Vol-12, No. 2, April 2016
Eleena Kumari, Ponnamma R. Singh, Neeta Austin Singha
Abstract : For individual members of a complex health care delivery system, it is important to achieve a sense of connectedness related to standards of quality in the work place or on specific units in large institutions. The present research study was to assess quality of care as expressed by clients in a psychiatric unit; to ascertain the relationship of expressed quality of care with selected variables. The design adopted for the study was descriptive using a structured interview schedule in accordance with levels of expressed quality care standards. The participants consisted of 30 clients with insight grade ³ 3. The structured interview was taken on the day of discharge. The clients were having diagnosis of substance abuse (40%) followed by neurotic disorders (33.3%) and equal number of clients were having psychotic and stress related disorders (13.3%). 63.3% of clients rated quality of care as high (standards met) and 36.7% of clients expressed quality of care as low (standards not met). Quality of care was rated higher by clients of age group ³ 40, males, unmarried, employed, those with a lower educational level, nuclear families, were having psychotic and neurotic illnesses,having duration of illness of ³ 1 year, having longer duration of hospitalisation, more number of hospitalisation, having insight of grade 5.
Keywords
Insight grade, Neurosis, Psychosis, Standard, Quality of Care.
Correspondence at
Ms. Eleena Kumari
Clinical Instructor
Khalsa College of Nursing, Amritsar, Punjab
Introduction
Most of the time, views and opinions of mentally sick patients are not taken for consideration. Although they are our clients to whom services are being provided. They must evaluate their care in order to make improvements in future. This research study may prove as a stepping stone to reach those mentally sick patients who are not being valued for their opinions.
Improving health care quality and patient safety are currently high on the national health agenda, a focus that will only intensify going forward. Nowadays patients have knowledge and expectations with regard to what care is available, including effectiveness, quality of service and treatments and they are more aware of their problems and diagnosis. (Shelton PJ, 2000).
The Indian government estimates that 1% to 2% (10 to 20 billion) of the Indian population suffers from major mental disorders and around 5% (50 billion) suffer from minor mental disorders. There are 37 government-run psychiatric hospitals in India, most of which are managed by state governments. These facilities have a total capacity of 18,000 inpatients; almost half of available beds are occupied by long stay patients. (Reddy VM, Chandrashekar CR, 1998)2. Only the patients themselves can describe their conceptions of quality of care regarding treatment, the staff and the accessibility of care. Such information can be used in the improvement of the care. Woodring, S et al. (2004)3.
There is no existing gold standard for measuring quality of care in the psychiatric setting and consequently one of the major problems in this area of research is the lack of uniform methods and instruments. This means that it is difficult to compare one set of results with another. Still, we can assess experiences and expressions of clients and their significant relatives to know about their perception of quality care. These kinds of small researches may help in improvement of quality care in mental health facilities and may provide a basis for further research.
Objectives
- To assess quality of care as expressed by clients in a psychiatric
- To ascertain the relationship of expressed quality of care with selected variables
Materials and methods
Quantitative research approach with descriptive research design was adopted to assess expressed quality of care by clients in the psychiatric unit of CMC & H, Ludhiana with a criterion measure of < 75%= Low quality (Standards not met), >75%= High quality (Standards met) and structure, process and outcome quality care standards were assessed using a structured interview schedule reared by researcher. It consisted of 46 items regarding assessment of expressed quality of care by clients. The structured interview schedule was divided into three parts according to expressed quality care standards; a) Items related to structure standard [13 items with maximum score of 52], b) Items related to process standard [24 items with max score of 96], and c) Items related to outcome standard [9 items with max score of 36]. Maximum quality care score was 184 and Minimum quality care score was 46. Levels of expressed quality care standards were High(standards met with score of ≥ 138 and percentage of ≥ 75%) and Low (standards not met with score of <138 and percentage of <75%).
