Patients' and staff's perceptions of the psychiatric ward environment

OBJECTIVE: This study examined the extent to which patients' and staff's perceptions of the psychiatric ward atmosphere and the working conditions of staff influence patient and staff satisfaction. METHODS: A total of 640 staff members on 42 wards completed the Ward Atmosphere Scale (WAS) and the Working Environment Scale-10 (WES-10). A total of 424 patients on the same wards completed the WAS. Both patients and staff members answered three questions about their general satisfaction with the ward. The ward means were used as the unit of analysis. RESULTS: The staff members had significantly higher scores than the patients on nine of the 11 WAS subscales. Patients' and staff's WAS scores were moderately correlated. No significant correlation was found between patients' and staff's scores on the three satisfaction items. Patient satisfaction was strongly correlated with patients' WAS scores and was moderately correlated with staff's WAS scores but was not significantly correlated with staff's WES-10 scores. Staff satisfaction was moderately correlated with staff's WAS and WES-10 scores but was not correlated with patients' WAS scores. CONCLUSIONS: Different aspects of the treatment climate seem to be important for patient and staff satisfaction. The ward atmosphere seems to be more important for patient satisfaction than for staff satisfaction. The working environment is strongly related to staff satisfaction but seems to be unrelated to patient satisfaction.     

Effect of voluntariness of participation in treatment on short-term outcome of inpatients with schizophrenia

OBJECTIVE: The purpose of this study was to examine associations between the voluntary or coercive nature of patients' participation in inpatient treatment and the short-term outcome of inpatient treatment for patients with schizophrenia. METHODS: Eighty-eight adult patients with schizophrenia and delusional disorders who were consecutively admitted to a 320-bed psychiatric hospital in southern Germany over a three-month period in 2002 were assessed with the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) at admission and discharge, a mean of 36.2 days later. The patients were grouped by whether their participation was voluntary or involuntary in each of five aspects of inpatient treatment: admission, hospital stay, medication, discharge, and intention to continue treatment after discharge. Outcome was defined as the change between admission and discharge in scores on the PANSS and the GAF and change in those scores per inpatient day. RESULTS: The outcome measures were not significantly related to the voluntariness of patients' participation in any aspect of treatment. CONCLUSIONS: The short-term outcome of inpatient treatment is independent of whether treatment is voluntary.     

The therapeutic community inpatient ward: Does it really work?

This study compared ward atmosphere, member satisfaction, and treatment effectiveness on community-oriented and medical model psychiatric inpatient wards. The method used for comparison was the Community Oriented Program Environment Scale (COPES) developed by Moos. The results showed that the community-oriented ward has greater patient autonomy, interpersonal involvement, and practical orientation than the medical model ward, whereas the medical model ward shows more order and organization. These results suggest that a community orientation sacrifices the appearance of an orderly ward for increased patient activity and involvement. In addition, the members of the community-oriented ward showed significantly greater satisfaction than the members of the medical model ward, suggesting that the community approach is more effective at creating a helpful level of morale and confidence in the treatment approach. A check of hospital records revealed that neurotics treated on the community-oriented ward were readmitted twice as frequently as neurotics on the medical model ward. Also, character disorder patients left the hospital against medical advice more frequently on the community-oriented ward.     

Consumer satisfaction with an adolescent inpatient psychiatric unit.

OBJECTIVE: To explore factors influencing the satisfaction of patients, parents, and referring clinicians who used the services of an adolescent inpatient psychiatric unit, and to explore how levels of satisfaction related to the patient's symptomatic and functional improvement during the admission. METHOD: All 105 adolescents, their families, and the referring community clinicians who used an inpatient service over a 1-year period were asked to rate the patient's symptoms and functioning on admission, at discharge, and 4 months after the patient's return to the community. We obtained satisfaction ratings at discharge, and consumers were asked to rate helpfulness of the ward experience at 4 months postdischarge. Ward psychiatrists provided Children's Global Assessment Scale (CGAS) ratings and diagnoses over the course of the inpatient stay. RESULTS: Most of the patients (83%) improved during their admission. Consumer satisfaction ratings correlated with improvement of self-identified problems and with the perceived usefulness of discharge recommendations. Satisfaction did not, however, correlate with the patient's symptomatic and functional progress. Interaction with ward staff was an important source of both positive and negative experiences. CONCLUSION: Our study indicates that inpatient psychiatric staff should attend closely to the consumer's perception of difficulties and the need for practical discharge recommendations.     

