International Journal for Quality in Health Care 2003; Volume 15, Number 3: pp. 213–221
10.1093/intqhc/mzg032
Indicators of quality of in-patient psychiatric treatment: the patients’ view G. LA¨NGLE, W. BAUM, A. WOLLINGER, G. RENNER, R. U’REN1, F. SCHWA¨RZLER AND G. W. ESCHWEILER Department of Psychiatry and Psychotherapy, University Hospital, 72076 Tu¨bingen, Germany, 1Department of Psychiatry, Oregon Health Sciences University, Portland, OR 97201, USA
Abstract Objectives. The object of this study was to find out from psychiatric in-patients which aspects of care and treatment they considered important and how satisfied they were with these. Design. One hundred and ninety-four in-patients were asked to rate the importance of, and their satisfaction with, 22 different aspects of in-patient care and treatment. The questionnaire, developed for the purpose of the study after a pilot phase including professional care givers and patients, contained 92 items and was returned by 52% of all discharged patients from the Psychiatric university hospital during a 3-month period. Results. Patients made a clear distinction between aspects of treatment they considered important and aspects they were satisfied with. Ranked of highest importance were various therapeutic relationships, and respect for their rights and privileges. They were satisfied with their relationships with clinical staff but dissatisfied with medication. Conclusion. A well differentiated assessment of importance and satisfaction has implications for the evaluation of the quality of psychiatric care, for specific methods of treatment, and for the improvement of in-patient psychiatric care. Keywords: evaluation, in-patient treatment, patient satisfaction, psychiatry, quality assurance
With psychiatric patients, the concept of satisfaction relates primarily to life satisfaction [1,2] and satisfaction with psychiatric care [3–5]. Economists long ago developed a concept of quality management that took customer satisfaction into account [6]. A similar development is slowly taking place in the field of health care in Europe [7]. In Germany, for example, some quality assurance measures that incorporate patients’ perspectives on treatment have been written into law [8]. In Germany, as in other European countries, studies into the effect of involuntary hospitalization have helped to raise awareness of the importance of including patients’ views in the evaluation of treatment and outcome [9–12]. As might be expected, these studies show that involuntarily hospitalized psychiatric patients report lower levels of satisfaction than those admitted to hospital voluntarily. Even so, many involuntarily admitted patients report satisfaction with treatment. In most studies, in fact, both psychiatric and medical patients report an unexpectedly high degree of satisfaction with their treatment [3,13]. Factors found to contribute to satisfaction include ward atmosphere, certain sociodemographic characteristics, diagnosis, duration of illness, and previous in-patient treatment [14–17]. Only some of these have been confirmed by all studies [18].
Still, there is an ongoing debate about the place of patient satisfaction assessments in the evaluation of quality of care. In addition, there have been extensive reviews of the methodological problems pointing to the inconsistency of the underlying construct, the lack of validity for many measures, and the multiple sources of bias [17,18]. Some authors have concluded that patient satisfaction measures are not yet good enough to be used as reliable indicators of quality of care [19,20]. This is a minority view, however. Increasingly, articles attest to the improved validity and reliability of such instruments as the Psychiatric Care Satisfaction Questionnaire (PCSQ) [21], the short version of the Client Satisfaction Questionnaire (CSQ-8) and its German adaptation, the ZUF 8 [13,22], as well as the Verona Service Satisfaction Scale (VSSS) [23]. On the whole, scales that attempt to measure patient satisfaction contain relatively few items. While this allows for ease of administration, it risks losing potentially important information and may not represent any advantage over asking patients a global question such as ‘Were you satisfied with treatment?’ [24]. Compared with patient satisfaction surveys, only a few studies concern themselves with what patients consider to
Address reprint requests to Dr Med. Gerhard La¨ngle, Universita¨tsklinik fu¨r Psychiatrie und Psychotherapie, Osianderstraße 24, D-72076 Tu¨bingen, Germany. E-mail:
[email protected] International Journal for Quality in Health Care 15(3) International Society for Quality in Health Care and Oxford University Press 2003; all rights reserved
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be the most important aspects of treatment. This is an oversight, we believe, since knowledge of what patients themselves consider important or unimportant about treatment not only gives satisfaction ratings a context, it can also identify areas that should be improved, modified, or even eliminated from the in-patient treatment setting. One of the aims of this study was to redress this oversight. It was crucial to ask for the different areas of therapy in a manner that differentiates between the importance and satisfaction for the patient and allows a correlation of both (see Figure 3). This is a prerequisite for a valid tool in quality management, as quality improving actions can be based hierarchically on these data. The issues that are important but dissatisfying for the patients should be improved with high priority to increase treatment quality.