In structure interview schedule used for hospitalised clients, there were 17 direct items and 29 reverse items. Each item has four options i.e. Not at all, somewhat, Quite a bit, A great deal OR Always, usually, sometimes, never OR No, unsure, sometimes, yes OR not showed any interest, casual response, little bit, warmly according to individual items. Scores for direct items were 4, 3, 2 and 1, whereas for reverse items, score were 1, 2, 3 and 4. Total score for structured interview schedule is 184 and minimum score for structured interview schedule is 46. The scores on the structured interview schedule were interpreted as follows: 1 and 2= Low quality (Standards not met), 3 and 4= High quality (Standards met).
Before conducting the study, ethical clearance was obtained from ethical clearance committee of college of nursing, CMC & Hospital and permission was taken from head of department of psychiatric unit.Period of data collection was December 2013 to February 2014. Insight may be defined as a conscious recognition of one’s own condition. Using a purposive sampling technique, hospitalised mentally sick clients with an insight grade of ≥3 and a hospital stay of ≥ 3 days were included with a sample size of 30. After giving self introduction, Researcher discussed type and purpose of research study with clients.
Insight is a routine assessment in which client is being questioned about his conscious awareness of mental disorder whether client recognises his illness or not. The questions being asked by researcher are as follows; 1) do you think that you are having any mental disorder as you are here in this psychiatric unit? Client may deny the illness completely saying I don’t have any disorder then he will be graded as insight GRADE-I mean complete denial of illness. The other answer may be an ambivalence about illness, client may answer I don’t have any mental sickness but sometimes I feel my mind is having some problem or I am mentally disturbed but I am not sure about presence of mental sickness then client will be graded as insight GRADE-II means slight awareness of being sick and needing help but denying it at the same time. If client says yes, then next question will be asked. 2) What is the cause of your mental sickness?
The client may blame external factors such as my work environment, home, spouse, or anything which is present in external environment (an accident, head injury, falls etc.) OR blaming psychological factors such as I am having childhood burdens, it is because spouse is not good to me or nobody ever loved me, it is because I am so alone, not having any friends and so on. Here, client will be graded as GRADE-III means awareness of being sick but blaming it on others, external factors, or organic factors, GRADE-IV means awareness that illness is due to something psychological which is unknown in the patient, 3) if client answers right to question no. 2 and demonstrates an understanding of the cause of mental sickness, it can be because of two reasons; a) any health care professional must have educated the client about his mental sickness which will be graded as GRADE-V is Intellectual Insight i.e. admission that the patient is ill and that symptoms or failures in social adjustment are due to patient’s own irrational feelings without applying this knowledge to future experience which is being told by health care professional. b) Client is having GRADE-VI i.e. True Emotional Insight: emotional awareness of motives and feelings within the patient and the important persons in his or her life, which can lead to basic changes in behaviour, here client completely understands the nature of mental sickness and reveals the psychiatric history in a chronological order.
Insight grade was assessed before actual interview. Written consent was obtained thereafter. Inter view was conducted in recreational room in psychiatric unit which was separate and free from noise.
Researcher and client were sitting face to face at the same level of chairs with a table making a distance of 4 feet. Researcher did ask each item in the serial order and wait for client to respond and accordingly it was marked as expressed by client. Item was explained in clear and audible voice in an understandable language (preferably regional language- Punjabi). Each interview took 25-30 minutes, which was conducted on the day of discharge. Responses for each query in structured interview schedule vary from always, usually, sometimes or never; Not at all, somewhat, Quite a bit, A great deal; No, unsure, sometimes, yes; not showed any interest, casual response, little bit, warmly according to individual items. Client has to select the correct answer according to his perspective which was scored later to assess expressed quality of care.
53.3 % were having duration of hospitalisation of 3 days- 6 days, 73.3% were admitted for the first time, and were having insight grade 5 (73.3%).
Table-I: clients’ illness related variables
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Analysis of the data was done in accordance with objectives of the study. It was done by using the descriptive statistics such as percentage, mean, mean percentage, standard deviation as well as inferential statistics i.e. ‘t’ test and ANOVA were used. Bar diagrams were used to depict findings.
