Feb 23, 2017 - arises from the suggestion (Francis et al,. 1989) that Black patients ..... N Greenwood, A Key, T Burns, M Bristow and P Sedgwick patient and ...
BRITISH J O U R N A L O F PSYCHIATRY (1999).
174. 159-163
Satisfaction with in-patient psychiatric services Relationship t o patient and treatment factors N A N GREENWOOD, ADRIENNE KEY, TOM BURNS, MIKE BRISTOW and PHILIP SEDGWICK
Background There is growing concern about patient satisfactionwith psychiatric in-patient provision.This paper measures satisfaction in psychiatric in-patients and its relationshipswith patient characteristics and ward experiences.
Aims To: (a) measure overall in-patient satisfaction; (b) examine its relationshipto in-patient experiences; and (c) examine its relationship to patient factors.
Method
Four hundred and thirty-
three patients were interviewed. Satisfactionwas assessed by a single question, the Client Satisfaction Questionnaire (CSQ) and by a semistructured interview.
Results Over three-quarters of the patients were satisfied, but two-thirds reported adverse events. Females, younger patients and those detained were more dissatisfied. N o significant relationship was found for ethnic group.
Patient satisfaction is frequently audited since the National Health Service Management Enquiry (Depamnent of Health and Social Security, 1983) often using the Client Satisfaction Questionnaire (CSQ; Attkisson & Zwick, 1982) or versions of the Verona Satisfaction with Services Questionnaire (Ruggeri et al, 1994). It has intuitive appeal, is related to clinical outcome (Svenson & Hansson, 1994) and willingness to use services (Priebe & Gruyters, 1995). Correlations with patient characteristics, such as age, diagnosis, legal status and ethnicity have been reported (Perrault et al, 1996; Leavey et al, 1997). Afro-Caribbean patients may be less satisfied with care (Francis et al, 1989; Parkman et al, 1997). This study reflects growing concern about patient satisfaction with current in-patient provision - particularly in overcrowded wards in outdated institutions (Thomas et al, 1995; Royal College of Psychiamsts, 1998). We studied an innercity mental hospital, with a substantial ethnic minority population (Springfield Hospital, Tooting) and a small, purpose-built, suburban district general hospital unit (Chiltern Wing, Sutton).
Results were similar in the mental hospital and district general hospital.
METHOD
Conclusions There remain problems
In-patients from six acute psychiatric wards from the two hospitals were approached over a six-month period. Names of patients who were shortly to be discharged were obtained from ward staff. Patients, who gave informed consent, were interviewed just prior to discharge or after a month on the ward if they were able to understand the interview. The researcher (N.G.) explained the study, that she was independent of the clinical staff and that refusal would not affect care. Confidentiality was assured. Patients were excluded if their stay was less than five days (because of difficulty in ensuring interviews and the brief, variable exposure to the ward environment), or if
with satisfaction scales.Qualitative approaches to examine patients' experiences in hospital and the causes of dissatisfaction are recommended.
Declaration of interest Support was received from Merton, Sutton and Wandsworth Health Authority
unable to understand the questions. Patients readmitted during the study period were not reinterviewed.
Measures of satisfaction
Three patient satisfaction measures were used. The first was the single question "Overall how satisfied are you with your treatment here?". The answers were fixedchoice: very satisfied, fairly satisfied, neither satisfied nor dissatisfied, fairly dissatisfied, very dissatisfied, don't know. This question was asked twice to test for consistency - once near the start (Satisfaction 1) and again near the end of the interview (Satisfaction 2). Only the first answer was used for analyses. The second satisfaction measure used was the CSQ (Attkisson & Zwick, 1982). This is an eight-question validated questionnaire producing a single satisfaction rating with a score from 8 to 32. Third, patient experiences on the ward were collected using a semi-structured interview administered by the research interviewer. Questions addressed areas of concern to patients which were derived from focus groups with the Patients' Council, a literature review and a series of unstructured interviews. The final semistructured interview was piloted with 100 patients to ensure comprehensibility. It consisted of 113 questions covering 11 domains: how the patient came to be in hospital, most and least helpful aspects of their treatment-stay, treatment and its explanation, ward activities, food, privacy, staff interpersonal skills, adverse events, diagnosis, ward rounds and plans for discharge.
