Pat ient Comments About Hospi ta l izat ion: Implications for Change

Jane t C. A l len and Gail M. Bar ton

p A T I E N T C O M M E N T S about their psychia t r ic hospi ta l iza t ion a~ie being looked at with new perspect ives . No longer a re their r e m a r k s elicited to

m e r e l y reassure t h e ca re providers tha t they did a good job. ~-'~ Pa t ien ts a re now being seen as consumers of hea l th care; they a re act ive par t ic ipan ts in the process r a the r t h a n passive recipients of ' t r ea tmen t f rom someone who knows what is good for them. ~or When taken less casually, pa t ien t s ' c o m m e n t s can be used as a p rog ram effectiveness m e a s u r e and may even be expanded and included in the record for review by represen ta t ives of the Profess ional S t anda rds Review Orga- nization (PSRO) .

The usefulness o f ascer ta in ing a t t i tudes of pa t ients could be far reaching. The i r con ten t could be collect ively analyzed t o measu re how the milieu is affect ing pat ients f rom the i r van tage point r a the r than f rom tha t of the staff, as was the prac t ice previously, s-~° Pa t ien t c o m m e n t s might be elicited about .adminis t ra t ive issues, such as p r o g r a m m a t i c changes , budget a l locat ions , s taf f a l t e ra t ions , and facil i ty modificat ions. The i r a t t i tudes would have the potent ia l for providing a focus for l ra in ing personne l , not only about the types o f i s sues tha t a r e focal points for pa t ien ts , but also about the t ra ining personne l ' s effectiveness and thei r c lar i ty of communica t i on i:n their t he rapeu t i c approach . Pa t ien ts might suggest a reas for fu r ther research , for example , unme t needs, explora t ions o f the l a t en t con ten t o f over t ly expressed a t t i tudes about hospi tal care , para l le l i sm of pa t ient a t t i tudes , etc.

N o t only would i t be potent ia l ly useful to look at the con ten t o f the types o f pa t ien ts ' con t inen ts ment ioned above but it would also be helpful to s tudy the po- lari ty, i.e., the positive, negative, or neu t ra l qual i ty o f each c o m m e n t . Resea r che r s have previously noted tha t the quali ty of the pa t ien t s ' a t t i tudes about the i r hospi- ta l izat ion varied depending upon the t iming o f the reques t for in format ion . 3-6-tj For example , K le t t el al. r epor ted tha t pa t ien ts expect ing to leave the hospi ta l within a month o f fililing out a ques t ionna i re were more cri t ical o f the hospi tal than pa t ien ts less optimis~tic about an upcoming discharge. ~

T h e p resen t s tudy will be concerned with w h e t h e r o r not a t t i t udes shif ted f rom

From the Contimzit), of ,Care Research Project, Department o f Psychiatry. Uni~,ersity o f Michigan, Ann Arbor. Mich.

This article is par t o f tt~e Continuity o f Care Research Project sponsored by the University o f Michigan Department o f P.Lt'chiatr~'. Prior to July t973, the Project was directed by Dr. Tsung-Yi Lin and sponsored be the School o f Public Health and the Michigan Department o f Menta l Health. .This paper was done in collaboration with Michael Brachman, B.S.

Janet Allen: Research Assistanz, Depar tment o f Ps),chiatr)'. University o f Michigan, A n n Arbor. Mich. and Social Work Major. Eastern Afichigan University, YpsilantL Mich.: Gall Barton, M.D. , M.P.H. : Assis tant Professor o f Psychiatry and Director o f the Continuity o f Care Research Project, UniverMty o f Michigan, A n n drbor , Mich.

Reprint requests should be addressed to Gall Barton, M.D. , e iverv iew Clinic, University Hospital, 1405 Ann Street , A n n Arix~r, Mich. 48104.

® 1976 by Grune & Strat ton. Inc.

