Background: Many factors can impact on the quality of the inpatient experience and the potential outcomes. Among the influences on inpatient unit functioning, including its current social-emotional climate, are a mixture of patient, physical environment, staff and organizational factors (e.g., patient characteristics, illness acuity, involuntary status, aggression, and diagnoses; unit layouts, overcrowding,patient-staff ratios, and seclusion practices; staffexperience and attitudes; and the quality of treatments provided).In short, psychiatric units are dynamic in nature, creating a different inpatient experience for each person and different opportunities (and barriers) for engagement, treatment and recovery.

‘Shift Climate’ Concept: We use the term ‘climate’ to describe the quality of the social-emotional treatment environment on a shift-to-shift basis in acute psychiatric inpatient settings, including overall tensions and pressures arising from the current mental state, behaviours and characteristics of patients and staff, as influenced by unit characteristics, activities and demands, and other interactions amongst patients, staff and visitors – in short, the overall ‘vibes’ (or feelings/tensions) within the unit during the shift (i.e., right here and now, and taking all relevant factors and perspectives into account).

Development of the SCR Scale: A brief instrument was required for a major service evaluation project (the Acute Services Project, see Carr et al., 2008)[1] that provided a snapshot of the overall social-emotional climate within each unit during each shift, and which could be completed as a routine part of nursing administration duties. Unfortunately, no existing instruments were suitable, although some concepts from measures such as the Ward Atmosphere Scale were relevant (e.g., involvement, anger and aggression, order and organization)[2].The immediate pressures confronting staff and patients in acute psychiatric inpatient units were our primary focus, and not the broader, therapeutic milieu, which is typically assessed by existing measures.

Initially, we trialled four 100-point anchored barometers assessing overall emotional state, perceived aggression levels, activity levels, and social cohesion, with ‘50’ identified as the ‘optimal pressure’ (i.e., a generally calm emotional state amongst patients and staff; cooperative behaviours; goal directed activities; and orderly social functioning). Following consensus meetings with experienced acute care clinicians, and an examination of initial response distributions, we simplified this instrument to four unidirectional, Likert-style ratings, measuring overall perceptions of the unit at that time, covering: emotional state (0: calm, to 4: frightening); aggression (0: cooperative, to 3: violent); activity level (0: goal directed, to 2: disruptive); and social cohesion (0: cohesion, or 1: fragmentation). The instructions (e.g., “… consider all aspects of the unit …”) and the full set of scale anchors are presented on page 3, with a sample Log shown on page 4.

SCR Scale Characteristics: The SCR scale provides a useful snapshot of the current social-emotional climate within each shift. It is easy to use, with clear anchor points, and can be administered on a routine, day-to-day basis by nursing staff or other clinical staff who are present for most of the shift. Although the domains covered are limited, they have face validity and are appropriate for capturing the immediate pressures confronting staff and patients within acute psychiatric settings.

Our experience with the SCR scale is based primarily on data collected over a one-year period from 11 Australian psychiatric units (n = 5,546 admissions), in which various nurse-completed logs were used to record patient- and unit-level events per shift, including ratings of the overall social-emotional climate using the SCR scale (n = 8,176 shifts).The SCR scale has been shown to have satisfactory psychometric properties; for example, high internal consistency(Cronbach’s alpha = 0.90), unidimensional factor structure, moderate correlations between adjacent day/afternoon shifts (r = 0.58 to 0.71), and evidence of discriminant and predictive validity, in the form of clear associations with independent indices reflecting factors such as occupancy, proportion of involuntary patients, and aggression rates[3].

Administration Strategies: In our project, the SCR scale was completed at the end of each shift by the nurse in charge of the unit, because we felt that he/she was in the best possible position to assess the overall social-emotional climate. Where possible, it may be desirable to have two staff members per shift independently complete the SCR scale, at least for the first month (to evaluate inter-rater agreement); as a pre-implementation, training exercise, it may also be useful to ask pairs of staff to make consensus SCR ratings for approximately one to two weeks. If possible, computerised forms should also be used (which record the subscales and generate the SCR total score), rather than the Log sheets used in our project, as the latter permit ready access to previous ratings (which could introduce elements of bias to the ratings, and potentially reduce variability).

Potential Issues: Importantly, the SCR scale does not attempt to assess the emotional state or behaviours of individual patients or staff, but the sum total of the feelings/tensions (or ‘vibes’) within the unit during the shift, particularly the more aversive aspects. These may, in turn, feed into greater levels of disturbed behaviour, including irritability, aggression, absconding, and disengagement – that is, the ‘climate’ is itself dynamic, which underlies our rationale for shift-level assessments.Arguably, any personal stresses experienced or sensed by the nurse in charge that arise from shift-level events and/or unit characteristics should legitimately be taken into account in completing the SCR scale. After all, patients and staff both react to and contribute to the overall shift climate – albeit that staff are temporary members and participants in the unit’s social-emotional milieu (during their shift).