Results: Participant characteristics
Majority of the clients were males (76.7%), matric-10+2 (53.3%), of age 41- 60 years (46.7 %) married (90%), having joint family (80%), and professional or were doing business (60%). Table-I depicts the frequency and percentage distribution of clients according to variables related to client’s illness in which 40% of clients were having diagnosis of substance abuse, 60% were having duration of illness for more than 1 year,
Table- II: Levels of Expressed quality
Table-III depicts mean, mean
care standards (EQCS)
Maximum Quality care score=184 Minimum Quality care score=46
percentage and rank order of expressed quality care score according to expressed quality care standards. It depicts that structure standard ranked first with mean percentage of 85.4; process standard ranked second with mean percentage of 77.3 followed by outcome standard ranked 3rd with mean percentage of 68.6 as expressed by clients.Table-II depicts frequency and percentage distribution of clients according to levels of expressed quality care standards. It depicts that 63.3% of clients rated quality of care as high (standards met) and 36.7% of clients expressed quality of care as low (standards not met).
Table III: Expressed quality care score of clients
|
EQCS |
Max Score |
Expressed quality care score |
||
|
Mean |
Mean % |
Rank Order |
||
|
Structure Standards |
52 |
44.4 |
85.4 |
1 |
|
Process Standards |
96 |
74.2 |
77.3 |
2 |
|
Outcome Standards |
36 |
24.7 |
68.6 |
3 |
Table-IV depicts frequency and
Table- IV : Levels of Expressed quality
percentage distribution of clients and their significant relatives according to expressed quality care standards and levels of expressed quality care standards. It depicts that Expressed quality care score of clients according to structure standard was expressed as high by 93.3%. Expressed quality care score of clients according to process standard was high as expressed by 53.3% clients. 46.7% of clients expressed quality of care as low (standards not met) in process standard. Expressed quality care scores according to outcome standard were low as expressed by 66.7% clients.
Clients expressed outcome standards as high. That indicates that most of clients were satisfied with structure standards but not with process & outcome standards.
care standards (EQCS)
|
EQCS (Max. Score) |
f % |
|
Structure (52) |
|
|
· High (≥75%) |
28 (93.3) |
|
· Low (<75%) |
2(6.7) |
|
Process (96) |
|
|
· High (≥75%) |
16(53.3) |
|
· Low (<75%) |
14(46.7) |
|
Outcome (36) |
|
|
· High (≥75%) |
10(33.3) |
|
· Low (<75%) |
20(66.7) |
Table V shows that mean Expressed quality care score was higher in clients who were having psychotic illness with mean 149.5 followed by clients who were having neurotic illness with mean 143.5 as compared to clients who had substance abuse and stress related disorders with mean 142.0 and 140.8 respectively. The table f value for 3/26 degree of freedom at 0.05 level of significance was 2.28 found to be statistically non significant which indicates that type of illness of clients did not influence clients’ expression of Quality of care in psychiatric unit (as per ANOVA).
Mean expressed quality care score of clients was higher in clients with insight grade of 5 with mean 145 as compared to clients having insight grade of 3 with mean 138.8. This difference in mean was not statistically significant (as per t test). Hence, it was concluded that difference in insight grade of clients did not influence clients’ expression of Quality of care in psychiatric unit.
Highest mean expressed quality care score of 148.5 was expressed by clients having duration of illness of more than 1 year followed by mean expressed quality care score of 144.7 of clients duration of illness of 2 months to 12 months and least mean Expressed quality care score of 126.5 was in clients having duration of illness of 1 week-1month. The F value was 5.4 at 2/27 degree of freedom which is significant at 0.05 level (as per ANOVA). Hence, it was concluded that duration of illness had impact on clients’ expression of quality of care in psychiatric unit.