ComprehensiVe Psyc,~Jat.ry~ Vol. 17. No. 5 (September/October). 1976 631

6 3 2 ALLEN A N D BARTON

a d m i s s i o n t o d i s c h a r g e t o f o l l o w - u p . I t wi l l a l s o g r o u p t h e c o n t e n t i n t o c a t e g o r i e s

a b o u t w h i c h t h e p a t i e n t s . e x p r e s s e d c o n c e r n , C o m p a r i s o n s o f t h e c o m m e n t s a n d

p o l a r i t i e s o f t w o w a r d m i l i e u x wi l l b e c o m p a r e d a s w e l l t o s e e i f d i f f e r e n c e s w e r e

o b v i o u s .

MATERIALS AND METHODS

The Set t ing This study consisted o f all patients admitted and /o r discharged over a 6-month per iod . (Feb-

. ruary-Ju|y 1972) to and from the two adult wards o f the Neuropsychia t r ie Inst i tute Of the Universi ty of Michigan .Medical Center . The wards were s imi lar to those of many o ther instRutions the .au thors have .visi'¢ed.

Both wards at NPI were alike physically: poor lighting, chipped paint, corridors too nar row to allow gathering in groups any las, ger than 2 or 3. The stairs for both wards we re usually locked, but the hos- pital elevator opened onto the t~ain corridor near the ward dining room, To maintain security, a s taff person monitored the elevator Corridor.

The format on the acute admitting ward consisted of patients and staff meeting together at least once weekly to discuss problems about rules, regulations, and ward issues. In weekly team meetings, ward staff.discussed patients" progress as well as plans for fur ther t rea tment and disposition. At least three times a week, patients met in groups led by their s taf f team. Individual therapy was planned ac- cording to the patients" and training therapists ' needs. Most of the therapists were first or second year residents supervi,:¢xd by senior staff psychiatrists or psychologists. Psychotropic medications were prescribed for most patients. Occupational and recreational therapy ( O T / R T ) consisted o f learning different ar ts and craf ts for leisure, team participation for improving interpersonal relationships, and organization o f t ime around activities o f daily living.

On the long-term ward, the doctors were in charge o f the ward staff teams. They made most of the decisions regarding the patients" privileges. Patients were seen in individual therapy at least three times a 'week by therapists who were at the same level o f experience as on the o the r ward. O T / R T was mainly diversionai, meant to pass the t ime between psychotherapy appointments.

The staffing on each ward included nurses, aides, clerks, social smarkers, psychologists, psychiatrists, housekeeping, and trainees from 'each of the professional disciplines. The acute ward was administered by the chief resident, the other by a par t - t ime senior staff psychiatrist.

ProCedure O f the 184 cases in the ent ire study, 95 patients provided at t i tude data from all three phases of care,

admission, discharge, Canal at least one follow-up: so these cases were selected for fur ther analysis. To de te rmine the at t i tudes-of the patients toward their hospitalization, personal interviews at 3, 6,

and 12 months af ter discharge were done by ei ther the.authors or trained interviewers. The interview items went beyond the scope o f this paper, since they were meant to give a picture of the patient from psychologic, biologic, and social bases. The interviews were conducted face to face or by te lephone if the patient lived a great distance away. The items assessed the patient 's level of activity, his participa- tion in psychologic therapies, his ability to re integrate into the community , and his symptomatology. In addition, the patients were asked .questions pert inent to ascertaining att i tudes toward hospitalization: "'Do you have any complaints about the care you received at NPI?'" ( I f no spontaneous reply: staff, rules, etc. were suggested.) "'Do you have any suggestions for improving the ca re at NPIT" "*Anything else?" (pause) "'Is there something 3"ou thought was particularly good about NPI?'" These comments were then groupe,J by matching like Reins into categories and subcategories indica t iveof each area o f concern.

The assignment o f polarity to each comment within each category was done in o rde r to establish if there were a majority o f comments more positive or negative about the specific categories . It was felt that compiling the polarity aspects of the subcategories could provide fur ther evaluative information about the'milieu and the general tone of patient att i tudes. The assignment o f polarity to the comments patient-by-patient would then allow fur ther comparison of the at t i tudes at each phase of the part icular patient 's care, as well as with other patients" at t i tudes at the different phases of care.