Scoring the SCR Scale: Simply add the four subscale ratings together to obtain a total SCR score out of 10. Thus, the SCR scale is essentially an anchored global rating of the current social-emotional climate within the unit, which allows different elements to impact on the total score.Preliminary evidence suggests that SCR scores ≥ 5 are indicative of a ‘severe’ climate. However, as units vary widely in their characteristics and patterns of acuity and comorbidity, it would be wise to set relative (rather than absolute) limits on the desired range within your unit.

Potential Uses for the SCR Scale:Simple measures such as the SCR scale could be used routinely to quantify and monitor the quality of the inpatient environment (e.g., identifying persistently severe climates), to compare similar units and changes over time, to assist clinicians and administrators to evaluate the impact of local interventions, and to examine associations with other outcome indices. Alterations to the timeframe for SCR data collection may also be worth considering. For example, studies examining changes in the day-to-day micro-climate within a single inpatient unit, and the impact of particular service changes, might utilize the SCR scale on an ongoing basis. On the other hand, for overall milieu comparisons across a range of units, periodic SCR assessments may be sufficient, say for 1 to 2 months at a time.Improved understanding of the role played by unit, staff and patient characteristics should facilitate the development and evaluation of better targeted interventions to reduce adverse incidents and improve the overall social-emotional climate.

Referencing and Feedback: We are happy for the SCR scale to be used for non-commercial purposes without our express permission, provided that it is appropriately referenced; please cite our paper in Social Psychiatry and Psychiatric Epidemiology (see Footnote 3). If you require any additional information, or would like to provide feedback about your experiences using this scale, please contact us at the Centre for Brain and Mental Health Research (CBMHR), Hunter New England Mental Health and the University of Newcastle, PO Box 833, Newcastle 2300, Australia, (Contact e-mail: ).

SCR Scale – Brief User Guide(September, 2011) 1

Instructions: This scale asks for your overall impressions of the ‘climate’ or ‘atmosphere’ during the shift. Consider all aspects of the unit, including the emotional state of patients and staff, levels of aggression, activity and social cohesion. These ratings should be completed by the nurse in charge of the unit at the end of each shift.

Please record your ratings on the attached Log, as well as the total score out of 10.

EMOTIONAL
STATE / AGGRESSION / ACTIVITY
LEVEL / SOCIAL
COHESION / TOTAL
0. Calm, tranquil / 0. Cooperative
behaviour / 0. Goal directed
activity / 0. Socialcohesion or
supportive groups / _ _ /10
1. Uncomfortable,
uneasy / 1. Uncooperative behaviour, needling, goading / 1. Aimless activity / 1. Fragmentation, lack of social cohesion, counter-productive groups
2. Anxious, on edge / 2. Arguments, conflict,
shouting, making
threats / 2. Disruptive activity
3. Very tense, sense
of foreboding / 3. Violent, combative
4. Frightening,
terrifying

SCR Scale – Brief User Guide(September, 2011) 1

UNIT SCR LOG    

Name of Unit ______

NOTE: Nurse in charge of unit to complete ratings

at the end of each shift. (One week to a page)

Date / Shift / Shift Climate Ratings (SCR) / Name/Signature/
Designation
Emotional
State / Aggression / Activity Level / Social Cohesion / Total
/10
Day
Afternoon
Night
Day
Afternoon
Night
Day
Afternoon
Night
Day
Afternoon
Night
Day
Afternoon
Night
Day
Afternoon
Night
Day
Afternoon
Night
SHIFT CLIMATE RATINGS
Emotional State
0 Calm
1 Uncomfortable
2 Anxious
3 Very tense
4 Frightening / Aggression
0 Cooperative
1 Uncooperative
2 Arguments
3 Violent / Activity Level
0 Goal directed
1 Aimless
2 Disruptive / Social Cohesion
0 Social cohesion
1 Fragmentation

SCR Scale – Brief User Guide(September, 2011) 1

[1] Carr VJ, Lewin TJ, Sly KA, Conrad AM, Tirupati S, Cohen M, Ward PB, Coombs T. (2008). Adverse incidents in acute psychiatric inpatient units: rates, correlates and pressures. Australian and New Zealand Journal of Psychiatry, 42:267-282.

[2] Moos R (1997).Evaluating Treatment Environments: The Quality of Psychiatric and Substance Abuse Programs. New Brunswick, New Jersey.

[3]Lewin TJ, Carr VJ, Conrad AM, Sly KA, Tirupati S, Cohen M, Ward PB, Coombs T (2011). Shift climate profiles and correlates in acute psychiatric inpatient units.Social Psychiatry and Psychiatric Epidemiology, In Press.