Table- V: Expressed quality care score of clients according to Type of illness, Insight grade and duration of illness
|
|
Expressed quality care score |
F ratio (df)/ t(df) |
P |
||
|
F |
Mean |
SD |
|
|
|
|
Type of illness |
|
|
|
|
|
|
Neurotic |
10 |
143.5 |
17.0 |
2.98 (26,3) |
0.23 |
|
Psychotic |
4 |
149.5 |
12.5 |
|
|
|
Substance abuse |
12 |
142.0 |
19.0 |
|
|
|
Stress related disorders |
4 |
140.8 |
12.8 |
|
|
|
Insight grade |
|
|
|
|
|
|
Grade-3 |
8 |
138.8 |
18.1 |
1.7 (28) |
0.92 |
|
Grade-5 |
22 |
145.0 |
15.8 |
|
|
|
Duration of illness |
|
|
|
|
|
|
One week to 1 month |
6 |
126.5 |
11.6 |
5.4(27,2) |
0.01 |
|
2-12 months |
6 |
144.7 |
22.6 |
|
|
|
More than 1 year |
18 |
148.5 |
11.7 |
|
|
Discussion
Client care needs to be evaluated from client’s point of view also. This would be helpful not only in evaluation, but will also improve client satisfaction and faith towards health care personnel. There is not enough literature regarding evaluation of client care by clients only. Expressed quality care standards (EQCS) refers to the structure, process and outcome standards in which, structure includes physical infrastructure of ward, staffing, and finance; process includes providing care and information, communicating therapeutically, considering ethical principles and outcome includes client satisfaction, knowledge, compliance and recovery.
Structured questionnaire used in present research study brings about two levels of EQCS i.e. High (standards met if client’s evaluation of structure, process and outcome standards according to structured questionnaire are above ≥ 75%) and low (standards not met if client’s evaluation of structure, process and outcome standards according to structured questionnaire is
<75 %). A score of ≥ 75% reveals that client is satisfied with structure which includes physical infrastructure of ward, staffing, and finance; process includes providing care and information, communicating therapeutically, considering ethical principles and outcome includes client satisfaction, knowledge, compliance and recovery.
The findings of the present research study may help in changing attitude of community towards mentally sick as they have proven to be good decision maker in improving the care provided to them.
Results indicated that quality of care was rated higher by clients who were having psychotic and neurotic illnesses, having duration of illness of more than 1 year, having insight of grade 5. These findings are supported by Barker et al (1996)4 who revealed that patients with a diagnosis of a non-affective psychotic illness, particularly those lacking insight were significantly less satisfied with their care.
Quality of care was significantly correlated with duration of illness which states that clients with more experience of health care services can evaluate care provided and make comparison between different settings. These findings were contradicted by Blenkiron P & Hammill C, (2003)5 who reported that duration of disorder were not related to service satisfaction.
In the present study, majority of clients expressed quality of care as high (standards met). These clients were having insight grade of 3 or more, and were having psychotic illness. Duration of illness was significantly correlated with expressed quality care. The researcher recommends this study to be replicated on a large sample to validate and generalize its findings; a similar research study can be conducted on sample using a different approach like evaluative research; qualitative research may be done to have in-depth interview to assess quality of care; an experimental study can be conducted to assess impact of specific care strategy on quality of care.
Nurses should routinely take feedback from clients and their significant relatives about quality of care. At the same time, quality of care should be evaluated at all hospitals in various wards and departments of the hospital. Administration needs to take initiative to organise in-service education, workshops and conferences for health care professionals so that they can be made well versed with standards and ideal practices of psychiatry in dealing with psychiatric clients to improve quality of care.
References
- Shelton PJ. Measuring and Improving Patients Gaithersburg, Medical: Aspen Publishers. Evaluation Review June 1997; 21: 357- 363
- Reddy VM, Chandrashekar CR. Prevalence of mental and behavioural disorders in India: a meta- Indian Journal of Psychiatry, 1998, 40:149–157.
- Woodring S, Polomano RC, Haagen BF, Nuun RR & Zarefoss, Development and testing of patient’s satisfaction measure for inpatient psychiatry Journal of Nursing Care Quality 2004; 19:137-148.
- Barker DA, Shergill SS, Higginson I, Orrell Patients’ views towards care received from psychiatrists. British journal of Psychiatry. 1996 May; 168(5):641-6.
- Blenkiron P, Hammill (2003). What determines patients´ satisfaction with their mental health care and quality of life? Postgraduate Medical Journal, 79:337-340.