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Ecological Analysis of a Hospital

Location Dependencies in the

Behavior of

taff

and Patients]

by

William

F

LeCompte and Edwin

P

Willems

University of Houston Baylor College of Medicine

Abstract

This is a report of an ongoing analysis and

evaluation

of

the Texas Institute for Rehabilitation

and Research in Houston, Texas, which provides com-

prehensive

rehabilitation

to persons with spinal cord

injuries. The major investigative purpose has been

to use methods that would yield

quantitative docu

mentation of a) the nature of the hospital as an

environmental system, and

b)

the nature of the

interface of the hospital's del ivery system with pa

tient

behavior and

experience.

The first

is

provided

by a behavior setting survey of the hospital

as de

veloped by Roger

G.

Barker) and the second by first-

hand observations

of patients.

Against

the

framework

of the

behavior

setting analysis, the observational

data

provide a

fine-grained, quantitative

picture of

patient

behavior, hospital

delivery,

and the loca

tional

dependencies

in

behavior and del

ivery.

This

research can be seen as a prototype or model for

other investigations of environmental dependencies

in human

behavior.

Introduction

Our talk today will describe what we have

discovered

about

the

treatment

environment

of pa

tients with injuries to the spinal

cord,

through the

convergent appl ication of two methods. The methods

to be described

are

different in level of analysis and

in

their data base,

but the two

can

be used to focus

on

a

critical aspect

of any environment designed for

people; namely, the actions

of

individuals within a

defined location. The

relevance

of this work for

environmental design seems

clear;

the field, at pres

ent, consists of a host of untested behavioral assump-

tions embedded in a structural context. The present

methodology is proposed as one way to

articulate and

generate data on these assumptions.

Method]: The Behavior

Setting

Survey

(William

F.

LeCompte)

As defined by Roger Barker (2), and as used

in previous

research,

the behavior

setting

unit

repre

sents a

stable

combination

of one

or more extra

individual patterns

of behavior

surrounded by a

non

psychological

milieu.

Slide] presents

three defin

ing characteristics of any behavior setting. The

following slides

illustrate

these points visually in a

number of locations around the

hospital.

Slide 2: Here is one of the most typical

hos

pital settings;

namely,

a one-man

office.

Slide 3: This

area, called the prevocational

skills area, is interesting because it provides an illus-

tration of

the need for

one

of the defining

character

istics; to the

left

of the

picture

is a fragile white

screen

that

marks the boundary

of

this

setting.

Its

function

is

to inform

one that

he is

entering

a

differ

ent

place.

As a boundary, its function is more sym

bolic than

real.

That

is,

it

does not

filter out

auditory stimuli, and it is too low

to effectively

stop

all

visual cues.

But

the inhabitants of the pre

vocational skills area need it to define

their

territory.

Slide 4: This setting has been labeled as

trafficways in view of its dominant action pattern

of

locomotion . It is

included to illustrate the variety

one finds

in

situations.

Slide 5: Here is a typical laboratory at the

hospital. Note

the high degree

of

individual

atten

tion to projects and the lack of social interaction.

The two people

at

the far

end of

the

lab

are convers

ing in low tones

about

a project, but there

is

little

disruption of the

others.

Slide 6: This is a typical ward

ofthehospital;

one sees occasional signs of boundary maintenance as

in this slide, but generally wards function as a

rich,

open behavior setting.

Slide

7: Let' s turn

to

the

classic areas of

the

t r e ~ n v i r o n m e n t

in a rehabilitation

facil

ity. Here is the general physical

therapy

area.

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Note the vast amount of

specialized

equipment in

this room. The area in the

center

has been affec

tionately designated as the fishbowl and is

speci

a i z e d for the administrative and

clerical

tasks

that

physical therapists

do.

However, the boundaries

here

are

transparent to

allow

the

staff

to observe

their patients.

Slide

8: In this

close-up of

the fishbowl

area, w ~

some of the ways in which the

exclusiveness of this

area

is

maintained, despite

the

visual access to outsiders.

Note

the narrow entrances

and the impossibility of defining the

area as

a

traffic

way.

Intruders sense

that

they must not

enter

and

wait, passively,

to be

noticed.

Slide

9:

This slide depicts quite a different

organization. t is the occupational therapy (OT)

department taken with a wide-angle lens. To your

right

is

the

recreational

therapy and to your

left

is

the general OT

area.

The doors

lead

to

other OT

settings such as a

kitchen,

a woodshop,

and

a driver

simulation room. Contrary

to

physical therapists,

the occupational therapists

apparently

prefer

closed

in areas for

specialized activities.

In

general,

there

are more than twice as many settings in OT than in

PT.

Slide 10:

Finally,

here

is

a view of a weekly

meeting of the rehabilitation team. Note that pa

tients

are

not present

here.

The Behavior

Setting

Survey:

With this much as

introduction,

then,

let me

describe the

behavior setting

survey

of

the treatment

environment.

To begin

with,

the slides

illustrate

one

facet

of this approach

that

is basic to an understand

ing of the method: the units of analysis here

are

not

created

by an investigator, but rather

are

discovered

by him in his survey.

