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ORIGINAL
Characteristics of psychiatric nurses’ observation techniques
for psychopathological symptoms
Shinichi Chiba1, Masahito Tomotake1, Rie Tsutsumi1, Tatsuya Komatsu1, and Takuma Mukumoto2
Department of Mental Health, Graduate School of Biomedical Sciences, Tokushima University, 2Daiichi Hospital, Tokushima, Japan

1

Abstract : The purpose of this study was to clarify characteristics of psychiatric nurses’ observation techniques
for psychopathological symptoms. The subjects were 21 psychiatric nurses and 20 nursing students who hadfinished their practicum in psychiatric nursing. Using a non-contact eye-tracking analysis system, we compared
quantitatively their radial motion while they were observing psychopathological symptoms of a schizophrenia
simulation patient. The radial motion of them was recorded while they were observing a video of a simulated
patient presenting psychopathological symptoms, and the recording was analyzed by the eye-tracking system.
The investigator set the important observation areas and determined the sum of the fixation time and the number of fixations in the areas. Differences between psychiatric nurses and nursing students were tested using theMann-Whitney U-test. The results revealed a significant difference in observation of the upper limbs area witha median of 7147.90 msec for nurses group and a median of 2447.54 msec for students group (U = 98.00, p = 0.01).
The finding suggests that nurses tend to pay more attention to patient’s upper limbs to be cautious about possible
violence and to find agitation caused by psychopathological symptoms, extrapyramidal adverse effects, and scars
caused by self-mutilation. J. Med. Invest. 68 : 271-275, August, 2021
Keywords : psychiatric nurses, observation technique, eye gaze analysis

INTRODUCTION
Sustained and mastered observation in nursing is considered
to be a core element of nurse’s outstanding practice (1), and it
is reported that 87% of the information collected using the fivesenses is visual information (2). It is the same in psychiatricnursing, and mastered technique for observing psychopathological symptoms is a core element of psychiatric nursing practicalability. The object of psychiatric nursing is patient’s mind, butsince the mind cannot be visually observed, nurses do not directly observe the mind. Nurses observe patient’s eye movements,
facial expressions, speed of movement, involuntary movement,
speed of speech, situation of self-care, and so on. Through theseobservations, they indirectly evaluate patient’s mind. Thisobservation technique is learned empirically through practice,and it is clinical knowledge that nurses accumulate individually
through experience. In psychiatric nursing, it is especially difficult to visualize observation techniques because subject to beobserved is patient’s mind, and much of the clinical knowledge
is implicit knowledge (3). In the field of basic and adult nursing,using the eye-tracking technique, observation of the hospital
bed environment (4, 5), observation of fall risk (6, 7), observation
during infusion pump operation (8), development of educational
programs (9) and so on have been studied.
The purpose of this study was to clarify characteristics of psychiatric nurses’ observation techniques for psychopathologicalsymptoms. In the analysis of nursing technology of psychiatricnursing, studies using quantitative (10, 11) and qualitative
methods have been conducted (12-15). However, quantitative research using the eye-tracking technique has not been performed.
Received for publication March 10, 2021 ; accepted April 28, 2021.
Address correspondence and reprint requests to Shinichi Chiba,
Department of Mental Health, Graduate School of Biomedical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima-shi,
Tokushima 770-8503, Japan and Fax : +81-88-633-7614.

In the present study, using the non-contact eye-tracking analysis
system (eye-tracking system), we quantitatively evaluated theradial motion of psychiatric nurses and nursing students when
they were observing psychopathological symptoms. We believethat the findings will help visualize the observation techniquesof psychiatric nurses and contribute to the improvement of psychiatric nurses’ practical skills and education for newcomers.

METHODS
Subjects

The subjects were 21 psychiatric nurses who were working ina psychiatric hospital in A Prefecture and had more than five
years of psychiatric nursing experience, and 20 nursing students
who were studying in a nursing course of university in B Prefecture and had completed their practicum in psychiatric nursing.
All subjects gave written informed consent to participate in the
study. Data were collected between August 2019 and October
2020.