Identification and treatment of substance misuse on an inpatient psychiatry unit

This chart review study examined identification and treatment of substance misuse on an inpatient psychiatry ward before and after the hospital's administration made changes to increase attention to patients' substance misuse. Before the ward changes, 113 of 250 inpatients (45 percent) were identified as misusing substances. Misusers were significantly more likely to be younger, male, single, and cigarette smokers. After the ward changes, substance misuse was more than twice as likely to be addressed in treatment planning and discharge diagnoses, and referrals to substance abuse treatment were nearly twice as likely to be made. Changes in assessment of and treatment planning for psychiatric inpatients may increase attention to substance misuse.     

What does the patient think? An evaluation of a general psychiatric ward

The authors used patients' ratings of treatment effectiveness, resolution of problems, and helpfulness of various staff to evaluate the effectiveness of a treatment program on a general psychiatric ward staffed mainly by nonprofessionals. The evaluation also included comparisons with the hospital's other general psychiatric wards on length of stay, cost, and other variables. Patients were found to be generally satisfied with the care provided and with improvements in their condition. The authors believe greater considerations should be given to patients' opinions of the treatment they receive.     

Re-thinking acute psychiatric inpatient care

BACKGROUND: Reports of low staff morale and high levels of patient complaints suggest that acute psychiatric wards are not achieving their full therapeutic potential. AIMS: This paper reviews some of the 'therapeutic milieu' literature to identify ways of construing ward functioning so as to maximise therapeutic and minimise destructive processes within inpatient units. METHOD: Relevant papers are reviewed, providing an understanding that permits the inpatient clinician to consider and apply the pertinent concepts. RESULTS: Five key therapeutic functions of the ward environment are identified containment, support, structure, involvement and validation. Four destructive processes are described, relating to: the isolated patient; group phenomena; the contribution of staff; and structural manifestations in the ward. CONCLUSIONS: The inpatient ward can be construed as a 'whole', embodying a range of therapeutic functions, which may need rapid deployment and dismantling, as dictated by changes in ward conditions. The 'ward-as-a-whole' construct complements individualised models of patient care and the practical implications of such thinking could engender a greater sense of agency and job satisfaction in staff.     

Suicide in the Arctic: A few stories

People recently discharged from inpatient psychiatric care are at high risk of suicide and self-harm, with 6% of all suicides in England occurring in the 3 months after discharge. There is some evidence from a randomized trial carried out in the United States in the 1960s–70s that supportive letters sent by psychiatrists to high-risk patients in the period following hospital discharge resulted in a reduction in suicide. The aim of the current pilot study was to assess the feasibility of conducting a similar trial, but in a broader group of psychiatric discharges, in the context of present day UK clinical practice.

The intervention was piloted on 3 psychiatric inpatient wards in southwest England. On 2 wards a series of 8 letters were sent to patients over the 12 months after discharge and 6 letters were sent from the third ward over a 6 month period. A total of 102 patients discharged from the wards received at least 1 letter, but only 45 (44.1%) received the full series of letters. The main reasons for drop-out were patient opt-out (n = 24) or readmission (n = 26). In the context of a policy of intensive follow-up post-discharge, qualitative interviews with service users showed that most already felt adequately supported and the intervention added little to this. Those interviewed felt that it was possible that the intervention might benefit people new to or with little follow-up from mental health services but that fewer letters should be mailed.     

Locked entrance doors at psychiatric wards--advantages and disadvantages according to voluntarily admitted patients

Entrance doors at wards where psychiatric care is provided are sometimes locked, which is not the case at wards where somatic care is provided. How locked entrance doors at psychiatric wards are experienced by patients has been investigated to a very limited extent. The aim was to describe voluntarily admitted patients' perceptions of advantages and disadvantages about being cared for on a psychiatric ward with a locked entrance door. Audio-taped, semi-structured interviews were conducted with 20 patients voluntarily admitted at psychiatric wards. Content analysis revealed six categories of advantages and 11 categories of disadvantages. Most advantages were categorized as "protects patients and staff against 'the outside' ", "provides patients with a secure and efficient care" and "provides staff with a sense of control over the patients". Most disadvantages were categorized as "makes patients feel confined", "makes patients feel dependent on the staff" and "makes patients feel worse emotionally". Patients perceive a variety of advantages and disadvantages, for themselves, their visitors and staff, connected to locked entrance doors at psychiatric wards. A locked door may make the ward appear as both a prison and a sanctuary. It is important that staff try to minimize patients' concerns connected to the locked door.     