T h e polarity at admission and discharge was predetermined by coded answers. Upon admission, the admitting physician was asked to assess the patient 's ~tttitudt: toward admission and choose one of the

PATI.ENT COMMENTS ON HOSPITALIZATION 633

following: positive, neutral, ambivalent, negative, .very negative, other, or don't know. At discharge the patient was asked "'Do you feel you have been helped by having been in the hospital?" and could choose one of the following answers: very much, some, not much, not at all, other, or don't know. These data were simplified in fire analysis to positive, neutral, and negative responses. The other and don't know responses werediscarded.

.In order to achieve the polarity of tkefo'llow-up questions, the authors had .to judge the comments for their degree of polarity. For example, comments such as "'Lack of commtmication among staffand patients" or "'1 would like to bomb the place" were considered negativ¢~ A comment such as "'I thought the staff was very good and helpful" or "'It really helped me" was catdgorize d as positive, ';It was okay" or a reply, "q have no complaints or suggestions'" was categorized as neutral.

To further make this data .comparable f~'om a polarity standpoint,.the data was first compared as far as patient-by-patient at 3, 6, and 12 months. Since the data showed 1hat a patient's iattitude did not change from one follow-up interview to the next, the attitudes were lumped into one follow-up category rather than separate 3-, 6-, and 12-month follow-up categories. If t-he follow-up interview data resulted in more than one comment per .patient, as it often did, the overall .polarity of the comments was de- termined by the following method.

Polarity of Comments

negative only neutral only positive only 3 negative and 1 positive 2 negative and2 positive 2 negative and 3 positive

Rating

negative neutral positive negative neutral neutral

This then made it possible to make an overall comparison of the polarity of each patient among all the phases of care: admission, discharge, and follow-up.

Furthermore, it was possible by using the polarity categorization of each patient 's follow-up at- titudes to assign patients into polarity groups: one of positive commentors, another of negative com- mentors, and a 1bird of neutral commentors. The demographic variables for ~ach patient, ~uch as age, race, sex, marital status, and education, were also ascertained and sorted into the appropriate polarity group. These "~ariables of the three groups were then compared to see if differences were apparent between the polarity groups.

R E S U L T S

Content o f Contrnents

O f t h e 342 c o m m e n t s f r o m t h e 95 pa t i en t s~ f o u r m a i n c a t e g o r i e s o f c o n c e r n e m e r g e d : (1) r e l a t i o n s h i p s , (2) t r e a t m e n t , (3) p h y s i c a l e n v i r o n m e n t , a n d (4) d i s - pos i t i on . M o s t c a t e g o r i e s h a d s e v e r a l s u b c a t e g o r i e s t h a t will b e m e n t i o n e d in t h e r e p o r t i n g o f t h e r e s u l t s . M o s t o f t h e c o m m e n t s w e r e e i t h e r p o s i t i v e o r n e g a t i v e , so t h e p o l a r i t y i s g i v e n i n p a r e n t h e s e s a f t e r e a c h s u b c a t e g o r y .

(1) Relationships. T h e r e w e r e m o r e c o m m e n t s a b o u t r e l a t i o n s h i p s o n t h e w a r d t h a n a n y o t h e r c a t e g o r y ( 1 4 1 ) a n d a l m o s t t w i c e as o f t e n n e g a t i v e t h a n pos i - t ive ( 9 3 - , 4 8 + ) . E l e v e n p a t i e n t s p e r c e i v e d t h e i r r e l a t i o n s h i p s w i t h w a r d s t a f f a s h a m p e r e d b y a l a c k o f s t a f f t r a i n i n g a n d c o m p l a i n e d t h a t " ' R e s i d e n t s a r e n ' t s u p e r v i s e d e n o u g h " a n d " ' N u r s e s a n d P C W s n e e d m o r e t r a i n i n g . ' , O n l y o n e p a t i e n t m a i n t a i n e d t h a t t h e s t a f f w a s " ' t r a i n e d f o r t h e i r j o b a n d k n o w w h a t t h e y a r e d o i n g . " T h e r e w e r e a n e q u a l n u m b e r o f p a t i e n t s c o m p l a i n i n g a b o u t s t a f f a t - t i t u d e s a n d a p p r o a c h as t h e r e w e r e p o s i t i v e c o m m e n t s ( 3 2 - , 3 2 + ) . S o m e o f t h e f a v o r a b l e c o m m e n t s i n c l u d e d " 'good u n d e r s t a n d i n g s t a f f , " a n d " ; the s t a f f h a d a l o t o f p a t i e n c e w i t h m e a n d w e r e v e r y n i c e . " I n c o n t r a s t , s o m e p a t i e n t s sa id : " T h e s t a f f t a l k s a b o u t i n s i g n i f i c a n t t h i n g s a n d r e p e a t s t h i n g s to t h e p a t i e n t s , " " ' S t a f f s h o u l d be w a r m e r , l e s s i n s t i t u t i o n a l , " a n d "'I fe l t an o v e r w h e l m i n g a u t h o r i t y o f

