting with peers, poor patient satisfaction, and restraint. Previous studies conducted on the topic has also presented some possible solutions to the challenge including mindfulness-enhancing activities, creativity-enhancing activities, and group activities. Mindfulness enhancing activities include meditation and yoga. Creativity-enhancing activities include art, coloring, and music therapy. Group activities include bingo and group walks. Because of the current COVID-19 pandemic restrictions, this study recommends individual activities: mindfulness-enhancing activities and creativity-enhancing activities.
Introduction
The Local Problem
Boredom has several definitions and can best be understood as an affective state that leads to the lack of meaning. The condition is characterized by a state of low arousal and dullness (Marshall et al., 2020). This dullness occasioned by the lack of group activities are significant problems in (HMC) and many other psychiatric units (Bowser et al., 2018). HMC is a state hospital providing a wide range of mental health services to patients who are individuals who have experienced mood disorders, anxiety, psychosis, and substance abuse. HMC has three psychiatric units, two of which offer different kinds of group activities and psychotherapy. However, the 5MB psych ICU does not have any group activities because it deals with more acute psychotic-related illnesses. The majority of 5MB patients are admitted to the hospital involuntarily due to having a grave disability or being diagnosed as posing a danger to themselves or others. These patients are often less cooperative than those voluntarily admitted to the other two psychiatric units. The lack of ward-based activities in 5MB reduces both the patients’ care experiences and their satisfaction.
Consequently, the patients suffer from apathy and ennui behaviors that leads to self-harm and aggressive behavior towards staff or other patients, negatively affecting the patients’ well-being (Marshall et al., 2020). If patients get bored from a lack of activities, they tend to stay longer at the psych ICU. Moreover, if they are not recovering sooner, the hospital ends up having increased recovery times resulting in increased health costs. Due to this problem, the hospital has been forced to focus more resources on patients to provide them with more individual or group activities. 
According to the hospital management, the local problem of boredom and lack of activity was raised by the patients' satisfaction survey they complete during their discharge process. The topmost complaint was the hospital’s lack of activity that made the patients feel bored and listless. The patients asked for different activities and sought to go out of the unit for a walk. The situation worsened during the COVID-19 pandemic when the hospital had to implement measures to prevent the spread of the virus and, at the same time, fight against the increased psychological breakdown among new patients (Brooks et al., 2020). The usual support patients received from their family and friends were no longer available, which put additional stress on their daily lives. It’s reasonable then to expect that the introduction of individual and group activities, including yoga, music therapy, bingo, coloring, and practicing mindfulness meditation, will significantly benefit patients by helping them to decrease their ennui and experience greater joy and satisfaction during their hospital stay (reference)
Background on Boredom in the Psychiatric Unit  
When mental-health patients are allowed to engage in ward activities such as their favorite music, playing puzzle, coloring, walking with buddies, it helps improve their care experience and enhances their recovery process, while a lack of engagement in these activities is associated with aparthy (Deenik et al., 2017; Foye et al., 2020). Moreover, boredom can increase the incidences of self-harm and enhance aggressive behaviors; it has also been associated with relapses in dual diagnosis, particularly in substance misuse more generally, and escapes from psychiatric hospitals (Foye et al., 2020). Additionally, boredom is more complicated than it appears to be and plays a significant role for both the patients and the psychiatric teams that are responsible for their care. Researchers also speculated that apathy and ennui might be a significant marker of psychosis (Marshall et al., 2020). Disgust in inpatient psychiatric wards is an issue because it leads to poor patient satisfaction, triggering feelings of frustration. Previous studies involving non-clinical samples have indicated that monotony proneness is linked to various characteristics of depression, including impulsivity, aggression, anger, and hostility (Masland et al., 2020).