In other words, they exist within the defined

phenomena, in the same way as do cells for a

biolo

gist or planets for

an

astronomer. The task of the

scientific investigator is to achieve a more precise

and

quantitative

description

of

these

naturally

occur

ring

phenomena.

In

the

behavior setting

survey of the

treatment

environment,

122 of these units were reliably

discrim

inated

at a level of interdependence corresponding

to the everyday

experience

of

their inhabitants.

Hence,

the total treatment environment within the

hospital consists of 122

equivalent

units which can be

systematically described in countless ways, depend

ing on the interest of an investigator. For our

pur

poses, let me mention some general findings regardirg

different parts of the treatment environment.

Perhaps the most general question

to

be con

sidered is: To what extent is the treatment

environ

ment devoted to

direct patient-care activities?

The

next slide has been prepared to provide a visual

answer to that

question--it

is based on the Occu

pancy

time

index,

defined as

the product

of i1ietotal

number

of people

in

the setting

times

their average

duration or stay within the

setting.

The

cumulative

result is then multiplied by the number of times the

setting happens within the survey

year.

Slide :

The occupancy time for

each set

ting has been represented in this figure as a circle,

the

area

of which increases proportionately

to

the

total

person-hours-per-year

occupancy of

that

setting.

The total treatment environment of the hospit

al is represented

here.

The 76 settings above the

horizontal

line

are

the

patient

sector

of

the

treatment

environment while the

46

settings below

the line

con

stitute that

part

of

the treatment environment in

which patients

are

not found. The

latter

constitute

the backstage in Goffman's 3) sense, where

im

portant decisions

are

made by professional staff

regarding the fate of the patients. Some

representa

tive backstage settings include: Weekly

chart

rounds

where a doctor reviews his case load; departmental

staff meet i ngs; offices of heads of departments.

To

the left of the

vertical

line bisecting the patient

sector of

the treatment environment

are the classic

treatment

areas.

They

constitute

somewhat more than

25 per

cent

of all

settings.

The remaining settings in

the

patient sector,

to the right

of

the

vertical line,

include a

cafeteria,

walking rounds, and

all other

non treatment settings in which patients

are

found.

In

general,

the total

occupancy

time of the

patient sector is nearly five times as large as

the non

patient

sector of the treatment environment. Hence,

one would expect to find approximately a

f i v ~ t o o n e

difference in occupancy time of professional

person

nel on the

average.

Table 1 presents the

actual percentage of

occupancy

times

in

back-

and frontstage

settings.

The first

column, territorial range,

contains the

per

centage

of the 122 settings in which

each

type

of

personnel is found.

Physicians have the highest territorial range,

entering

over half of the settings in the treatment

en

vironment, while vocational counselors have the

narrowest range,

entering

less than one-quarter of the

122

settings.

Despite this

evidence of

an

extremely

broad

territorial range,

Table 1 shows

that

far

from

maintaining a

five-to-one ratio of

occupancy time

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Table 1

Overall Territorial Range and Percentage

of

Occupancy

Times for Hospital Personnel

in

Frontstage and Backstage Settings

Occupational

Group

Physicians

Aides and

Orderlies

Nurses

Administrative Personnel

Physical Therapists

Occupational Therapists

Social Workers

Vocational Counselors

Other

Occupations

Totals

Contribution to

Occupancy

Times

( of

Total)

Overall Patient

Territorial Sector

Range (N=76)

55%

32

43

49

29

25

39

24

4.9%

34.4

20.2

13.2

2.8

4.9

6.0

2.5

11.1

100.0

Nonpatient

Sector

(N=46)

17.5%

7.3

6.2

47.6

3.7

4.2

3.1

3.3

7.0

100.0

between patient

and

nonpatient sectors

of

the

treat

ment environment, physic ians

actually

reverse the

expected proportions. That

is,

they occupy

non

patient

settings

nearly

four times more than patient

settings. Only

administrative personnel are as remote

from patients. Aides,

orderlies, and nurses

constitute

frontline groups, while

other

professions seem to

dis

tribute

their

time more

evenly.

Turning now to a consideration

of

the

treat

ment environment as a whole, the behavior setting

data are capable

of

generating quantitative,

precise

inter-

as

well as intra-environmental comparisons.

Many writers have described aspects

of

institutions

which

care

for a target population 24 hours a

day

(e.g.,

Goffman,

4).

Such descriptions are

typically

rich in qualitative

detail

and correspondingly poor

in

quantitative

analysis.

Before presenting some

compar

ative data,

let

me

digress for a moment to describe

another

useful unit.

One

of the most important classifications

of

the inhabitants

of

behavior settings relates the amount

of

control a person has over

the activity

in the setting.

Leaders

and active

functionaries within settings

are

called

performers, while customers,

audience,

and

onlookers

are

referred to as member s. We have

found

that

a classification

of

settings on the basis

of

their

performers

is

an important taxonomic step in

studying the treatment environment. Such a

classifi

cation

has been

labeled

a

genotype.

Genotypes:

I n

brief,

two settings are judged to be in the

same

genotype

i at least 75 per cent

of

the timespent

by performers

in

them

is

spent by

people

with

equiva

lent

backgrounds (Barker,

2,

Pp. 80-89).