Investigation method
To perform accurate gaze measurement, each subject’s jaw
was placed on a platform and each subject was instructed not tomove it. Next, we performed a calibration using the eye-tracking system (QG-PLUS, manufactured by DITECT) to capture
the distance between the eyes and the curvature of the cornea,
which are the physical characteristics of each subject. Then, a3-minute video of a simulated patient presenting psychopathological symptoms of schizophrenia such as auditory hallucination, delusion, restlessness, and lack of self-care was projected ona monitor (“Basics of Psychiatric Care Learned through DVD,
First Volume, Edited,” Nakajima Video Teaching Material
Publishing), and the radial motion during the observation by the
subject was recorded by an eye-tracking camera and analyzed byan eye-tracking system. The sampling frequency of the system
was 60Hz.

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The fixation is the state of gaze in which the eyeball does not
move, the gaze is fixed, and the person acquires visual information. Conventionally, the fixation point is defined as a point
where the eye movement speed is less than 5 deg/sec for morethan 165 msec (16). There are two types of fixations : a specificsearch that looks at a specific part of an object of interest in
detail, and a diffuse search that looks at the parts one wants tosee when looking at an object (17). The observation of subjects inthis study was regarded as a specific search because they looked
at some parts with interest from which they thought they could
observe psychopathological symptoms of the simulated patient.
The feature of the fixation time of the gaze line in a specificsearch tends to be more than 300 msec (18), so in the present
study, the fixation point was defined as a point where the eye
movement speed was less than 5 deg/sec for more than 300 msec.
Important areas that the researchers judged to be necessary
for observation and a region frame for gaze analysis were set
up in advance. In the video of a simulated patient showing psychopathological symptoms, the patient’s facial area, body area,
upper limbs area, and the doctor’s facial area were selected asimportant areas because through these areas, subjects were
thought to be able to observe psychopathological symptoms, side
effects of drugs, and reactions to external stimuli.

Analysis method
The sum of the fixation times and the number of fixations ineach important observation area was calculated, and the differences between psychiatric nurses and nursing students groups
were tested using the Mann-Whitney U-test.

Ethical considerations
This study was conducted with approval from the Tokushima
University Hospital Medical Ethics Committee (approval number : 3233).

Table 1. Characteristics of subjects
Psychiatric
NursesNursing
students

Number of subjects (Men / Women)

21 (10 / 11)

18 (0 / 18)

Age (years)

51.43 ± 7.44

21.00 ± 0.46

Number of nurses who had work
experience only in psychiatric department

10―

Years of experience in psychiatricdepartment (years)

22.93 ± 8.00―

Number of nurses who had work
experience in other departments

11―

Years of experience in otherdepartments (years)

2.86 ± 3.97―

Number of mid-level nurses

2―

Years of experience (years)

7.25 ± 0.75―

Clinical experience19―

25.00 ± 6.48―

Third year in nursing course ofuniversity―

14

Fourth year in nursing course ofuniversity―

4

Graduated from nursing school

17―

Graduated from nursing course ofuniversity

2―

Graduated from master’s course ofuniversity

2―

Number of skilled nurses
Years of experience (years)
Educational backgroundMid-level nurses ; nurses having more than 5 years clinical experience, skilled nurses ; nurses having more than 10 years clinicalexperience.

RESULTS

Characteristics of the subjects
Of the 20 nursing students, 2 whose fixation point basedon gaze analysis was clearly out of the important observation
area were excluded from the analysis. Therefore, the data of 21
psychiatric nurses (51.43 ± 7.44 years of age) and 18 nursing students (21.00 ± 0.46 years of age) were used for the analysis (Table1). Regarding psychiatric nurses, there were 2 mid-level nurses
who had clinical experience in psychiatric nursing for more than
5 years and 19 skilled nurses who had clinical experience in
psychiatric nursing for more than 10 years. 10 had been working
only in psychiatric department. 11 had work experience in otherdepartments, and the number of years of their work experiencein other departments was 2.86 ± 3.97 years. As for educational
background, 17 graduated from nursing school, 2 from nursing
course of university, and 2 from master’s course of university.
Regarding nursing students, 14 were in the 3rd year and 4 inthe 4th year of nursing course of university, and all of them hadcompleted their psychiatric nursing practicum.

