Overview of the evidence

Effects of boredom on clinical outcomes

There is evidence, albeit limited, that attests to the importance of attending to patients’ psychosocial needs in influencing length of stay in general hospitals. For example, in a Canadian study the severity of psychosocial problems was found to be significant in explaining the difference between actual and target length of stay for acute care hospital patients referred to Social Services (Reference Lechman and DuderLechman 2006). In a second study by the Canadian researchers, the severity of psychosocial problems of psychiatric and medical/surgical patients was reported to be more significant in predicting length of stay than was severity of medical condition (Reference Keefler, Duder and LechmanKeefler 2001). The need to consider preoperative psychosocial factors as predictors of length of stay following heart transplantation has also been highlighted (Reference Grady, Jalowiec and White-WilliamsGrady 1999).

Hope and boredom

Hope ‘has been shown to be important among cancer patients in coping, perceived control over the illness, and psychologic adjustment’ (Reference Vellone, Rega and GallettiVellone 2006). Interestingly, hope was found to be negatively correlated with boredom during hospital stays of Italian patients with cancer (Reference Vellone, Rega and GallettiVellone 2006). Another study found that stimulation and avoidance of boredom were predictive of quality of life among advanced cancer patients (Reference Inman, Kirsh and PassikInman 2003). Given that hope is highly important for promoting treatment effectiveness, its correlation with boredom is significant and suggests that addressing boredom could have much wider implications for patients with cancer in terms of experiencing hope and coping with their illness in multiple ways.

Conditions that may contribute to or falsely present as boredom

Although not a focus of this article, readers should be mindful of other conditions that may be contributing to boredom or be falsely presenting as boredom (or lack of drive) (Box 2). Particular problems can arise in patients with established and recognised mental disorders such as schizophrenia or those with intellectual disabilities (often referred to as learning disabilities in UK healthcare services). We would recommend in this case first asking the patient whether they have noticed a change in themselves and second, seeking corroboration and information about their usual behaviour, volition and functioning from someone who knows them well. It is also worth considering that some treatments that patients receive in general hospitals can affect volition.

Theories of boredom

There are two major (but not mutually exclusive) theories of boredom – situation-dependent boredom and situation-independent boredom. Situation-dependent boredom is externally driven, primarily due to a monotonous environment. In contrast, situation-independent boredom arises from internal factors (Reference TodmanTodman 2003; Reference Steele, Henderson and LennonSteele 2013). Proponents of situation-independent boredom believe that boredom results from an inability to use coping mechanisms such as fantasy and anticipation to escape from monotony (Reference TodmanTodman 2003).

Meaningful relationships while in hospital

The diversity of demographic characteristics and physical health factors among general hospital in-patients mean that interventions designed to address their needs for meaningful relationships while in hospital must be adapted accordingly.

With children and young people, being admitted to hospital has significant implications for their continued educational and social connections (Reference Nisselle, Hanns and GreenNisselle 2012). The Royal Children’s Hospital, Melbourne offers an excellent example of using the latest technologies (such as laptops and tablets) as part of a multidisciplinary educational programme to provide access to flexible learning and socialising while in hospital (Reference Nisselle, Hanns and GreenNisselle 2012). Having the opportunity to experience meaningful relationships is also important for adult inpatients. This has clearly been demonstrated among psychiatric in-patients, who have expressed a desire for social support from peers and fellow patients (Reference Thomas, Shattell and MartinThomas 2002) and healthcare professionals (Reference Higgins, Hurst and WistowHiggins 1999).

For older in-patients, the provision of organised meeting times/patients’ clubs to promote social interaction may be helpful, given the prevalence of loneliness among older people in general (Reference Routasalo, Tilvis and KautiainenRoutasalo 2009). Older people undergoing a period of rehabilitation found that opportunities for social interaction were restricted (by both physical factors and lack of staff time) (Reference ClissettClissett 2001). They thought that the patients’ club they could attend was beneficial overall, but it appeared only to promote activity and not to address their need for social interaction. Thus, while activities may be useful in terms of filling time and providing diversionary outlets, greater thought may be required to engagement in deeper social interaction. For example, a 2-week exposure to an enriched environment, compared with a standard stroke rehabilitation ward, resulted in stroke survivors experiencing increased social interaction, increased feelings of personal control and an alleviation of boredom (Reference Bartley, White and JanseenBartley 2012). Given that boredom has also been hypothesised to be related to a feeling of loss of control over one’s situation, these findings are noteworthy.