Material and methods The overall aim of this study was to identify those areas of hospital treatment that patients consider important and/or satisfactory. It was carried out in the Department of Psychiatry and Psychotherapy at the University of Tu¨bingen, and included 194 participants who were admitted for acute psychiatric reasons to any of six general psychiatric wards between 14 April and 14 July 1997. To determine whether the sample was representative for the population of the hospital as a whole, basic characteristics of the sample were compared with those of the entire psychiatric patient population admitted during the year, as recorded on the hospitals’ database. Data were extracted from the basic documentation of the department. Sociodemographic data, personal medical history, and prior and acute drug intake for every patient were taken [25,26] in the following forms: gender, age, level of education, level of professional education, employment, housing status, relationship, psychiatric diagnosis according to WHO ICD10 criteria [27], compulsory treatments, and number of inpatient treatments. The level of significance for alpha in the chi-square tests was fixed to P = 0.05. Two of the psychiatric wards (n = 29 beds) were ‘sheltered’, meaning that they could be locked quickly if the need arose. Patients admitted to psychogeriatric wards or wards for the treatment of drug and alcohol dependence were excluded from the study. To determine whether length of treatment had an effect on patient satisfaction, one group of patients (n = 89) was asked to complete the questionnaire 2 weeks after admission, while the second group (n = 105) was asked to complete it during the last 5 days of their hospital stay, which lasted a minimum of 4 weeks. The questionnaires were distributed by research assistants and filled out anonymously by patients. The questionnaire developed for this study covered 22 areas of care and treatment, and contained 91 items plus one summarizing item. Each area was composed of several questionnaire items that were related to each other. The areas and the items can be seen in Figure 1. The 22 areas, such as relation to the psychiatric doctor, cooperation with the clinic staff, food, group psychotherapy,
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and compulsory treatment, and additional specific items were collected from Medline research of German and English questionnaires on patient satisfaction [11,17,21,22,28]. The preliminary questionnaire of 100 items was evaluated by several professional groups (physicans, psychiatric nurses, social workers, psychologists). The questionnaire was shortened after this pilot phase evaluation of its practical use, acceptance, and understanding by the patients. As has been pointed out by Gruyters and Priebe [17], both open questions and visual analogue scales lead to comparable results, 77 of the items were presented as visual analogue scales (0–100 mm). This was easy for patients to understand and allowed differential responses, which are needed for the use of parametric procedures in statistical analysis. (Where averages of patient answers are mentioned in the text, they refer to these 77 items.) The remaining items were presented as nominal scales. Global assessment of satisfaction was contained in item 92: ‘All in all, I am not satisfied (0 mm) to very satisfied (100 mm) with my present stay in this hospital as a patient’. Statistical analysis Each of the 22 areas (or domains) of in-patient care and treatment comprised the independent variables. The patients’ ratings of importance and satisfaction were the dependent variables. Several additional variables that could have influenced the ratings were included in the analysis, such as time of measurement (2 weeks after admission or near the end of treatment), the ward on which the patient was hospitalized, psychiatric diagnosis (estimated by senior consultants according to ICD-10 criteria [27]), gender, age, educational level, and health-related quality of life. Excel V5.0 and SPSS for Windows V7.5 were used for statistical analysis. To decide whether an item was rated as positive or negative by patients, a statistical criterion known as ‘discrimination point’ [29] was used. In this procedure the distribution of arithmetic means for all of the scales of the 22 areas are determined. The median of this distribution of means defines the discrimination point, which is then used to classify ratings as positive or negative (see Figures 1 and 2). The means of all domains were compared statistically with this discrimination point to determine whether they differed significantly. The one-tailed t-test was used for analysis. To evaluate the effects of concomitant independent variables, we used univariate one-factorial analyses of variance (ANOVAs) or t-tests for independent samples and Scheffe´’s test for contrasts.