Comparison of the sum of fixation times between psychiatric nurses
and nursing students
Median of the sum of the fixation times in the observationof the patient’s facial area was 97725.85 msec for psychiatricnurses group and 99830.88 msec for nursing students group,and there was no significant difference between the two groups(U = 183.00, p = 0.87) (Table 2). The upper limbs area was observed with a median of 7147.90 msec for nurses group and a median of 2447.54 msec for students group, showing a significant

difference (U = 98.00, p = 0.01). In the observation of the bodyarea, median was 11716.07 msec for nurses group and 11862.03
msec for students group, showing no significant difference(U = 175.00, p = 0.69). In the observation of the area of thedoctor’s face, median was 4505.53 msec for nurses group and9263.10 msec for students group and there was no significant
difference between the two groups (U = 147.00, p = 0.24). As
for the relation between years of nurses’ working experience in
psychiatric department and nurses’ fixation time of the upper
limbs area, there was no significant correlation between them(r = 0.27, p = 0.26).

Comparison of the sum of the number of fixations between psychiatric nurses and nursing students
Median of the sum of the number of fixations in the observation of the patient’s facial area was 185.00 times for nurses groupand 175.00 times for students group, showing no significant difference (U = 181.00, p = 0.87) (Table 3). In the observation of theupper limbs area, median was 14.00 times for nurses group and11.00 times for students group, showing no significant difference(U = 140.50, p = 0.17). In the observation of the body area, median was 120.00 times for nurses group and 93.50 times for students group, and there was no significant difference (U = 176.00,
p = 0.71). In the observation of the doctor’s facial area, medianwas 25.00 times for nurses group and 25.50 times for students
group, showing no significant difference (U = 167.00, p = 0.54).

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The Journal of Medical Investigation Vol. 68 August 2021
Table 2. Comparison of fixation times between psychiatric nurses and nursing students
Important observation areas

U-valueP-value

Patient’s face

97725.85

Psychiatric nurses (n = 21)(79402.95 - 114528.00)

99830.88

Nursing students (n = 18)(84709.03 - 109043.92)

183.000.87

Patient’s upper limbs

7147.90(3254.44 - 10947.37)

2447.54(390.72 - 6583.24)

98.00

0.01

Patient’s body

11716.07(6532.78 - 16983.70)

11862.03(7454.88 - 18902.05)

175.000.69

Doctor’s face4505.53(797.86 - 13424.38)

9263.1(2584.40 - 12222.13)

147.000.24**

Statistical analyses were performed by Mann-Whitney U-test, **p < 0.01.
The values indicate medians of fixation times (msec) and interquartile ranges.

Table 3. Comparison of number of fixations between psychiatric nurses and nursing students
Important observation areas

U-valueP-value

Patient’s face185.00Psychiatric nurses (n = 21)(144.00 - 251.50)

175.00Nursing students (n = 18)(140.75 - 223.25)

181.000.82

Patient’s upper limbs

14.00(9.50 - 31.50)

11.00(2.50 - 27.75)

140.50

0.17

Patient’s body

120.00(58.50 - 154.50)

93.50(52.75 - 159.50)

176.000.71

Doctor’s face

25.00

(2.50 - 46.50)

25.50(14.50 - 36.75)

167.000.54

Statistical analyses were performed by Mann-Whitney U-test, **p < 0.01.
The values indicate medians of number of fixations and interquartile ranges.