The literature indicates a positive correlation between a lack of activities and boredom and ennui levels, which increases the chances of patients developing unhealthy coping strategies such as violence towards themselves and others. This higher tension and increased violence levels plausibly increase the incidences of seclusion and restraint, which, in turn, causes higher burnout levels for the staff who are dealing with these patients (Chieze et al., 2019). First-hand evidence from 5MB managements shows nurses have left the psychiatric ward because they were either burnt out or feared injuries or harassment during the seclusion and restraint process
Recent literature also supports the causal connection between disgust and violence by documenting evidence regarding nurse burnout related to Workplace Violence (WPV) (Yang et al., 2018) and evidence regarding patients’ trauma and dissatisfaction as a result of restraint and seclusion (Chieze et al., 2019). The literature review by Chieze et al. (2019) on the effects of seclusion and restraint in adult psychiatry suggests that seclusion and restraint have harmful physical or psychological consequences. Post-Traumatic Stress Disorder (PTSD) incidence estimates after seclusion or restraint vary from 25% to 47%, which is not negligible, especially for patients with past traumatic experiences (Fugger et al., 2016; Whitecross, 2013 in Chieze et al., 2019). Therefore, to decrease the incidences of PTSD, patients should be allowed to make their own decisions whenever possible, such as opting to take part in individual or group activities rather than seclusion or restraint. Moreover, management and clinical nurses should work together targeting the major identified risk areas to decrease the incidence of workplace violence and minimize its impact on nurses (Yang et al., 2018). Need some evidence about psych patient violence against one another and self-harm when in non-stimulating and engaging environments
Review of the Evidence
Databases used to conduct the article search included PubMed, Medline, Google Scholar, CINAHL, PsycINFO, Wiley, EBSCOhost. The keywords used to obtain the relevant information were healthcare fatigue, anxiety, depression, healthcare group activity, and inpatient mental health. Parameters to narrow the topic were used, including peer review and the article published date less than five years. The sources obtained were then sorted out in terms of the themes of the interventions towards managing monotony in inpatient mental health facilities.
Evidence about the Problem:
Implications of Lack of Activity and Boredom in the Psych Ward. Boredom is slowly but surely becoming a problematic issue emerging in mental health in-patient settings. A study conducted on the subject indicated that patients admitted to these facilities reported fatigue due to the nature of their stay (Marshall et al., 2020). The study was conducted with patients that were admitted to forensic units where a lot of restrictions were imposed on them The researchers found patients had little-to-no activities to occupy their time and were mostly confined within their rooms. The study concluded that these restrictions lead to them feeling bored during their stay in the facilities Apathy was also associated with a lack of meaningful engagement in the facilities, especially between patients and staff.
Psychiatric wards often lack important activities that may help alleviate ennui and listlessness, help patients cope with their situation, and facilitate their recovery. When previously self-sufficient adults are placed involuntarily, they tend to get bored and engage in counter-intuitive activities such as self harm, aggression, fighting with peers and staff that may jeopardize their treatment (Marshall et al., 2020). Such patients are then generally not involved actively in roles that provide them a sense of purpose. A lack of activities that offer patients an opportunity to have meaningful relationships also leads to lassitude because patients feel increasingly lonely, especially those who rely on stimuli interactions (Woodward et al., 2017). Facilities that do not offer patients an opportunity to interact with one another, either in groups or pairs, tend to report higher cases of monotony than those that do (Woodward et al., 2017). Hospitals should emphasize the alleviation of lethargy in their facilities to ensure patients do not fall into this state and exhibit the adverse effects that have been linked to it. There should be activities that stimulate patients’ creativity, bring joy, significantly foster relationships, and foster a sense of autonomy and self-worth (Wilson et al., 2018). These activities could be group or individual, and they can also be weekend or evening activities such as games, painting, or music (Pavlov et al., 2017).