Results One hundred and one (52%) of the 194 questionnaires were completed and returned by the patients. This is comparable to other studies [13,15]. Fourteen per cent of the patients refused to take part in the study, 5% were excluded because of language problems, and 8% were excluded due to their acute psychiatric status. Four per cent of the questionnaires
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Figure 1 Importance of treatment: 22 areas (n = 80). BA, therapeutic relationship (physician, psychologist) (2–9); BP, relationship to nursing staff (10–13); BS, relationship to social workers (14–17); BK, relationship to physiotherapists (18–20); BE, relationship to occupational therapists (21–23); ZA, cooperation of hospital staff (24); UB, accommodation (26–36); VP, food service (38); AN, situation on admission (40–44); EB, reachability of and contacts outside hospital (45–48); US, medical/psychiatric examinations (49–51); EP, individual psychotherapy (53–55); GP, group psychotherapy (56–58); MT, medication (61–66); KT, physiotherapy (67–70); OT, occupational therapy (71–73); WT, information about alternative treatments (74); GB, patient’s input in treatment planning (76); ZM, involuntary hospitalization (79–82); FZ, leisure time (78); WV, laboratory and investigative examinations (85–86); NB, aftercare and preparation for discharge (87–91).
were returned uncompleted and the rest (17%) were not returned for unknown reasons. Three questionnaires were excluded because they showed positive ratings only with no variation across items. Nine patients who were mistakenly asked to complete the questionnaire on two occasions were also excluded. Thus, 80
patients (34 who completed the questionnaire 2 weeks after admission and 46 who completed it in the 5 days before discharge) were included for further analysis. The patients in our sample did not differ significantly in their sociodemographic characteristics, including age and sex, from other patients who had been admitted to the hospital
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Figure 2 Satisfaction with treatment: 22 areas (n = 80). Abbreviations are as in Figure 1. over a period of 1 year. With respect to psychiatric diagnoses, however, patients with depression (14%) and anxiety disorder (10%) were underrepresented in the sample (P = 0.000), while those with personality disorder (15%) were overrepresented (P = 0.000). Nearly half of the patients in both groups suffered from schizophrenia. A few more patients were in-patients based on court decisions, but the increase was not significant (12% compared with 9% of all in-patients). Ratings of importance The means of all 22 areas were tested for significance (onetailed t-test; level of significance P = 0.05 or P = 0.01), taking the discrimination point of 76.6 as a reference point. The results for the 22 areas are presented in Figure 1.
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The areas that received importance ratings significantly above the discrimination point included (1) the therapeutic relationship (physician, psychologist; P < 0.001); (2) relationship to nursing staff (P < 0.001); (3) relationship to social workers (P < 0.001); (4) cooperation of hospital staff with each other (P < 0.001); (5) medical/psychiatric examinations (P = 0.004); and (6) individual psychotherapy (P = 0.008). Importance ratings significantly below 76.6 were (1) group therapy (P < 0.001); (2) laboratory and other investigative procedures (P = 0.004); (3) physiotherapy (P = 0.003); and (4) information about treatment alternatives (P = 0.02). Some items from areas with an average rating were rated as significantly important when analysed separately, such as confidentiality, rules about temporary leave or telephone calls,
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Figure 3 Comparison of importance and satisfaction ratings of 22 areas of treatment (n = 80). Abbreviations are as in Figure 1.
information about the effects and side-effects of medication, effectiveness of medication, and participation in medication decisions. Items specific to care in a university hospital, such as participating in a scientific study or contributing to medical student education, were rated as unimportant by patients.