634, ALLEN AND. BARTON

s taf f ." T h e r e were a n u m b e r of c o m m e n t s t h a t singled out pa r t i cu la r s taf f m e m b e r s ; these c o m m e n t s usual ly paral!ed each o the r for a pa r t i cu la r person and tended to have s imi lar polar i ty for each staff.

A n o t h e r a rea tha t was men t ioned f requent ly waS s taf f communica t ion ( 2 3 - , i + ) . T h e compla in ts i nc luded : " 'Communica t ion to my local d o c t o r was not made, . . . . T h e "rules and regula t ions were ambiguous and leaves ques t ions in the pat ients" minds as to what is expected , allowed, e t c . , " " 'There is a lack of com- munica t ion between doc to r and ward s taff as far as o rders for the pa t i en t , " and " 'My pa ren t s c ame to pick me up and I wasn ' t even told I was leaving. '"

(2) Treatment. I n genera l , twice as many pa t ien ts expressed posit ive reac- t ions about the usefulness o f the i r t r e a t m e n t as those who felt it did no good ( 1 3 - , 27+) . Examples o f the posi t ive c o m m e n t s included: " 'I t really helped me a lot, '" " I t helped me in amazing ways, . . . . N P I was g r ea t and it was exact ly what I needed a t tha t t ime in my l ife ." An example of an opposing view was s ta ted : " 'We d idn ' t s tay on one subject 10ng enough for me to get any th ing out o f it.'"

M o r e specifically, t r e a t m e n t wi th -medica t ion received a number of negat ive c o m m e n t s ( 1 9 - , D+) . All the pa t ien ts c o m m e n t i n g said tha t drugs were "'too s t r o n g " and were used "'too much. ' " T r e a t m e n t for physical p roblems was also ment ioned : the re were a few compla in t s t ha t physical p rob lems had been over- looked.

Group the rapy was ment ioned by nine pat ients , all negatively. M a n y of those pa t ien ts had had admissions to b~th wards. C o m m e n t s included: " 'Group the rapy saves hospi tal t ime and money but is not good for pa t i en t s , " " G r o u p the rapy is a farce. '" O n e pa t ien t ' s a t t i tude may summar ize the disl ike o f groups: : 'The idea o f g roup the rapy is poor. S t a f f d idn ' t know how to do group therapy. In o rde r for groups to work, pat ients have to t rus t each o t h e r and tha t is hard on wards with people coming and going so often. '"

The activity the rapy p rog ram received an equal n u m b e r o f con t rad ic to ry s ta te- ments ( 8 - , 8 + ) of: " 'nothing to d o , " "'too much volleyball , '" or " ' the out ings were real nice,'_" " I l iked the music and in te res t g r o u p s , " with one pa t ien t summing it up, " 'The level o f activity is incons i s t an t f rom day to day . "

O t h e r c o m m e n t s about t r e a t m e n t included length o f s tay, teaching and re- ¢.

search , and compar i sons with o t h e r inst i tut ions. C o m m e n t s on length of s tay were con t r ad i c to ry w i th th ree shying they were kept too long and four saying they were not kep t long enough. T h e t h r ee c o m m e n t s re lat ing to teaching and research at t he hospi ta l were all negative: " 'There is too much money in r e s ea r ch , " "'I had a