For

ex

ample, 12 of

the 122

behavior

settings were found to

have physicians in single leadership positions. These

constitute

a single genotype,

and it

can be compared

with

another

genotype in which physicians and nurses

share leadership positions. I n

general, the

122 set

tings

form

a total

of

52

genotypes, each controlled

by

a different combi nation

of

performers. If the number

of

settings in an environment provides a measure

of

the

size

or extent

of

the place, then the number

of

genotypes can be consi dered a measure of the vari

ety

one finds in

that place.

t answers

the question,

How many different kinds

of

things

are there here?

Cqnsider the following

analogy.

A farmer

may tell

that

he has 100

acres

under

cultivation,

with four different kinds

of crops.

Number

of

settings

can

be considered equivalent to

acres

in the

analogy,

and number

of

genotypes to the four types

of crops.

Just

as the

25-to-one

ratio

of acreage

to crops is

meaningful,

the setting-tcrgenotype ratio can tell

us

the

relation of

extent to variety within

the

treatment

environment.

Hospital-Town Comparisons:

Barker

(2)

has provided a number of structural

indices

from

a small midwest town, surveyed during

1963 and

1964.

Table 2 summarizes the

data

from

both hospital and town environments on both extent

and variety measures. These data

bear

on the

ques

tion of the similarity between community types.

Table 2

Ecological Comparisons between

TIRR

and Midwest,

Kansas

Item

T1RR

Midwest

No.

of

Behavior

Settings 122 884

No.

of

Genotypes

52

198

Genotype/Setti ng

.430 .225

Ratio

Total

Occupancy

1,316,185 1,822,004

Time hrs.

hrs.

Time/Setting

Ratio

10,800

2,129

TIRRJ

MWX 100

14%

26%

191%

65%

197%

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The data in Table 2

tell

an interesting story;

the hospital is far less

extensive

than the community,

and t provides only about o n e q u a r t ~ r of the variety

one encounters in the small town. However, one

finds nearly twice the amount of variety per unit set

ting in

TIRR

than in

Midwest.

The hospital records

only about two-thirds

the occupancy

time

of

the town,

yet

here

again

one finds almost

twice

as much

occu

pancy per unit setting in the hospital than in

the

town.

The town

data

in Table 2

include

only com

muni ty behavi or settings;

obviously, the addition Qf

family settings would give rise

to

much greater figVres.

However, the hospital

data

obviously do not i n l u ~ e

the homes

of

the working personnel. I n that respect,

then, it seems quite legitimate

to

compare the two

envi ronments.

Let

me

summarize this

part

of

my

talk

to

pro

vide a

contextual

framework for

Dr.

Willems' descrip

tion of the patient observation methodology. After

his

presentation,

I shall return to discuss some more

specific findings regarding the settings

actually in

habited

by the patients in his observation

sample.

We have found the treatment environment to be

struc

tured into a backstage and a frontstage with

the vari-

0us types

of

hospital personnel positioned accordingly.

The physician seems to operate as a kind

of

back

stage controller, receiving inputs about patients in

directly and sending decisions back through the net

work to frontline personnel. Further, the entire

treatment environment seems, in comparison to

the

small community, to be a more specialized but more

densely populated

place,

with

greater

diversity per

un

it

setting.

Method 2: Direct Observation

(Edwin P. Willems)

Against

the

framework

of

the overall environ

mental survey

of

the hospital presented by Dr. Le

Compte,

we were in the position to study the interface

between the treatment environment and the behavior

and experience

of

its primary target population: the

patients.

What do patients do? What does their behavior

look

like in terms

of events, structure, pace, and dy

namics?

In

what ways,

predicted

or not, do the

behavioral repertoires and

activities of

patients

charge

as they progress through

the

hospital's program

of

treatment? From

the standpoint

of patient behavior,

what happens

in

the various subparts--the behavior

settings--of

the hospital; how can

the

various

behavior

settings be characterized in behavioral terms? How

does the

behavior

and experience

of

patients

change,

and how does the impact of the hospital change as pa

tients

move

from

one subpart

of

the hospital to

another? These questions and others I ke them point

to several notable issues. (a) They poin t to the

crux,

the

payoff point,

of

hospital functioning--they point

to the direct

interface

between the hospital system

and the

behavior

and

experience of patients. b)

Fur

thermore,

such questions

point to the

kinds

of

data

for which students of design and behavior

have

been

pleading.

As is true in so many other areas

of

human

behavior,

these questions

are

u ually answered

through a combination

of crude,

hit-or-miss

observa

tion,

retrospective summaries, interviews,

anecdotes;

and

a host

of

beliefs, assumptions,

and

pet

ideas. In

order to

generate

a more

systematic,

quantitative pool

of data to answer such

questions--and

taking out

pro

cedural cues primari

Iy

from

the

work

of

Herbert F.

Wright and Roger

G.

Barker

(5)--we

began a program

of

direct observation

of patients;

patients

actually

in

the hospital at the time of the behavior setting survey

that

Dr. LeCompte has

described.