Patient characteristics
Patient characteristics of age, gender, respondent-defined ethnicity, first language, diagnosis, length of time since admission, Mental Health Act status on admission, number of previous psychiatric admissions, age at onset of the illness, home circumstances, accommodation, medication and years of education were collected. A subset of these characteristics (including ethnicity as defined in case notes or by staff) was extracted from case notes for non-responders to test for representativeness of the sample.
G R E E N W O O D E T AL
RESULTS
Analysis
The open-ended questions were contentanalysed and the frequency of the answers recorded. These data were subjected to simple descriptive statistics. Cross-tabulations of the Satisfaction 1 using satisfaction-dissatisfaction as the dependent variable with both patient baseline characteristics and the closed questions were carried out using 2 tests (satisfied patients were defined as those who described themselves as 'very satisfied' or 'fairly satisfied' and dissatisfied patients as those who described themselves as 'very dissatisfied' or 'fairly dissatisfied'). Logistic regression was undertaken with dissatisfactionsatisfaction as the dependent variable in order to obtain a reduced series of relative risks in terms of explanatory variables. Those predictive variables for which their univariate risks were significant at the 5 % level were entered. The derived estimated relative risks are conditional based on the other variables in the model. Forward conditional logistic regression was employed and probability for entry set at 0.05 and removal at 0.10. 2 tests were also used to look for differences in reports of adverse events between different groups of patients in terms of their characteristics and whether satisfied or dissatisfied with their care. Statistical significance was set at the 5% level. Kendall's r was used to test for correlation with ordinal variables.
Four hundred and thirty-three out of 464 eligible patients were interviewed (93.3%). Responders and non-reponders did not differ significantly for age, diagnosis, ethnic group, legal status, gender or length of admission. The mean CSQ score was 22.5 (s.d.=5.94) which represents moderate satisfaction. On the fixed-choice Satisfaction 1 question, almost three-quarters of the patients (73.4%) described themselves as 'very satisfied' or 'fairly satisfied'. Active dissatisfaction (those describing themselves as 'very dissatisfied' or 'fairly dissatisfied') was expressed by 15.5%. When the same question was repeated at the end of the interview (Satisfaction 2), there was a slightly reduced satisfaction rate (71.9% satisfied and 16.8% dissatisfied), but this was not statistically significant (McNemar's test n=384, P=0.359). The CSQ was strongly correlated with both the Satisfaction 1 rating (Kendall's r=0.56, P < 0.001) and with Satisfaction 2 (Kendall's r=0.67, P < 0.001).
Determinants of satisfaction
When only the ratings of those patients who considered themselves to be either satisfied or dissatisfied were cross-tabulated with patient characteristics, age, gender
Table I Patient characteristicsand satisfaction Satisfied group' n
(%I
Dissatisfiedgmud n
x2 test statistic
(d.f.)
P
(%)
Legal status
and Mental Health Act status (formallinformal) were significantly associated with satisfaction. Females, younger patients and those detained under the Mental Health Act were more likely to be dissatisfied with their treatment (see Table 1). No statistically significant relationships were found for ethnic groups (Whitdnon-White, WhiteiBlack) regarding satisfaction, although a marginally higher proportion of White patients than either non-White or Black patients were satisfied. Logistic regression was used to obtain relative risks for dissatisfaction (Table 2). Features of the hospital stay were more strongly associated with dissatisfaction than patient characteristics. The seven variables that emerge as significant concern staff in 'staff want to help' or 'staff have explained treatment', patients feature in 'believe it is essential to be in hospital', 'feel better' and 'able to complain' and features of the environment such as 'food is liked' and the patient 'felt safe'. Overall, the ratings for satisfaction and adverse experiences were fairly similar for the district general hospital and the mental hospital settings (Table 3) with a non-significant but consistent advantage to the district general hospital. The only statistically significant difference reported was being sexually harassed (9.9% in the mental hospital and 2.7% in the district general hospital; zZ=5.82, P