• feeling o f being a guinea pig for t e ach ing , " and " 'NPI is too teach ing-or ien ted and not pa t ien t -or ien ted . ' " When N P I was compared to o the r p r iva te and s t a t e menta l hea l th facilit ies, t he re were twice as many posit ive c o m m e n t s as negat ive com- men t s ( 3 - , 7 + ) . For example, N P I was descr ibed as the " 'best menta l unit l ' ve been in" as opposed to " 'Kalamazoo S t a t e Hospi ta l was much bet ter . ' "

(3) Physical environment. T h e pa t ien t c o m m e n t s focusing on the physical en- v i ronmen t were most ly negat ive. T h e locked doors (11 - , 1 + ) and lack o f f reedom of m o v e m e n t ( 1 2 - , 1 + ) were mos t of ten ment ioned. Pa t i en t s expressed feelings about the rules ( 6 - , 1 + ) such as : " 'We need more patients" r igh ts" and "'I was not al lowed to call my husband when admi t t ed because "no phone calls a f t e r 11:00" and it was 1 l : 3 0 : T h a t was ridiculous and it upset me all the more. '" T h r e e pa t ien ts agreed tha t "'visiting hours a re too short . ' " The diet elicited con t rad ic to ry s ta te-

P A T I E N T C O M M E N T S O N H O S P I T A L I Z A T I O N

T a b l e 1. Po fa r i t y P a t t e r n s o f A t t i t u d e s A b o u t H o s p i t a l i z a t i o n a t D i f f e r e n t P h a s e s o f C a r e in Each M i l i e u

6 3 5

Patterns of Attitudes Number of Patients From Each Milieu

Acute Long-term Admis,;,=o,1 Discharge Follow-up Admitting Ward Ward Total

Total

+ 4 + 7 - - 7

+ + 0 1 2 7 1 9 + + - - 1 5 7 2 2 + 0 + - - 1 1

+ 0 0 3 - - 3

+ 0 - - - - 1 1

+ - - + 1 - - 1

+ - - 0 1 - - 1

0 + + 6 3 9

0 + 0 6 4 1 0 o + - 8 7 1 5

0 - - - - 1 - - 1

-- + 0 1 ~ 1 -- + -- 2 2 4

6 3 3 2 9 5

Key:-1- = p o s i t i v e . 0 = n e u t r a l . - - = negat ive .

m e n t s ; m o s t a g r e e d t h a t t h e "'food w a s g o o d " but s o m e c o m p l a i n e d t h a t t h e "'food w a s too f a t t e n i n g " ( 5 - , 2 + ) .

T h e a c t u a l p h y s i c a l a p p e a r a n c e o f the w a r d w a s b r o u g h t up f r e q u e n t l y ( 2 0 - , 4 + ) . "'It h a s a very d i s m a l a p p e a r a n c e , " "'It n e e d s r ~ , - o d e l i n g , t h e r o o m s a n d c o l o r s a r e d e p r e s s i n g , " "'We n e e d b i g g e r fac i l i t i e s ," a n d "'It c o u l d b e c l e a n e r . " O n t h e o t h e r h a n d , a f e w w e r e s a t i s f i e d and sa id "'the p l a c e w a s c l e a n " a n d "'the fac i l i t i e s w e r e good.'"

(4) Disposition. Al l 15 o f t h e p a t i e n t s w h o c o m m e n t e d a b o u t the i r d i s p o s i t i o n p l a n s w e r e n e g a t i v e . "'I w a s not p r e p a r e d wi th a j o b and a p l a c e to l ive w h e n d is - charged. '" "'There is a n e e d for a t h e r a p e u t i c c o m m u n i t y a n d h a l f - w a y h o u s e o u t - s ide o f NPI . '" " 'People w h o l e a v e a r e o n l y a b l e to exist, n o t l ive, N P I is g o o d w h e n t h e r e , but no t w h e n o n e l e a v e s . " "'I w a s r e f e r r e d to a p s y c h i a t r i s t w h o t u r n e d o u t to b e t err ib le . R e f e r r a l s s h o u l d be c h e c k e d o u t . I s h o u l d h a v e been g i v e n s e v e r a l r e f e r r a l s so I c o u l d choose . '"

Polarity o f Comments T a b l e 1 s h o w s t h e d i f f e r e n t p a t t e r n s o f po lar i ty a s c e r t a i n e d at t h e t h r e e

d i f f e r e n t p h a s e s o f c a r e . T a b l e 2 s h r i n k s t h e p o l a r i t y c a t e g o r i e s d o w n so tha t

T a b l e 2 . P e r c e n t a g e o f P a t i e n t A t t i t u d e s in E a c h P h a s e o f C a r e

Admission D=scharge Follow-up

"Long- L o n g - Long- Acute term Acute term Acute term Ward Ward Total Ward Ward Total Ward Ward Tara!