The Correlation between Lack of Activity, Boredom, and Poor Patient Satisfaction. Most patients in mental health facilities have a lot of unoccupied time. In a survey conducted on patients in a forensic unit (Woodward et al., 2017), it was shown that a vast majority of the patients did experience monotony during the daytime, even though they underwent occupational therapy. The fatigue experienced by these patients worsened over the weekend when they did not undergo occupational therapy. According to the study, most patients spent a significant amount of their time sleeping, talking when allowed to, watching TV, and even smoking. Most of these same patients spent their time in restraints and were often secluded from their counterparts, which proved destructive to their recovery. Many of the patients admitted to the facility often reported dissatisfaction with their services as they spent most of their time unoccupied. Some even picked up self-destructive behavior, such as smoking, to spend their time since the facilities did not proactively try to find ways to help patients beat monotony by engaging them with activities.
Families that admitted their friends and loved ones also reported dissatisfaction, given that the tiresomeness that their loved ones experienced proved to be counter-intuitive and led them to relapse. Being bored and lack of activities resulted in both the patients and their families spending large amounts of money on these facilities, which did not produce satisfactory results for the patients or provide them with the best overall, meaningful experience to aid their recovery (Pavlov et al., 2017).
However, this is not the case for all facilities as several of them have recognized lassitude as an issue. Inpatient psychiatric hospital researchers observed that patients exhibited severe signs of depression, frustration, and anxiety due to having a lack of meaningful activity (Knapen et al., 2015). Research has also established a negative relationship between self-directed activities and monotony (Marshall et al., 2020). The more engaged the patients were, the less prone they were to experiencing irksomeness. This engagement helped patients tap into their creativity and become more actively involved in their recovery, thus improving their mental state. Patients have been reported to experience an improvement in their moods and spirits, as they could form meaningful relationships among themselves and their families, enhancing their sense of inclusion and belonging (Pavlov et al., 2017). These meaningful activities helped patients feel more satisfied with their stay at the facility and even with themselves. 
Incidents of Self-Harm, Aggression, Seclusion, and Restraint. Proneness to jadedness and ennui has been linked to aggressive behavior. According to researchers, tiresomeness proneness can bring out aggression by making people increase their impulsivity to trait anger (Knapen et al., 2015). A study conducted on the substance users inpatient ward indicated a positive relationship between lassitude and aggression (Woodward et al., 2017). Most of the patients often resorted to violence to cure their monotony, which gives them some excitement in their otherwise dull daily lives. Others shared their lack of meaningful activities and isolation as a cause for their aggressive behavior, and some even began to self-harm. The study associated the patients' impulsivity, anger, and sensation-seeking behaviors with monotony (Woodward et al., 2017). Therefore, engaging patients in different activities that ignite their sense of adventure, excitement, and creativity has reduced digression and self-harm. Stimulating their senses by tapping into their need for excitement helps them quench that need without turning to aggression, violence, and self-harm (Wilson et al., 2018). It also helps them acquire skills necessary for coping with their sensation-seeking behavior once they are out of the facility; further, it provides them healthy replacement behaviors and activities (Pavlov et al., 2017). These replacement activities help them in their long-term recovery, reducing their chances of relapsing.
Evidenced-Based Solution for the Problem
The challenge of boredom in psych wards should be appropriately addressed to avoid further harmful effects in patients’ lives. The negative impacts of monotony have been vastly discussed, justifying the need for the health care system to solve this problem (Wilson et al., 2018). Activities that have been found through research promising to use fall in three categories: mindfulness-enhancing activities, creativity-enhancing activities, and group activities.
Mindfulness-Enhancing Activities: Mindfulness, meditation, and yoga
Mindfulness: Mindfulness is one of the current trends found to be helpful in reducing anxiety, bringing about clarity of thought, improving awareness, attention, development of a better attitude (Blum et al., 2019). The purpose of mindfulness in clinical practice is to change patients' perceptions of their symptoms (Blum et al., 2019). Several mindfulness-based interventions have been implemented as therapeutic treatments in managing stress and depression among the users. These include meditation (Blum et al., 2019) and yoga (Bukar et al., 2019). These approaches have been shown to reduce patient stress by increasing their physical activity and relieving world-weariness.