Loneliness and social isolation

‘Loneliness’ and ‘social isolation’ are often assumed to be the same, but they are distinct phenomena. Social isolation relates to the frequency of an individual’s contacts and to their integration into their social environment; loneliness is determined not by the frequency of contacts, but by how satisfying these social interactions are to the individual (Reference Routasalo, Tilvis and KautiainenRoutasalo 2009). This theoretical distinction has implications for general hospital in-patients. Although being in hospital will not, in itself, alter a patient’s level of social isolation in the community (because family, friends, acquaintances and social networks outside the hospital will remain intact), the quality of an in-patient’s social interactions with visitors may result in feelings of loneliness, for example if visits are rushed because of hospital visiting hours. Furthermore, if members of the patient’s social network outside the hospital do not visit at all, patients may perceive themselves to be socially isolated. Hospital staff should therefore facilitate opportunities for patients to interact with their existing social network whenever possible.

Experiencing a sense of control and having meaningful roles

The importance to patients of experiencing a sense of control by having the opportunity to engage in autonomous activities as opposed to generic organised activities has been highlighted with reference to psychiatric in-patients (Reference Newell, Harries and AyersNewell 2012).

Autonomously driven activities to provide ‘structured meaningful activity for elderly patients in a hospital setting’ were successfully promoted by a programme in which in-patients received a purposeful visit from volunteers trained by a recreational therapist (Reference Cumbler, Mramor and HagmanCumbler 2011). Women admitted to a high-risk antepartum unit during pregnancy likewise highlighted that the loss of control was a stressor for them, although they were equally keen on the provision of organised activities to relieve boredom (Reference Richter, Parkes and Chaw-KantRichter 2007).

Indeed, organised activities may help general hospital in-patients experience meaningful roles. For example, a person-centred arts programme for hospital-based stroke patients reported that the most frequently mentioned benefits of participation included experiences of ‘engagement in purposeful occupation and relief from boredom, and reconnection with valued aspects of the self’ (Reference Baumann, Peck and CollinsBaumann 2013). The link between the chance to engage in meaningful roles and occupations and relief from boredom is noteworthy, as is the fact that such ‘experiences of participation contrast strongly with the acute and chronic distress associated with stroke, impairment, and spending long periods of time in hospital’ (Reference Baumann, Peck and CollinsBaumann 2013).

Effect of smoking regulations on boredom

Smoking was banned in England in nearly all enclosed workplaces and public spaces in 2007. Consequently, National Health Service (NHS) acute hospitals in England operate no-smoking policies on hospital grounds; similar policies are in operation in Scotland, Wales and Northern Ireland. The health benefits of this are clear, particularly considering the harmful effects of second-hand smoke on cardiovascular health (Reference BauldBauld 2011). However, the potential implications of smoking bans on levels of boredom of general hospital in-patients has been underexplored in the literature.

Nicotine crosses the blood–brain barrier and binds to nicotinic cholinergic receptors, causing the release of the neurotransmitters noradrenaline, serotonin, dopamine, acetylcholine, γ-aminobutyric acid and glutamate (Reference Campion, Checinski and NurseCampion 2008). Smoking also inhibits the enzyme monoamine oxidase B (MAO-B), causing dopamine levels to increase (Reference Campion, Checinski and NurseCampion 2008). The mesolimbic dopamine pathway is central to motivation, pleasure and reward (Reference WiseWise 2004; Reference StahlStahl 2008) and is also implicated in creativity (Reference FlahertyFlaherty 2011). Studies of dopamine antagonist antipsychotics have reported that some can induce negative symptoms of schizophrenia in healthy volunteers and consequently that these dopamine-blocking agents could contribute to a lack of drive and therefore to boredom (Reference Artaloytia, Arango and LahtiArtaloytia 2006; Reference Park, Park and YangPark 2012). Consequently, we might hypothesise that stopping smoking suddenly may contribute to experiences of boredom, given the decrease in dopamine levels that the smoker will experience. However, there may be some differences between general hospital inpatients and psychiatric in-patients in this area. Nevertheless, the decrease in dopamine levels that will accompany sudden smoking cessation should be considered as a potential contributor to boredom among general hospital in-patient who are regular smokers.