DISCUSSION
The significant difference we found between psychiatric nurses and nursing students groups was the sum of the fixation
times in the upper limbs area, which was significantly longer
for nurses group. However, there was no significant difference inthe fixation times in other areas and in the numbers of fixations.
From this finding, we found that psychiatric nurses observed thepatient’s upper limbs area multiple times over a longer period oftime compared to nursing students. It has been reported that
there were some characteristics in the differences in times andnumber of fixations depending on number of years of clinicalexperience of nurses, and the characteristics were related to risk
prediction (19, 20). Generally speaking, schizophrenia patientsin the acute phase are thought to be at a high risk of violence.
As the simulated patient in the video used in this study wasmoving their hands and upper arms throughout the durationof the video, nurses seemed to have observed the upper limbs
area more in anticipation of possible violence. Patients’ violence
towards psychiatric nurses has been increasing recently (21-23).
Therefore, the Comprehensive Violence Prevention and Protection Program (CVPPP), which teaches appropriate responseof nurses towards such violence, is attracting attention andmany nurses are receiving the training. In the CVPPP, nursing
techniques used for violence include detecting the presence or
increase of violence risk, lowering the current and immediate violence risk, determining strategies for violence risk, preventing
the occurrence of violence, and encouraging the improvement of
the patient’s ability to deal with violence risk (24). This suggeststhat in the present study nurses might have observed the upper
limbs area from the viewpoint of sensing a heightened risk ofviolence. As one of the nursing techniques in psychiatric acutecare wards in the UK and Australia, risk assessment and management of patients’ aggressiveness have been reported (13, 14).
So, it can be said that the risk prediction of violence is an important nursing technique throughout the world. In addition, it isreported that nurses working in other departments took shortertime to observe for danger prediction than nursing students,
and appropriate observation was carried out and evaluated ina shorter time (7). However, psychiatric nurses in this study observed upper limbs area longer than nursing students, psychiatric nurses’ fixation time of the upper limbs was not significantly
correlated with years of their working experience in psychiatricdepartment. The movement of upper limbs may reflect not only
danger of violence but also agitation caused by psychopathological symptoms (25), involuntary movements which are side effectsof psychotropic drugs (26), scars caused by self-mutilation (27,28) and so on. Therefore, it is suggested that psychiatric nurses
observed the movement of the upper limbs for a longer time
while examining various possibilities including the possibilityof violence. It is already said that one of the characteristics ofobservation in psychiatric nursing is to observe patients while
being involved (29, 30), and the finding we obtained seems to beconsistent with the characteristic.
In the present study, nursing students showed the same fixation times in other observation areas and the same number offixations as psychiatric nurses. Since the nursing students had
already taken all the lectures and completed their practicumin psychiatric nursing, the findings may reflect their improved
practical skills in psychiatric nursing (31). It is reported that
nursing students tend to be patient-centered observers, andmany observe psychopathological symptoms, side effects, andsleep state (32). On the other hand, although the danger ofself-mutilation and violence is taught in lectures and during thepracticum, there is little opportunity for nursing students to experience the danger in practice, which may lead to less observation of upper limbs area from the viewpoint of danger prediction.
As a characteristic of inexperienced nurses, it has been reported
that their ability to predict distress and danger is poor even if
the fixation times and number of fixations are the same as thoseof experienced nurses (5). So, although in this study there wasno significant difference in the fixation times in the areas except
for upper limbs area and in numbers of fixations in all areas
between psychiatric nurses and nursing students, there may besome differences in analysis ability after observation between
the two groups. Further study about analysis ability after observation will be required in the future.

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LIMITATIONSThis study has some limitations. First, we used simulated
patient in this study. Second, the sample size was small. Therefore, further study with actual patients and a larger sample size
would be required to confirm the results.

CONCLUSION
The findings show that psychiatric nurses pay more attention
to patent’s upper limbs than nursing students, and it is suggested that psychiatric nurses may do this because they try to predictpossible violence and to detect adverse effects of medication,
agitation caused by psychopathological symptoms, scars left byself-mutilation and so on.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest directly relevant tothe content of this article.

ACKNOWLEDGEMENTS
We would like to express our deep gratitude to everyone who
cooperated in the data collection of this study. This study was
carried out with the support of the Grant-in-Aid for Young Scientists (18K17486).

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