Meditation: Blum et al. (2019) found that mindfulness meditation could be a practical approach in reducing the anxiety levels
among inpatient psychiatric individuals. Mindfulness meditation is about focusing at the present moment. It involves focusing on what one is going through, their feelings, and sensations. Meditation is associated with several benefits, including better sleep, the ability to cope with mental illness symptoms, reduced psychological challenges that control chronic pain, and even improved cognitive and behavioral functions of those who practice it (Blum et al. (2019).
Yoga: Yoga is an ancient exercise that focuses on an individual’s strength, flexibility, and breathing to enhance both the physical and mental wellbeing. It is a therapeutic approach that helps unify the body and the mind by matching breath to
physical movement. The technique has received increasing attention from adults, as indicated by its increased usage between 2002 and 2012 (Bukar et al., 2019). Bridges and Sharma (2019) conducted a systematic review of yoga as an effective intervention towards improving depressive symptoms. The authors reviewed 23 interventions published between 2011 and 2016, which utilized various study designs, with a majority being randomized control trials. Multiple methods were used in the interventions and according to the findings, the interventions proved to be efficacious regardless of the length of intervention. These findings supported the findings by Bukar, et al. 2019, who concluded that adults in acute inpatient psychiatric units who engaged in yoga practice reported significant improvement in managing their anxiety. Therefore, yoga comes across as an effective intervention that the hospital can utilize to increase patient physical activity and reduce jadedness.
Creativity Enhancing Activities
Creativity enhancing activities are exercises that stimulate one’s mind to think more critically and creatively. The exercises allow an individual to engage with the external environment and inner selves and realize certain aspects of life that can be interesting. Activities such as art, coloring, and music give people an opportunity to explore their potential and become more productive.
Art -art engages the mind by stimulating imaginative and creative thinking. There is extensive literature on the benefits of the arts for mental health. Engaging in various activities, including singing, drumming, dancing, and art, has helped reduce mild-moderate depression in people of different ages (Fancourt & Ali, 2019). Two of the common art techniques that the HMC health facility can explore are coloring and music therapy.
* Coloring - coloring is another meaningful activity for patients that helps to enhance their creativity. Like contemplation, coloring helps patients relax their brains as their thoughts focus on the simple task ahead of them, and they are often not disturbed by their thoughts (Deenik et al., 2017). Coloring has been considered beneficial to patients as the low stakes involved in the activity make it fulfilling and exciting. Patients get to pick colors and focus on completing the activity. For example, in the study done by Flett et al. (2017), adult coloring impacted patients with depressive symptoms, stress, and anxiety resulting in positive psychological outcomes such as flourishing, resilience, and mindfulness. Coloring is a rewarding activity as patients can create their pieces of art in which they may freely express themselves.
* Music Therapy - music therapy is a common non-pharmacological intervention that has been extensively used to treat psychiatric disorders around the world (Pavlov et al., 2017). It is also used to treat other conditions, including sleeplessness, agitation, anxiety, and drug abuse. Pavlov et al. (2017) assessed the effects of music therapy on anxiety among hospitalized patients with thought disorders. The participants’ anxiety levels were assessed using a visual analog scale (VAS). According to the results, the intervention resulted in VAS scores that were overall reduced when compared to the pre-intervention scoring. The researchers concluded that music therapy could be a practical approach in managing anxiety without the risks associated with other interventions such as medications and seclusion. In addition to anxiety, research has shown the numerous benefits of music therapy on mental health conditions such as autism, depression, schizophrenia, and trauma (Wang & Agius, 2018). Music also acts as a medium for people to process their trauma, emotions, and grief while calming patients that battle with anxiety (Pavlov et al., 2017). Therefore, the HMC should also explore the possibility of installing music systems to entertain the patients and reduce their stress and anxiety levels.