Patient satisfaction with inpatient psychiatric care

The aim of the study was to investigate the influence of personality traits, diagnosis and perceived coercion on patient satisfaction with inpatient psychiatric care. The study was performed as a cross-sectional study on 7 inpatient wards in southern Sweden. A cohort of 50 psychiatric inpatients evaluated satisfaction with care and also made ratings on a personality questionnaire. Patients with a higher level of the trait aggressive nonconformity were significantly less satisfied with the ward's physical and psychosocial environment, the treatment design and the treatment program. The phenomenon of acquiescence was not related to the reported level of satisfaction. Analyses of patient satisfaction according to diagnostic groups showed that patients with affective disorders had significantly better satisfaction than patients with a diagnosis of schizophrenia. Patients who perceived that they were involuntarily admitted were measured as being significantly less satisfied with the care in all areas. It is concluded that, to attain a higher specificity in analyses of variation in patient satisfaction, focus may be put on situational and setting factors of the care delivered along with specific patient characteristics. Risk groups, which require great attention in the development of quality assessment and quality assurance policies, are patients with schizophrenia and patients who perceive coercion in connection with inpatient psychiatric treatment.     

Psychiatric assessment wards for older adults: a qualitative evaluation of two ward models

This study was requested to investigate the relative strengths of two different ward arrangements. Both wards were psychiatric assessment wards for people over the age of 65 and both were mixed sex wards. The major focus was to examine if the separation of cognitively impaired (CI) and functional clients on an elderly assessment ward had benefits in terms of client and staff satisfaction. The study involved 192 hours of observation, following four clients on each ward for 24-hours. Results indicate that the split ward and the mixed ward differ qualitatively and that in terms of user and staff satisfaction the split model is preferable. Implications for service development and future research are also discussed.     

Patient satisfaction and ward atmosphere during a crisis in an open psychiatric ward

Background There is great need for useful indicators of quality of care for inpatient psychiatric treatment. The study examines whether patient satisfaction and ward atmosphere can be used as a means of evaluating an assumed decline in quality of care during a crisis in an open psychiatric ward. Methods Twice a year for 2 years ten patients filled out a standardized patient satisfaction questionnaire developed by the Swedish Institute for Health Services Development (SPRI) on their day of departure. At the same time all the patients in the ward evaluated the ward atmosphere using the Ward Atmosphere Scale (WAS). In the third study period the ward went through a crisis where quality of care was expected to be lower. Results The SPRI questionnaire confirmed the decline in patients' perceived quality of care on six of 41 questions, WAS was markedly lower on five of ten subscales. Conclusions Both WAS and the SPRI questionnaire gave useful information on how the ward was affected by the crisis. WAS seemed to be a more sensitive way of measuring quality of care, while the SPRI questionnaire indicated more clearly the practical consequences. Accepted: 12 August 2001     

Computergestützte Patientenbefragungen als Grundlage für eine moderne Qualitätssicherung in der Psychiatrie Ergebnisse der Pilotstudien

We report on a novel computer system for psychiatric patients that runs an interview procedure on the outcome and quality of care (e.g. well-being, mood, satisfaction with treatment). Patients are asked to perform the interviews on a daily basis and on their own initiative. The information is meant to provide feedback to the therapeutic team. In the pilot studies we investigated the feasibility and acceptance of the computerised interviews. Four computer systems with touchscreen input were integrated into the routine of an open inpatient ward and of the day hospital of a psychiatric university clinic for a period of 17 weeks. The patients' attendance and the acceptance of the interviews were good. Patients were able to interact with the touchscreen terminals without greater problems. Accurate and valid data were recorded. Because of some problems with the administration of the patients' identification numbers we develop suggestions how to improve the computer systems. Possible applications of the computerised interview system in quality assurance and research are discussed.     