Ratings of satisfaction For satisfaction ratings, the arithmetic mean for all patients across all 77 items (with the visual anologue scale) was 68.4, and for item 92 the global rating was 66.9. The correlation between these measures was 0.63 (P = 0.004). The discrimination point for all ratings of satisfaction was 67.5 on
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a scale of 0–100. The results are presented in Figure 2. Six areas received a significantly higher positive rating than the mean rating of all areas as represented by the discrimination point. These were: (1) the therapeutic relationship to a physician or a psychologist; (2) relationship to nursing staff; (3) relationship to social workers; (4) relationship to physiotherapists; (5) relationship to occupational therapists; and (6) cooperation of hospital staff with each other. Seven areas received satisfaction ratings significantly below the 67.5 discrimination point. These were: (1) group therapy; (2) medication; (3) medical/psychiatric examinations; (4) other laboratory or investigative studies; (5) patient input in treatment planning; (6) information about treatment alternatives; and (7) physiotherapy. Areas relating to more general environmental factors (such as friendliness) and the ‘hotel factor’ (accomodation, food service, and some aspects of leisure activities) received an average rating. The negative rating of medication was based on items that pertained to: (1) side-effects of drugs; (2) lack of consideration for the patient’s attitude toward medication; and (3) lack of consideration for the patient’s preference for mode of administration of medication. Comparison of importance and satisfaction Areas that were rated as highly important yet received low satisfaction ratings (Figure 3) were: (1) medication; (2) medical/psychiatric examinations; and (3) the patient’s participation in treatment planning. Areas such as patient–staff relationships were rated as important and satisfactory, while other areas such as group therapy and physiotherapy were rated as unimportant and unsatisfactory. These results indicate that the patients are easily able to discriminate between importance of and satisfaction with different treatment apects. This individual evaluation has several implications for using these patients’ perspective in quality management. Concomitant factors of influence Ratings of importance and satisfaction were not significantly dependent on length of treatment, i.e. no significant differences in the t-test of independent samples for the mean of all areas (P = 0.77) and the summarizing item 92 (P = 0.92) in any of the 22 areas were found between patients given the questionnaire 2 weeks after admission and those given the questionnaire during the last 5 days of their hospitalization. There were no significant differences between the wards with respect to the importance ratings in any of the 22 areas [one-factor ANOVAs for all areas (P = 0.34) and summarizing item 92 (P = 0.34)]. Also, there was no significant difference in importance or satisfaction ratings between the sheltered and unsheltered wards (t-test for independent samples: P = 0.69 and P = 0.52, respectively). A significant difference in satisfaction ratings between the six different wards was found for only three of the 22 areas: (1) relationship to nursing staff; (2) cooperation of hospital staff; and (3) leisure activities. Psychiatric diagnoses had
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no significant influence on the ratings (Scheffe´ test for independent samples). Schizophrenic patients, however, rated the importance of their relationship to occupational therapists significantly higher (mean = 82) than patients with a personality disorder (mean = 62; P = 0.04). With respect to sociodemographic characteristics, food service on the ward was rated as significantly more important by males (mean = 86) than by females (mean = 75; P = 0.033). Ratings of importance showed no relationship to educational level. Significant differences on satisfaction ratings, however, were found for levels of education. Based on all 91 areas and excluding the global question about satisfaction, nonacademic patients who had held a job had a mean rating of 71 (on a scale of 100), while university graduates had a mean rating of 59 (P = 0.02). There was a significant positive correlation between overall quality of life and satisfaction with treatment (t-test for independent samples) whether it was measured by global item 92 (P = 0.007) or by the total arithmetic mean of the 77 visual analogue items (P = 0.000). At the P Ζ0.05 level, correlations were significant in 11 out of 22 areas, and at the P Ζ0.01 level correlations were significant in four areas relating to outward orientation (preparation for discharge and aftercare), leisure time activities, information about other treatment alternatives, and reachability and availability of contacts outside the hospital. No significant correlations were found between quality of life and areas relating to particular aspects of in-patient care, such as relationships to nursing staff, social workers, and physiotherapists, or to food service, medication, and cooperation of hospital staff.