Twelve adult patients with high spinal cord in

juries and involved

in

comprehensive

rehabilitation

programs

at

the Texas Institute for Rehabilitation

and

Research made

up the

observational

target group,

including

eight males,

four females, a mixture

of

races and

ages,

and patients who varied

from

early

in

treatment to

predischarge.

For

each

patient, a con

tinuous descriptive protocol was

generated,

based

upon continuous firsthand observation of his

behavior

and situation for one day, beginning at 5:00 a.m.

and ending at 11 :00 p.m.

To

obtain the protocols, a

team

of

three

observers was assigned to

each

of the

patients. On a patient's appointed day, the team

assigned to

him

rotated

in

two-hour observation shifts.

A minimum

of

stri ctures was placed on the

observa

tional

process--observations were recorded in the

everyday

language

of

the obseryers. All observations

were dictated into

small,

battery-operated tape re

corders and in

general,

each passing minute

of clock

time was

noted.

A series

of

systematic

editorial

and

clerical

steps then yielded what we were after: twelve

18-hour protocols, totaling 216 hours

of

patient time,

representing

on-the-spot

descriptions

of

what-the pa

tients did and

including

enough

of

the context

of

their

behavior

to make it

intell

igible.

Our

first

analysis,

keyed

to

answering some

of

the questions mentioned

earlier,

has been based upon

a distinction between molar

and

molecular events

in

the behavior

streams

of

the

patients, or

between what

we call chunks and bits. The analysis assumes

that

a

protocol captures

anddescribes the

ongoing experience

behavior

stream

of

a patient and

that

the

events

in the

behavior stream include things the patient does, things

that are done to him or with him, and segments in

which the patient is idle or

passive.

For our purposes,

our major coding

unit,

a

chunk, is

a molar

event

in

the

behavior

stream of a

patient

which

a) can

be

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readily characterized

by a

single principal

activity,

b) begins at a

clearly described starting

pClint, (c)

occurs

over

time

in

a

characteristic, regular

manner

with

all

its essential

accompaniments, and

d)

ends at

a

clearly described

stopping

point. One

necessary

condition for marking a chunk is that the patient him

self

be

directly involved

in

it.

Thus, if

the

patient

is

clearly described

as

having been involved

in

two

distinct,

molar, principal

activities

at

the

same

time,

two chunks

are demarcated

as

occurring simultane

ously. Chunks

are

marked off with major

brackets.

To

each

chunk marked on

the protocol, the

following

items of information

are attached:

(a) a

descriptive

label for

the chunk; b)

how long

the chunk lasted;

(c)

who, out of

31

categories of other

persons, was

directly involved

in

the principal

activity

of

the

chunk, and

how many such persons

were involved;

d) who instigated the chunk; e)

the degree

of in

volvement by the target patient in

the principal

ac

tivity, on a

scale

from active participation through

passive participation,

to resistive participation; f) the

number

of other

persons in

the

immediate

situation,

but

not

directly involved

in the

principal

activity of the

chunk; g) the beginning clock

time of the

chunk; and

h)

the specific behavior setting

in which

the

chunk

occurred.

The protocols

describe

more

than the

molar

behavi

or

events, or

chunks.

We

have

focused on two

kinds

of

short, fleeting

social

encounters

( bits )-

fleeting

intrusions by others

in

the patients'

behavior

streams. The bits of the first type are directed toward

the patient's care, safety,

comfort,

or treatment. The

second

type

includes

greetings,

fleeting

small talk,

and

other

short, but purely

sociable, encounters.

Each

is accompanied

by a code for who was involved

in

it. Finally,

transfers (from

bed

to

wheelchair,

etc.)

and

transports to formally

scheduled events are coded

as

chunks.

Other

changes of location

or position

are

indicated

by a

separate code.

For our

analysis,

one person

coded

an

entire

protocol, after

which a second person

coded

a portion

of

it

independently.

Across

seven

independent

checks,

involving a total of

730

minutes of protocol time and

four independent coders, pairs of coders agreed on 84

per cent of

their

accounting for protocol time

in

terms

of

chunks (6). A

second

coder

then

studied

each pro

tocol

in

its

entirety and

he

and

the

original

coder

re

solved

any

questions

and

disagreements

that

arose (7).

In order

simply to

illustrate

some

general

characteristics of

the

data

we are

retrieving

from these

observations,

I shall summarize

several aspects of

the

behavior

and experience of

four of the

twelve patients.

All four

were

males,

but,

by

date of

admission

and

progress through

the

hospital's

program

of comprehen

sive

rehabilitation,

two were early

in

treatment and

two

were advanced,

or

predischarge, at the

time

the

observations

were made.

The first two

examples illustrate descriptions

of topographical or structural

aspects

of behavior.

Table 3 shows the total number of separate major

be

havior

stream

events,

or

chunks, that occurred

in the

days of the

early and advanced patients,

as

well

as

the

number

of

different

kinds

of

chunks

that occurred.