Homeless people at disadvantage in mental health services

OBJECTIVE: The aims of this study are threefold: to depict characteristics of homeless at discharge from a psychiatric hospital; to describe the utilisation of inpatient care and treatment measures during hospitalisation; and to analyse to what extent psychiatric disorders and clinical variables contribute to the risk for homelessness at discharge. METHODS: Based on case register data we analysed all 28,204 people consecutively referred in 1996-2001 to psychiatric hospitals of a well-defined catchment area in Switzerland. RESULTS: 1% (N=269) of all admissions were homeless at discharge (mean age: 32.0 years; women: 27.9 %). Compared to other psychiatric inpatients, we found among the homeless more males, more people with younger age and lower education. Regarding treatment measures during the inpatient stay, homeless received less often psychopharmacotherapy, ergotherapy and physiotherapy, but more vocational training, occupational therapy and support by social workers. There was no difference between homeless and others regarding compulsory medication or seclusion. Homeless had a shorter length of inpatient stay. Risk factors for being homeless at discharge were: being homeless at admission, not living in a relationship, having a multiple substance abuse or a dual diagnosis, low clinical improvement during inpatient treatment and discharge against medical advice. DISCUSSION: To prevent homelessness at discharge, it is important to consider all independent contributors, i. e. the living situation before admission, health care inequalities during inpatient treatment (care received, low clinical improvement, discharge planning) and psychopathology.     

Single sex or mixed sex treatment in the psychiatric clinic from the viewpoint of patients

Patients in a psychiatric hospital were surveyed by questionnaire to evaluate their preferences on separate or mixed-sex treatment. The adjusted response rate was 74.5%. About 75% of the responders preferred a mixed ward and about 25% preferred a single-sex ward. Females more frequently chose the type of ward to which they had been allocated. By contrast, males were in favour of mixed wards, independently of their present type of ward. Younger patients, voluntarily admitted patients, and those with substance addiction preferred mixed-sex wards. After mixing the sexes in formerly single-sex wards, a significant increase in preference of mixed-sex wards was found, due to increased affirmation by female patients. However, about 9% of women and men preferred single-sex treatment. Two open general psychiatric wards, each with 20 beds and separating females and males, could be established in psychiatric hospitals to satisfy this preference.     

The effects of a psychiatric patient education to medication program on post-discharge compliance

The effect of a structured program of education on subsequent psychiatric patient compliance with medication-taking was investigated. The subjects consisted of 150 hospitalized patients housed on four acute-care receiving wards and ready for discharge from Fallsview Psychiatric Hospital in Ohio. They were randomly assigned to one of three groups. Results indicated that subjects who received written information with verbal reinforcement were significantly more compliant than the control subjects. These findings suggest that, if the hand-out is discussed with them, the patients given medication handouts similar to those used in the study will comply with medication-taking after discharge at a higher rate than those given no hand-out. Implications of these findings for increased psychiatric patients' post-discharge compliance with medications are discussed.     

Impact of a rehabilitation legislation on the survival in the community of long-term patients discharged from psychiatric hospitals in Israel

BACKGROUND: The aim of the present study was to examine the impact of the Rehabilitation Law 2000 in Israel (which provides a basket of rehabilitation services for every mentally disabled patient) on the survival in the community of a population of long-stay psychiatric patients released from psychiatric hospitals. METHODS: A naturalistic follow-up study was performed on long-stay patients discharged ("key discharge") from two Israel psychiatric hospitals closed before (in 1997) and after (in 2000) introduction of the Rehabilitation Law 2000. The data source was the National Psychiatric Hospitalization Registry. RESULTS: The study population consisted of 611 patients. The percentage of patients who, at closure of hospital, were discharged directly into the community was eightfold higher following the Rehabilitation Law 2000 than before. There was also a trend for a lower readmission rate for those patients who were discharged into the community in the post-law period, both for those whose key discharge was directly to the community and for those who were later discharged after being transferred to another hospital at key discharge. Concerning the mean duration of inpatient stay, there was no difference between the two cohorts, whether hospitalizations followed transfer to another hospital from key discharge or rehospitalization from the community. Interestingly, the Rehabilitation Law did not have a significant effect on patients' mortality after key discharge. CONCLUSION: The Rehabilitation Law 2000 has a beneficial effect on the opportunities of long-stay psychiatric patients to resettle in the community without increasing risk of death.     