Discussion and conclusions The reponse rate of 52% in this study is comparable to other non-interventional studies [13,15]. The recruitment of patients is satisfying, although from a methodological point of view we had wished for a higher rate. Two methodological aspects are important: (1) To obtain a representative sample without selection, all patients being discharged during the time window were recruited. However, some of the patients were acutely ill or refused further treatment and decreased the participant rate at the questionnaire. (2) The data sheets were filled in in the absence of the researchers to avoid a socially accepted answering style. The patients were asked to place the questionnaire in an envelope, to seal it, and to put it into a letter box at the entrance of the clinic. The data, therefore, were genuinely anonymous and the investigators were not able to identify answers of individually known patients. There was no researcher influence on questionnaire feedback after they had been distributed to patients. The anonymous type of questionnaire, which was also mandatory
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for data protection, is in contradiction to the scientific goal of describing the study population precisely. Fifteen per cent of patients refused the questionnaire at first contact. Four per cent of the questionnaires in the closed envelopes were not filled in. Some patients simply forgot to deliver the questionnaire. In this study, patients made it clear what they thought was important with respect to treatment, and what they were satisfied or dissatisfied with. Various therapeutic relationships, intra-staff cooperation, medical and psychiatric examinations, and individual psychotherapy were the areas that were considered important. A good relationship with therapeutic staff was highly relevant for the patients in accordance with other studies from German-speaking countries [19,30,31]. This is the case for all therapeutic subgroups and underlines the patients’ appreciation of a multiprofessional team inside a psychiatric hospital. This was also shown by the high ranking of cooperation between staff on the ward. This is more important for patient satisfaction than the ‘hotel factor’ (ward accommodation and quality of food) or the psychopharmacological treatment. The interpersonal relationship is clearly the most important and central factor of psychotherapeutic and psychiatric treatment, at least from the patient’s perspective. Also important were specific items within several domains pertaining to rights, privileges, and participation in various decisions. In future studies it would be worthwhile to construct a separate domain from these items under the heading of ‘autonomy’, since this represents an area that is clearly important to patients but has not yet been given sufficient attention in most studies similar to ours. Gender and diagnosis influenced importance ratings in only one area apiece. Male patients rated food service as significantly more important than did female patients, and schizophrenics rated their relationships with occupational therapists significantly higher than did patients with other diagnoses. The lack of differences between diagnostic groups could be caused by the group sizes. The large group of schizophrenic patients contained >50% of the patients, while other diagnostic groups had very small group sizes. Group therapy, laboratory and other investigative procedures, physiotherapy, and information about treatment alternatives were considered unimportant. This statement is astonishing as sufficient information in particular is demanded by affected patients and relatives groups. It is even more surprising given that satisfaction with the amount of information was low. Perhaps the patient’s discharge from hospital was so well prepared that his additional need for information is small. With respect to satisfaction, other studies in addition to ours have also shown that relationships with individual staff members receive a high ranking, whereas psychopharmacotherapy, group therapy [17,32], and autonomy [28] do not. Neither duration of hospitalization nor the wards themselves had any significant influence on satisfaction ratings in our study, although Spießl et al. [30] found otherwise. Patient satisfaction may develop within 2 weeks and does
not change during the mean stay of 24 days—or results may be biased by the fact that patients who are still acutely ill after 2 weeks may be less motivated to fill out the questionnaire and return it. Neither gender nor age had a significant influence on satisfaction ratings. Greenwood et al. [24] found a higher degree of dissatisfaction with treatment among younger females but we did not, nor did we find that other sociodemographic variables (other than level of education) or diagnosis correlated significantly with either satisfaction or dissatisfaction. Kelstrup et al. [15] and Barker et al. [16] found that patients suffering from affective disorders reported more satisfaction with hospital treatment than schizophrenics. There was no evidence for this from our data. The patients’ view of the importance of therapeutic relationships for treatment here is not only in line with other German studies, but also adds weight to the many research studies in the American literature that show that the doctor– patient relationship is more positively associated with successful therapeutic