Posit ive 6 1 . 9 5 0 . 0 5 7 . 9 9 0 . 5 9 3 . 8 9 1 . 6 2 2 . 2 1 2 . 5 1 9 . 0 Neut ra l 3 3 . 3 4 3 . 8 3 6 . 8 4 . 8 6 . 3 5 .3 3 6 . 5 3 4 . 4 3 5 8 N e g a t i v e 4 . 8 6 . 3 5 3 4 . 8 0 3 . 2 4 1 . 3 5 3 1 4 5 3

Totals 1 0 0 0 1 0 0 . 1 1 0 0 . 0 1 0 0 1 1 0 0 . 1 1 0 0 . 1 1 0 0 . 0 1 0 0 . 0 1 0 0 . 1

8 3 6 ALLEN A N D BARTON

t rends can b e more easily seen and compared . T h e tables show twice as many pa t ien ts were a d m i t t e d to the acu te admi t t ing ward as the long- te rm ward. T h e re la t ionship o f 2:1 was fair ly ma in t a ined for all groupings of a t t i tudes through the various phases o f ca re except t he p a t t e r n s 0 + " and - - + - , where more f rom the long- te rm ward a re obvious. Th i s d i rec ts our a t t en t ion to the fact tha t a bit more than one -ha l f o f the long- t e rm ward pa t ien ts had negat ive a t t i tudes at follow-up. The to ta ls show a very heavy weight ing in the positive d i rec t ion at d ischarge , while the re were many more mixed a t t i tudes on admiss ion and follow-up. T h e r e were very few posi t ive a t t i tudes f rom the long- te rm ward p a t i e n t s a t follow-up. All the pa t i en t s who s tayed posi t ive t h roughou t were on the acu te ward. W h e n the demo- g raph ic cha rac t e r i s t i c s o f the two wards were ana lyzed using ehi square , age and diagnosis proved significantly d i f ferent (p < .01 - < .00t ) b e t w e e n the two wards. T h e acu te admi t t ing ward had t h r e e t imes the n u m b e r o f pa t ien t s in the 25-50 age g roup as the long- te rm ward had; the long- t e rm ward had a m o r e even d is t r ibut ion between age groups . As fa r as compar ing the wards iu r egard to d iagnost ic ca te- gories, the acu te ward had four t imes as many s i tuat ional d isorders but t he s a m e n u m b e r of neurvses as the long- t e rm ward. Fu r the r , the long- te rm ward had no dominan t d iagnost ic group. T h e compar i son o f the d e m o g r a p h i c var iables o f sex, mar i t a l s ta tus , and e m p l o y m e n t did not reveal any signif icant dif ference be tween the two wards. By sor t ing the d e m o g r a p h i c d a t a of the pa t ien ts f rom both wards c o m b i n e d in to t h r e e a t t i t u d i n a l g r o u p s o f pos i t ive , n e u t r a l , and n e g a t i v e responders , no significant d i f ference resul ted e i ther :

DISCUSSION

Con ten t

T h e con ten t o f the c o m m e n t s revealed tha t the pa t i en t s took the in terview seriously and focused on issues t ha t were of mutua l concern . I t is possible to discern the re la t ive degree of conce rn about the var ious issues from the quan t i ty o f c o m m e n t s noted in each subca tegory . The follow-up ques t ions were s lanted so they drew out compla in t s and may par t ia l ly explain t he m o r e abundan t negat ive c o m m e n t s .