Table

3

Summary

of

Numbers

of

Chunks

No. of

different

Total

kinds of

number

chunks

of (out of

chunks

4 kinds)

Early

patients

139.SO

21.0

Advanced patients 193.5

27.5

Advanced/Early

1.39

1.31

aEntries

are averages

for two

patients.

Here

is

a

behavioral documentation of what we com

monly

assume, or at least hope:

as

the patient pro

gresses in

treatment,

his

behavioral

day

becomes

fuller,

more eventful, and more differentiated. The

first two lines show this progress

in

terms of

absolute

numbers

and

the last

line

shows it in terms of ratios

of

advanced

patients over

early

patients.

Table 4 shows

structural aspects in

terms

of

behavioral overlapping.

The first column summarizes

the

average total

number of

observational

minutes

Table 4

Summary of Overlapping, by Instances and Time

Instances

Observational of

Minutes

Overlap

Early

patients

1020.0

23.5

Advanced

patients

1080.0

51.5

Advanced/

Early

2.19

Overlapping

of

Total

Minutes

(Col.

1)

77.75

7.6

180.00

16.7

2.32

2.20

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ava i1able as a basel ine; the second column records the

number of times

that

behavioral chunks occurr ed

simul

taneously, or

in

overlapping fashion, for

each set of

patients; and the third column shows the average num

ber of observational minutes that involved

overlap.

The last column summarizes the proportion

of overlap

ping minutes to

total

observational minutes. The table

summarizes the

extent

to which

the

behavior streams

of

the

patients

proceeded

in

multiple file as against

sim

pie,

single

file.

The ratios in the last line

indicate

that

the behavior streams

of

the

advanced patients

marched along in

complex,

multiple patterns more

than twice as

often,

more than twice as

long, and in

more than twice as high a proportion

of

total time as

the behavior streams

of

the early patients.-fnSUnimary,

the

data in

Tables 3 and

4,

which

exploit

only the

number

of

chunks, the chunk labels, and the length

code,

illustrate that

the

behavior

of

early and ad

vanced patients differs

in

overall richness,

differenti

ation, and complexity.

There

are

many dimensions on which

the

over

all diversity and variation in the

experience

of

pa

tients can be documented

from

these observational

data.

The

data

in Table 5

exploit

the chunk codes

for transfer and transport and the

other change-of

location codes to provide one

picture of

environmental

diversity and change to which the patients were

ex

posed.

From

left to right, the columns summarize

a)

location changes within one room,

b)

movements

across the boundary

of

one room, (c) movements across

the boundaries

of

more than one room,

d)

totals

of

these three kinds

of

changes

of

location, (e)

the num

ber

of

separate behavior

settings

entered, and

f)

the

number

of

times they

entered behavior settings.

First,

whereas

advanced

patients also ranged

in

and

out of

immediate rooms (second column), prob::lbly

reflect

ing the

fact

that they were

in

wheelchairs

and

could

move themselves.

I have focused on the distinctions between two

early and two advanced patients and the normaliz

ing of

behavior

streams with progress

in

rehabilitation

to provide a

relatively

straightforward illustration

of

the

validity

and

usability of

the kinds

of data

we have

obtained

with the procedures we have

described.

We

are

finding such

data

indispensable

in

the

documentation

of

many aspects

of

the system for de

livering

care, treatment,

and service to

patients.

Dr. LeCompte will now present some general

charac

teristics

of

the 19 behavior settings that were

actually

entered by

the 12

patients we observed, after which

we shall demonstrate some

of

the ways we

are

using

the

observational data to study environmental depen

dencies in patient behavior.

Home Range

Characteristics

of

the

12

Patients

(William

F.

LeCompte)

David

Stea's 8)

term, Home

Range, is

an

ecological concept

that can be useful to key in to the

results

of

the present

study.

We have defined the

home range

of

this sample

of

patients as the

total

num

ber of behavior settings penetrated by them during the

day in which they were

observed.

Table 6 contains a

listof the 19settings

in

the

home range

of

these

patients.

Perhaps the first item

to

be considered

regard

ing these

data relates

to

their validity;

to what

extent

Table 5

Changes

of

Location

and

Behavior Setting Entries

Movements

No.

of

Different

No. of

Across

One

Within

Room

Boundary

Room Only

Only

Early Patients

13.0

0.0

Advanced Patients

35.0

7.0

Advanced/Early

2.69

as the

entries in

the last

line indicate, the advanced

patients were involved in much higher numbers

of

lo

cation

changes

of

all

types than were

early patients.

Second, early

patients were

either

involved in

move

ments within rooms (transfers, etc. , first column) or

major transports about

the

hospital (third column),

Past More

Behavior Behavior

Than

One

Settings

Setting

Room

Total Entered

Entries

7.5

20.5

5.5

16.5

29.5 71.5 11.5 56.0

3.93 3.49 2.09

3.39

does the sample

of

12 observation days

reflect

the

general occupancy

time

of patients

at

TIRR? In

order

to generate

data on

this

question,

estimates

of

patient

occupancy

time were

calculated separately from

the

protocol records and from the behavior setting survey

for each

setting.

The last two columns in Table 6

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Table 6

Home Range

of

the 12 Patients in the Observation Sample

Behavior Setting

Total Occupancy Time

Patient

Occupancy Time Estimates

(Person -Hours/Year)

From Behavior

From

No.