outcome than any other factor [33]. As the study patients were highly satisfied with the doctor–patient relationship, it might also positively influence the treatment benefit. This assumption could be tested decisively in a prospective study. Notable in our study is the finding that on in-patient wards, most relationships between patients and professionals, not just physicians, are considered more important than many other factors by the patients themselves. Fortunately, these relationships were also considered to be satisfactory by patients in the present study. However, the patient’s interpersonal relationship does not play an important role in reflecting quality of treatment. The importance of the several aspects of it, and satisfaction with it, is only one factor in psychiatric treatment. Treatment efficacy might be determined by factors that are either not realized by the patients or have satisfied them. Our findings highlight possible areas of future research. It would be worthwhile to learn why group therapy, particularly in light of the time and effort expended on it in most in-patient programmes, and information about treatment alternatives, a bedrock of the informed consent concept, are rated as unimportant. It would also be useful to know why some areas—physiotherapy and particularly group therapy— received such negative satisfaction ratings. It could be that importance ratings reflect a more general attitude towards treatment than do ratings of satisfaction, which reflect a set of treatment circumstances that patients encounter in a particular setting. This also implies that importance ratings may be more uniform in different in-patient locations, throughout Germany for example, while satisfaction ratings reflect local conditions, such as the quality of in-patient care at the University of Tu¨bingen. This idea is also supported by the studies cited above, which reveal significant differences between sites in satisfaction ratings for areas such as autonomy, and other variables such as duration of treatment, a specific in-patient unit, and gender. Indeed, the fact that all patients in our study were treated in the same university hospital represents a limitation of our study since it is hard
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to know to what extent the findings are a function of our particular group of care givers. A strong case can be made for asking patients to rate the importance of a particular aspect of care whenever satisfaction is evaluated. If an area is rated as satisfactory but is considered unimportant, for example, the satisfaction rating will have little meaning. Only when the two dimensions are measured together can they serve as an evaluation instrument and guide to action. Our findings have practical significance. The areas that were rated as important by patients and yet received low satisfaction ratings are the obvious candidates for remediable action. The first step of course would be to discover, in a systematic manner, why satisfaction with medications, medical and psychiatric examinations, and the treatment planning was in fact low. The provision of clear information to patients about the rationale, benefits, and possible untoward effects of any therapeutic activity is in every case necessary and may be helpful, as is the inclusion of patients and their families in the decision-making process, but whether or not these measures would improve satisfaction ratings remains to be shown. Replications of studies such as ours might, in the long term, have important implications for in-patient psychiatric treatment. If, on the one hand, it was widely reported in different in-patient settings in Germany or the United States that a particular kind of therapy was consistently rated as unimportant by patients, how should, or how could, those modes of therapy be improved? Or should they be eliminated? How much weight should be given to patients’ perceptions in such cases and what other evidence about usefulness should be considered if such a course of action is considered? If, on the other hand, different settings reported the importance of therapeutic relationships to patients and the relationships were rated as unsatisfactory, researchers and clinicians alike should wonder why. It takes time to develop relationships within in-patient units, and it could be that the relentless shortening of in-patient stays under the claim of cost effectiveness in all industrialized countries would be identified as a contributor to lack of satisfaction. If so, it would constitute a strong argument for a policy that advocated longer, not shorter, stays on psychiatric units. Until these general statements are validated by further studies, patient satisfaction can be used in a local setting. To improve quality of care in our institution, a patient questionnaire is issued every year over a period of 2 months. The questionnaire in this study is based on a precursor from previous research [34,35]. The interview identifies the patients’ views of our treatment and monitors the efficacy of the intended quality improvement steps. Despite the methodological problems and open scientific issues, the local usage of the patient satisfaction survey can currently be used for quality improvement in psychiatric hospitals.
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Accepted for publication 21 January 2003
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