It should be noted, however, that the widely held assumption that smoking is associated with mental health benefits was challenged by a recent systematic review (Reference Taylor, McNeill and GirlingTaylor 2014). This reported that in both the general population and populations with physical or psychiatric disorders, smoking cessation was associated with reductions in anxiety, depression, mixed anxiety and depression, and stress.

Boredom and cognition in elderly people

In a study involving community-dwelling older adults in Ireland, Reference Conroy, Golden and JeffaresConroy et al (2010) found that both loneliness and proneness to boredom were associated with reduced cognitive function in older age. Although the cross-sectional nature of this investigation precludes conclusive attribution of causality, they theorise that loneliness and boredom-proneness ‘may have a common underlying mechanism in the failure to select and maintain attention on particular features of the social environment (loneliness) or the nonsocial environment (boredom-proneness)’. They suggest that boredom-prone individuals may lead cognitively unstimulating lives.

As mentioned above, those who espouse the theory of situation-dependent boredom argue that boredom is primarily due to a monotonous environment. They suggest that individual differences reflect a differing level of vulnerability to the absence of environmental stimuli, with individuals more prone to boredom using particular (usually maladaptive) behaviours or traits (Reference Steele, Henderson and LennonSteele 2013). An inability to maintain attention on the non-social environment, and a lack of cognitive stimulation in one’s life, could be regarded as a ‘maladapative’ trait (although a lack of cognitive stimulation in one’s life is not necessarily something for which we can blame the individual). The theory of situation-independent boredom is also relevant to Reference Conroy, Golden and JeffaresConroy et al’s (2010) theory on boredom-proneness because having reduced cognitive function may lead to difficulties in using escape mechanisms such as anticipation and fantasy (Reference TodmanTodman 2003).

For the reasons put forward by Conroy et al, it is therefore likely to be challenging for staff and liaison mental health teams in general hospitals to engage patients with reduced cognitive function. Perhaps the strategy most likely to be successful with this group would be to provide structured, organised activities to ensure that the external environment is as stimulating as possible. This is probably a sensible approach given the difficulty of encouraging patients with cognitive decline to try to alleviate their own boredom by using the cognitive coping mechanisms needed to compensate for ‘boring’ external environments.

The physical environment of the hospital

A BMA report argues that ‘poor design works against the wellbeing of patients’ and that hospitals must be mindful that physical surroundings can be ‘psychologically supportive’ (BMA Science & Education 2011: p. 11). Although the report acknowledges that financially challenged hospitals may not easily be able to make alterations to existing structures, it states that the design of new hospitals should avoid overcrowding of patients and should ‘provide a variety of spaces such as a big day room, a dining room that is well lit and ventilated and a spacious lobby and corridors and give sufficient attention to natural and artificial lighting’ (p. 11). Noting that the structural environment of hospitals can significantly affect in-patients’ social interaction, the report makes practical suggestions that hospital staff can implement, such as ensuring that room layouts make it easy for patients to interact with one another and with friends and family, and providing lounges with comfortable furniture that people can arrange to suit themselves.

Challenges for healthcare professionals in the recognition of boredom

The notion that it is appropriate for clinicians to seek to recognise and alleviate boredom among general hospital in-patients is somewhat at odds with the traditional medical model of healthcare, which focuses on the biological and physiological basis of illness, and in which ‘The broader wellbeing of the person experiencing illness […] can be lost’ (BMA Science & Education 2011: p. 4).