Treatment of acute schizophrenia in open general medical wards in Jamaica

OBJECTIVE: The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals. METHODS: The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of their illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status. RESULTS: More than half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and severity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment. CONCLUSIONS: While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients superior to, the outcome of treatment in conventional psychiatric facilities.     

Discharge dynamics and related factors of newly-admitted patients in psychiatric hospitals

The focus of psychiatric services in Japan is being shifted from hospitalization to community care, and the Ministry of Health, Labour and Welfare aims for the prompt discharge of newly-admitted patients. Correspondingly, it set a goal to lower the "mean residual rate (MRR)", which indicates the discharge dynamics of newly-admitted patients, to 24%. As a measure to achieve this goal, the present situation should be investigated in each homogeneous patient group. In this study, we conducted a survey of newly-admitted patients to investigate discharge dynamics and related factors by the diagnosis and type of hospitalization. Out of 1,459 psychiatric hospitals to which we sent questionnaires, 183 (12.5%) replied. Each hospital completed questionnaires regarding a maximum of 5 patients for each type of hospitalization (voluntary hospitalization [VH], hospitalization for medical care and protection [HMCP], and involuntary hospitalization ordered by the prefectural governor [IHOPG]) between October 2005 and January 2006. We weighted the obtained patient data in proportion to the estimated total number of patients, and analyzed valid data on 1,784 patients. The MRR for the whole sample was 29.4%. By diagnosis, dementia showed the highest MRR (45.6%), followed by schizophrenia (34.9%); depression, bipolar disorder, and alcoholism showed the lowest MRRs (20-21%). We calculated MRRs by the type of hospitalization for dementia and the other diagnoses separately, considering confounding effect between the diagnosis and type of hospitalization (markedly high proportion of HMCP observed in dementia). In dementia, HMCP showed a higher MRR (46.8%) than VH (43.7%). In the other diagnoses, IHOPG showed the highest MRR (43.7%), followed by HMCP (34.5%) and VH (25.6%). Dementia differed from the other diagnoses in the distribution of residential settings before admission, with a higher proportion of residential care facilities (25.5%) and hospitalization in other departments (19.3%). In dementia, the residential setting after discharge showed a similar distribution, and death was also frequent (6.6%). Multivariate analyses revealed that a long stay (one year or longer) was significantly associated with a residential setting before admission, the type of ward at admission, a founder (a private hospital or public/university hospital), and symptom severity at admission in schizophrenia; and with the type of ward at admission and hospital founder in dementia. In schizophrenia, the risk of a long stay was higher on hospitalization in other psychiatric hospitals (odds ratio [OR] : 28) and other departments (OR: 18), and living alone (OR: 2.1) than in living with the family by residential setting. The risk was also higher in psychiatric long-term care wards than in general psychiatric wards by the type of ward (OR: 3.0), and in private hospitals than in public/university hospitals by hospital founder (OR: 3.0). Additionally, the higher risk was associated with higher symptom severity assessed using a 6-point scale (OR: 1.3 per point). In dementia, the risk was higher in senile dementia wards than in general psychiatric wards by the type of ward (OR: 2.9), and in private hospitals than in public/university hospitals by hospital founder (OR: 6.8). The most frequently reported direct causes of a long stay were problems regarding a family's acceptance (51.5%), poor improvement of symptoms (48.8%), and poor recovery of daily living abilities (44.0%). In dementia, physical diseases (20.8%) and undecidedness of residence after discharge (29.2%) were also frequent. Considering the elapsed time after survey, the low response rate, and the data analyses with sampling bias adjustment, the results should be interpreted carefully. Nevertheless, the discharge dynamics and related factors in newly-admitted patients varied with the diagnosis and type of hospitalization. Particularly, schizophrenia and dementia, as well as IHOPG and HMCP, showed high MRRs and frequent long stays. Additionally, a long stay was related to patients' demographic and social characteristics. Adopting measures suiting patients' characteristics and arranging treatment and casework for patients at high risk of a long stay are important to facilitate community care.