Group Activities
Group activities are events undertaken by more than one person. Such activities require collaborative efforts or support to achieve. Examples of such activities include group walks, games, and even work. Activities such as bingo and group walks are beneficial to patients as they help them foster friendships and other meaningful relationships such as teamwork and partnerships among themselves (Wilson et al., 2018). This activity can also be done jointly with the nursing staff to help patients cope with their monotony. The American Psychological Association recently recognized group activities as an approach with sufficient evidence to manage psychological disorders, such as sleep and other serious mental illnesses (Janis et al., 2020). Bingo and group walks are some of the main group activities that patients can engage themselves for faster recovery. In addition, group activities can alleviate the issues related to seclusion discussed by Masland et al. (2020). For example, patients can develop communication skills as they are provided an opportunity to improve their socialization skills.
* Bingo - Bingo is a group game where participants receive cards and match the numbers to determine the winner after following specific laid down procedures. Clinically, the game is part of a multi-activity intervention, which several studies have shown improved the potential of older adults in social interactions and feeling valued (Riggins et al., 2020). Several researchers have conducted studies to assess the impact of this game on the players. Riggins et al. (2020) sought to determine the bingo game's impact on the players’ mood, satisfaction, and acceptability. The feedback shows that the bingo game had a significant impact on the players. Competition when it comes to playing games like bingo (and others like it) has been proven to help quench the need for thrill and excitement for addicts (Knapen et al., 2015). Patients in the HMC should also be exposed to such bingo games as it will help the players acknowledge the worth of the rest of the members.
* Group Walks - Nature plays an essential role in improving the psychological and physiological wellbeing of humans. Spending time in nature and breathing the fresh air has been shown to positively impact people’s mental health, especially in reducing anxiety (Kotera et al., 2021). Therefore, taking mental-health patients for nature walks can also help reduce their depressive symptoms and ultimately improve their outcomes. Although nature walks may be of most benefit, given the current pandemic and the restrictions set in place by the hospital for the safety of the patients and staff, HMC may consider group walks on the unit. Walking is a group activity that can be practiced regularly. Since most of these patients are taking antipsychotic medication, the most substantial side effect is weight gain. As a result of significant weight gain, patients are at high risk of developing diabetes, hypertension, high cholesterol, and other medical issues. Therefore, starting a walking program daily will decrease patients’ risks of obesity and will significantly improve their physical and mental health (Kotera et al., 2021).
Creating individual and group activities like bingo, coloring, yoga, mindfulness meditation, listening to music, and group walks are promising activities that could address the lassitude and associated problems in the psychiatric inpatient units like 5 MB. Hence, creating activities is recommended for psychiatric hospitals to improve patient care quality. It will also reduce patients' aggression, restraint, and seclusion while decreasing staff burnout.
Evidence on Theories and Frameworks
In implementing the discussed solutions, there should be a positive change in the staff’s and administration’s mind set on providing appropriately stimulating environments to help patients on 5MB not experience lassitude and ennui while they undergo therapy to lead a healthier life. One way to help achieve this change is to use Lewin’s Change Theory. According to Lewin, the change process is classified into three stages: unfreezing, change, and refreezing (Hussain et al., 2018). This theory is grounded in several underlying theories: motivational theory, readiness to learn theory, readiness to change theory, and leadership theory. The motivation theory entails the study towards understanding the forces that drive a person to work towards a particular goal. People tend to be motivated when they achieve their needs and therefore, any efforts at utilizing this theory will motivating the patients by creating a need for them to work towards fulfilling.
The readiness to learn theory is based on a principle, which states that learning depends on the learner’s readiness to act, which in turn, strengthens the bond between stimulus and response. The patients will only learn if they are ready to act. The readiness to change model emphasizes on the level of preparedness of the members to embrace change. Successful change at the organizational level only occurs when the members are ready to embrace the proposed changes. Finally, the leadership theory is a model that explains why certain people become leaders. The model highlights specific characteristic...