In conceptualising the nuances and wider implications of boredom in general hospitals, it is helpful to consider the difference between ‘disease’ and ‘sickness’ in the broader biopsychosocial model. As Dieppe puts it, disease is an ‘abnormality of the structure and function of the body’ but ‘the illness experience and sickness are not always caused by the disease; they depend on psychosocial factors as well’ (Reference Dieppe, Bowling and EbrahimDieppe 2005: p. 3). Psychosocial factors such as the experience of boredom therefore interact with the physiological symptoms of disease to lead to a more complex experience of sickness. It is much more straightforward to diagnose and treat ‘disease’ than to consider the patient’s situation in a more holistic manner that encompasses the contribution of myriad psychosocial factors to their well-being and experience of sickness (or wellness).

Suggestions for further research

It should be noted that there is a lack of research employing a randomised controlled trial (RCT) design to investigate patient boredom, well-being and psychosocial issues in acute hospitals. However, the fact that healthcare systems are so complicated, with myriad potential confounders, makes the RCT design essential for illuminating these issues (Reference Sheldon, Oakley, Duley and FarrellSheldon 2002). Only in RCTs can we disentangle the potential effect of manipulating an independent variable on a dependent variable from the ‘noise’ of factors attributable to the patients and to other healthcare systems in acute hospitals.

MCQs

Select the single best option for each question stem

1. 1 The following can contribute to boredom or falsely present as boredom:

   1. a frontal lobe dementia

   2. b schizophrenia

   3. c Korsakoff dysmnesia

   4. d depression

   5. e all of the above.

2. 2 In research into the interplay between boredom, psychosocial factors and physical health conditions:

   1. a a 2001 study found no difference between severity of psychosocial problems and severity of medical condition as predictors of length of stay

   2. b hope was found to be positively correlated with boredom among cancer patients

   3. c loneliness is not at all common among older people

   4. d social isolation is not at all common among older people

   5. e there is no evidence that elderly patients who lead cognitively unstimulating lives may be at increased risk of cognitive decline.

3. 3 Enforced smoking cessation may contribute to boredom among general hospital inpatients because:

   1. a smoking decreases blood serum levels of MAO-B, which causes dopamine levels to increase; stopping smoking will therefore decrease dopamine, and this may contribute to boredom because dopamine is important for motivation, pleasure and reward

   2. b smoking increases blood serum levels of MAO-B, which causes dopamine levels to increase; stopping smoking will therefore increase dopamine, and this may contribute to boredom because dopamine is important for motivation, pleasure and reward

   3. c smoking increases blood serum levels of MAO-B, which causes dopamine levels to decrease; stopping smoking will therefore decrease dopamine, but this will have no effect on boredom because dopamine is not important for motivation, pleasure and reward

   4. d smoking decreases blood serum levels of MAO-B, which causes dopamine levels to decrease; stopping smoking will therefore decrease dopamine, but this will have no effect on boredom because dopamine is not important for motivation, pleasure and reward

   5. e smoking decreases blood serum levels of MAO-B, which causes dopamine to increase; we cannot say whether an increase in dopamine may contribute to boredom because we do not know whether dopamine is important for motivation, pleasure and reward.

4. 4 Nature and hospital gardens may play a part in improving hospital patients’ well-being because:

   1. a hospital gardens can promote social interaction

   2. b looking at built scenes may be more stressful to patients than looking at nature scenes

   3. c hospital gardens can give patients a sense of control in the midst of stressful clinical settings

   4. d looking at built scenes is less conductive to patients’ recovery than viewing natural scenes

   5. e all of the above hold true.

5. 5 Regarding the interplay between in-patients’ psychosocial needs and boredom:

   1. a engaging with patients’ psychosocial needs and thereby addressing their boredom is consistent with the traditional medical model

   2. b engaging with patients’ psychosocial needs and thereby addressing their boredom requires content communication skills rather than process communication skills

   3. c engaging with patients’ psychosocial needs and thereby addressing their boredom entails a focus on ‘disease’ rather than ‘sickness’

   4. d engaging with patients’ psychosocial needs and thereby addressing their boredom necessitates a focus on ‘sickness’ rather than ‘disease’

   5. e engaging with patients’ psychosocial needs and thereby addressing their boredom requires doctors to structure their patient interactions by using the ‘traditional medical history’ rather than the ‘communication model’.

MCQ answers

1

E

2

d

3

a

4

e

5

d