Name

Setting Survey) Sample)

l

Nursing Wards

317,828 hrs. 21.00

hrs.

12.22 hrs.

2.

Sel f-care Ward

117,192

hrs.

19.00hrs.

13.30

hrs.

7.

Dental CI inic

4,860

hrs.

1.00hrs.

.59

hrs.

10.

Physical Therapy Area

26,475hrs.

.68

hrs.

2.97hrs.

12.

Electrical Stimulation 261 hrs. .52

hrs.

.14

hrs.

13.

Occupational Therapy Area

22,430

hrs.

.08

hrs.

1.14

hrs.

16.

Recreational Therapy Area

5,935 hrs.

1.00

hrs.

1.37hrs.

20.

Job Clinic

360 hrs. 1.50 hrs.

.11 hrs.

22.

Men's

Lounge

1,150hrs.

-0-

hrs. .10 hrs.

24.

Hallways

207,750

hrs.

.

01

hrs.

.12 hrs

26.

Korner Store

2,667hrs.

.

01

hrs.

.03 hrs

27.

Food Machines

73,444

hrs.

.25

hrs. .63 hrs 0

28.

Waiting Area

30,021

hrs. . 25

hrs.

.33hrs

29.

Cafeteria

24,732 hrs.

1.00hrs.

1.62 hrs.

35.

X -Ray Laboratory

2,781

hrs.

25 hrs. .41 hrs

40.

Photography Studi

4,453

hrs.

12

hrs.

.02 hrs .

49.

Doctor's

Office

4,740 hrs.

-0-

hrs.

.15

hrs.

111. Schoolroom

4,720

hrs.

1.50hrs.

.79 hrs.

112. Evening Recreation 3,750 hrs. 1.50

hrs.

1.13 hrs.

Total

855,549 hrs.

49.67

hrs.

37.17hrs.

provide estimates from the

behavior

setting survey and

from the protocol records, respectively.

In

both cases,

the figures represent average

occupancy

times for a

single patient during one

occurrence of

the

setting.

The patient

occupancy

estimates

from

these two

sources are remarkably close, as is apparent in Table6.

The total times

are

within

12 .5hours of each other.

More impressively, the product-moment

correlation

between the two estimates across the 19 settings

is

+.98.

It seems

clear that

the set

of 12

observation

days furnishes an extremely accurate sample of

patient

occupancy within the home

range.

Turning to the home range

itself,

perhaps the

first item

of

interest is its smallness. This list

of

19

behavior settings constitutes only 15 per cent

of

the

total number of settings in the treatment environment

and with regard to

genotypes,

only 37 per

cent

are

included.

Thus, the

patients'

days

occur

within quite

narrowly define d boundaries, even within the rather

narrow confi nes

of

the treafment envi ronment.

Although the home range

is,

thus, restricted

in

number of settings and

in

genotypes, it

is interest

ing

that

the total

occupancy

time in the patient home

range accounts for more than 75 per

cent of

the total

time in the patient sector.

In other

words, these 12

patients are

located

where the

action

is in the treat

ment environment.

Physical Structure of the Patient Habitat:

As

might be

expected

from the enormous

occu

pancy time

of

the

patient

home

range,

the physical

size

of

these settings tends on the

average

to be

quite

large.

We have measured this with an index

called

the longest

look.

It

is

simply the number

of

feet

in the diagonal from one

corner of

the setting

to

the

opposite corner, representing the longest possible

view withi n the

setting.

Longest look data for the

patient home range provide a mean value

of

nearly

55 feet, compared to 35 feet for all settings entered

by patients, and 27 feet for backstage settings.

Interpersonal Structu re

of

the Patient Habitat:

The

variety of

members

of

the

rehabilitation

team in the patient home range

is

also impressively

large.

Taking the

eight occupational

groups

dis

played in Table 1 and adding another seven groups

that were not displayed we constructed a people

variety index by tallying

the

number

of

times in

each

setting that at least one member

of

a group

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appeared

as a regular inhabitant. The mean people

variety for the patient home range was 6.58,

signifi

c a n t y larger than the mean

of 4.45

for all settings

entered

by patients or the mean

of 4.09

for backstage

settings.

Despite this

evidence

of

greater variety

in

;:>ersonnel,

however,

the

behavior

setting survey

data

show that patients had an unequal probability

of en

countering various types

of

personnel. Ranking

the

15 groups in the

rehabilitation

team on the basis

of

their contribution to

yearly occupancy

time in the

home range provides an index

of

differential

expo

sure to patients. Far in excess

of

any

other

group are

aides and orderlies with a figure above 150,000 hours.

Next in frequency are nurses, with nearly

80,000

hours

of

exposure. Secretaries, custodians, and

occu

pational therapists appear

next

most frequently wi th

approximately

20,000

hours

of

exposure

each. Vol

unteers

occur in

the next category with about

16,500

hours. Three members

of

the

rehabilitation

team

ap

pear next,

with

about 11,500

hours, namely,

physi

cal therapists, physicians, and social workers.

Only

dietitians, vocational counselors, and bracemakers

have fewer hours

of

exposure

in

the

patient

home

range than physicians.

One

very

clear

implication

of

these data on performances is

that

the "front

ine

groups tend to involve poorly trained, low power oc

cupations,

while the appearance

of

physicians is

pro

porti onate Iy few and far between.

Finally,

I would like to

characterizesomeas

pects

of

the "social

weather of

the

patient

home

range.

To what

extent are

the

people

in these

be

havior settings involved in

certain characteristic ac

tivities?

The data show that the most prevalent action

patterns

are

those involving social interaction, cleri

cal

activities, and

nutrition, while treatment and

rec

reation

occur

in about 50 per cent of the

settings.

Somewhat less present are actions such as physical

evaluation,

mai

ntenance,

and activities devoted to

improving personal

appearance. Nearly completely

absent are research and religious activities.

In closing, let me try to summarize some of the

main features of these contextual

data on

the structure

of the

patients' habitats.

We have found the

patient

home range to be larger both

in

physical

size

and in

population than typical behavior settings in the

treat

ment environment, to possess,

on

the

average,

a

greater variety of

occupational types, and to include

a vastly

greater

exposure time

of

low level performers

than skilled

rehabilitation

personnel.

Noticeable

by

their lack

of

exposure in the patient home range

are

such groups as physicians, social workers,

and

physi

cal therapists. Almost completely ab sent from patient

home range are

dietitians,

vocational counselors and

bracemakers. Characteristic

activities

in the patient

home range include social interaction, nutrition,

clerical

jobs, with some recreation and

treatment,

while

physical

evaluation,

personal

appearance,

re

ligion, and research seem to be underrepresented.

With this much

ofa chart

to help

us

survey

the

ecological terrain over the

patients'

habitat,

let us

turn to Dr.

Wi

IIems observational

data

to discover how

individual behavioral indices fit into this

picture.

Behavioral Landscapes: Location Dependencies

in the Home Range of Twelve Patients

(Edwin

P.

Willems)

Dr. LeCompte has presented the actual home

range

of

the 12

patients

who were observed so inten

sively, and he has described that home

range.

In

the parlance of the ecologist, he

has,

first of all,

presented the overall ecological survey of a particu

lar

habitat--the

hospital. Then,

using the

actual

occu

pancy and

behavior ofa subpopulation--the

patients-

as

the

criterion,

he has demarcated a special subpart

of

the

habitat

as the home range of the patients, and

he has described

that

home range by some of its

gen

eral soc

ial, environmental, and

behavioral

charac

teristics. We come now to the final questions

of

this

presentation: Considering the

day-long

observations

of

the 12 patients, how did

their

behavior distribute

itself over the behavior settings that constituted their

home range? And, what were some of the critical

dependencies

on location that occurred in their be

havior?

Across the

12

patient

protocols, our coding

system

yielded

a total

of

1815 chunks and the

addi

tion

of

lengths

of

these chunks

yielded

a

total of

14227 chunk minutes . Table 7 displays the way

in

which these behaviors were distributed across several

behavior settings, in

terms of per cents of chunk

Table 7

Distribution

of

Chunk Minutes by Behavior

Setting

in Which They

Occurred

Stations

1-3

2 Station 4

1 Genera

I

PT

Area

13 General

OT Area

16 Recreationa l Therapy

24 Hallways

29 Cafeteria

Other

Total

No.

of

Minutes %

of

Total

5082

4709

1704

749

403

395

48

837

14227

35.7

33.1

12.0

5.3

2.8

2.8

2.4

5.9

100.0

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minutes that occurred in each. Several things stand

out: (a) Ninety-four per cent of the patients chunk

minutes occurred in the 7 settings displayed.

b) That

means

that 94 per

cent of

the patients behavior time

was captured by fewer than six per

cent of the

hospit

al s

122 behav ior sett ings . (c)

In fact,

about 69 per

cent of

the patients behavior time was spent in only

two

settings--the

two wards or primary living

areas.

Table

8

characterizes three of these settings in

more detail, in terms of the distributions of patient

behaviors that occurred within each. These data in

dicate that in addition to capturing a high proportion

Table 8

Characterizations of Three Settings By

Patient Behaviors

Occurring

in Them

2) Station 4 (4709 Chunk Minutes)

Idle

Nursing Care & Hygiene

Conversing

Sleeping

Eating Scheduled Meal

Passive Recreational

Transferri ng

Telephoning

Exercise & Performance Training

Other

N

1149

1045

828

666

217

151

129

126

123

275

(10) General PT Area (1704 Chunk Minutes)

Exercise & Performance Training

Conversing

Idle

Transferring

Other

29) Cafeteria (348 Chunk Minutes)

Eating Scheduled Meal

Conversing

Other

N

1025

317

161

110

91

N

213

131

4

24.4

22.2

17.6

14.1

4.6

3.2

2.7

2.7

2.6

5.8

60.2

18.6

9.4

6.5

5.3

61.2

37.6

1.1

of

patient

behavior, the wards were also quite diverse

and complex in terms of

patient

behavior. The cafe

teria,

on the other hand, was a much more specia l ized

setting for patients, being devoted to eating and con

versing.

We turn now to a more dynamic,

inferential,

and program-oriented aspect

of

patient behavior.

From

our codes, it is possible to retrieve a) the total

number of waking and non-idle chunk minutes for the

patients, b)

the number

of

chunk minutes in which

the patients acted

alone,

and (c) the number of chunk

minutes instigated by the patients themselves--all

differentiated by behavior settings. With total wak

ing and non-idle minutes as the baseline, averaging

the two per cents for acting alone and patient instiga

tion gives us an index

of

the extent to which the

be

havior streams of the patients were under their own

control, or,

if you

will,

an index of

patient indepen

dence.

Table

9

displays indices of independence for

the seven behavior settings that contained the largest

amounts of

patient behavior.

The highest rates of

behavioral independence by patients were associated

with the

cafeteria

and hallways, two settings which

Table 9

Indices of

Patient

Independence for

Seven Behavior Settings

29)

Cafeteria

24) Hallways

1) Stations 1-3

2)

Station 4

13) General OT Area

10) General PT Area

16) Recreational Therapy

Total

Chunk

Minutes

a

346

387

3003

2894

697

1543

388

Index

of

Independence

64.3

48.1

29.7

23.9

15.1

7.5

.2

aExcludes Idle and Sleeping time.

are only tangential to the formal program of rehabili

tation. By contrast, three settings

that

lie at the

heart

of

the formally defined program

of

rehabilita

tion--physical

therapy,

occupational

therapy,

and

recreational therapy--produced the lowest

rates.

Another way to summarize these data is to say that

when the patients moved from

cafeteria

and hallways

--two

settings that

are

complex and demanding, but

peripheral to the formal

rehabilitative

process--to

the more formal treatment settings, the message some

how got through that they were to be much more de

pendent and doci Ie.

t is possible that these differences in rates of

independence were produced by different patients

who entered the settings at varying rates. To test

this alternative hypothesis, we calculated combined

indices

of

independence for (a)

cafeteria, hallways,

and

wards;

b) occupational therapy,

physical

ther

apy,

and recreational therapy; and c)

each

of the

12

patients.

In the case of each

patient,

the results

corroborated the pattern found above; for all

12

pa

tients,

the index of independence dropped

dramatic

ally as they moved

from

cafeteria-hallways-wards to

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occupational therapy-physical therapy-recrea tional

therapy.

Data such as these not only point to powerful

location dependencies in the dynamics of

behavior,

but they should be useful to those who wish to evalu

ate how their programs

are

being

carried

out. The

use of

patient

instigation and

acting alone

to measure

variations in independence among settings is only one

example of what the observational data

enable us

to

do.

We have analyzed associations between

inde

pendence and types of behavior and differences among

patients. We have studied differences among patients,

settings, types of behavior, and involvements by vari-

0us persons with the patients for their effects upon be

havioral zest, as measured by

patient

initiative and

degree of involvement. We

are

planning analyses

which exploit--singly and in various combinations-

dimensions of behavior such as numbers of chunks per

hour, rate

of overlapping,

and degree of involvement

to make inferences about behavioral pace.

* * * * *

We have presented only a few sparse illustra

tions of our approach to the study of human environ

ments: overal l environmental analys is with conver

gence

down to the way in which the moment-by

moment behavior of inhabitants distributes itself

within that environment. The general investigation

of environment and behavior can

benefit from

the

application

of strategies similar to these because de

facto environmental dependencies should be our point

of

departure.

f

this be

so,

then there

is

no substitute

for being present to observe and measure behavior

when and where it

occurs.

Notes and References

I . The research reported here and the preparati on of

this paper were supported by Research and Train

ing Center No.4 (RT-4), Baylor

College

of

Medicine, funded by Social and Rehabilitation

Services, USDHEW.

2.

Barker, R. G. Ecological psychology. Stanford,

Cali fornia: Stanford University Press, 1968.

3.

Goffman , E. The presenta tion of self in

every

day life. Garden City, New York: Anchor

Book5,l959.

4. Goffman , E. Asylums. New York: Doubleday,

1961.

5. Wright, H. F. Recording and analyzing chi Id

behavior.

New York: Harper Row, 1967.

6. In order to check agreement on the ratings

attached to the chunks, we selected 43 chunks

on whose demarcation two coders had agreed

exactly. Out of these 43 chunks, pairs of

rat

ers

agreed

on the following number and per

cents: T code--39 (90.7 ); 0 code--41 9 5 . 3 ~ ;

I code--40 (93.0 );

01

code--38 (88.4 ); RP

code--33 (76.7 ).

7. Detai Is of the

entire

observational and coding

process are presented in: Wil lems,

E P., &

Vineberg,

S.

E. Procedural supports for the

direct observation

of

behavior in naturciT

settings.

Houston, Texas: Texas Institutefor Rehabilita

tion and Research, 1970.

8. The writers are indebted

to

David Stea for a copy

of an unpublished manuscript which contains the

text of his paper presented

at

a symposium

at

the

University

of

Michigan in 1968.