T h e ca tegory o f re la t ionships was mos t f requent ly men t ioned . This was an a rea with which m a n y pa t ien ts have difficulty. This was ref lec ted in the i r c o m m e n t s shared with the in terv iewers abou t t he re la t ionships they found on the ward and may have con t inued to play i t se l f ou t in the t r e a t m e n t se t t ing for each pa t ien t . For example , c o m m e n t s such as the s ta f f did not unde r s t and t hem or did not know how to c o m m u n i c a t e ~ i th them may have been a pro jec t ion o f thei r own feelings o f ambiva lence abou t becoming involved with anyone on a meaningful level o r thei r own inabil i ty to express t h e m s e l v e s clearly. T h e y may also have been express ing the i r hope for a chance to ta lk to someone who did not s eem a l iena ted in a world o f people they perceived as a l iena ted . On "the o t h e r hand, t he s taf f may have been having the i r own difficulties in re la t ing to o the r s . T h e pa t ien t s may have been perceiving this and mak ing it known by thei r c o m m e n t s . T h e pa t i en t s ' d e m a n d s for c lar i ty of communica t ion , openness , wa rmth , cons i s tency , and respect were reasonab le d e m a n d s to m a k e upon the staff. They seem like admi rab l e goals toward which both s taf f and pa t i en t s should and could str ive. ;2

T h e a t t i t ude expressed by the pa t i en t s toward the overal l t r e a t m e n t in hospi ta l

PATIENT COMMENTS ON HOSPITALIZATION 637

was tha t it had been helpful. T h e r e seemed to be a sense of g ra t i tude , relief, and surpr ise at itff efficacy. Accep t ance of the i l lness i tself was felt to have been es- tabl ished in the t r e a t m e n t set t ing also. I t was felt tha t the sample was not espe- da l l y biased toward interviewing " 'bel ievers ," since ha l f the pa t ien ts w h o left against medical advice were in the follow-up phases and did express some of the "he lp fu l " commen t s . A number of pa t ien ts a g r e e d to the follow-up interview specifically because they felt they could voice thei r dissat isfact ion.

Much of the d i sg run t l emen t about spec i f ics /n t r e a t m e n t seemed to have been re la ted to communica t ion problems. Medica t ions were perceived as "'too strong'" and "'too m u c h , " pe rhaps because adequa te in format ion about the medica t ions and the il lness had not been conveyed to or ass imila ted by the pa t ien t before dis- charge . T h e length o f s tay issue seems to be a veiled reques t to unde r s t and the t iming of the leaving. This suggests t ha t s ta f f might t ry to discuss this issue more fully w i t h t h e pa t i en t s and thei r relatives. T h e compla in ts about research and t ra ining seem to be a reques t tha t pa t ients should know before admission t ha t these activities will be a par t o f the ward exper ience. New regula t ions now recognize this as reasonab le and mandi to ry in format ion to be provided to pa t ients pr ior to admission. T h e c o m m e n t s about the low level o f activit ies may be a reflec- tion about the lack o f communica t ion by the ward s ta f f as to tha t t he r apy ' s overal l ra t ionale . 13 I t may also reflect a real need to upgrade thei r activit ies to be t t e r suit the pa t ien ts needs.

Only those pa t ien ts s taying on the sho r t - t e rm ward focused on the issue of g roup therapy . The i r cri t icism had the usual initial g roup pa r t i c ipan t ' s expression of uncer ta in ty as to its efficacy and efficiency con t r a s t ed with 1:1 the rapy . T h e r e is what may be more of an inst i tut ional ly id iosyncrat ic t h e m e in the c o m m e n t s as well: tha t the t ra in ing of the ward s taf f to do g roup the rapy was probably insufficient. Pa t ien ts should be provided with compe t en t group therap is t s who, by their, t he rapeu t i c a cumen and rappor t , can c r e a t e an a t m o s p h e r e conducive for pa t ien ts to unders tand , accept , and benefi t f rom group therapy . T h e s taf f should also be made cognizant o f the fact tha t g roup the rapy is not effective with every pa t i en t and should be assigned by individual a s ses smen t r a the r than by ward.

The c o m m e n t s a round the issues of rules and regulat ions seem to reflect the idea tha t the pa t ien ts a re asking for more c o m m o n sense to be used in the applica- tion o f rules. T h e r e also seems to be an expression o f pro tes t agains t a u t h o r i t y , which is a c o m m o n theme today. T h e r e were fewer c o m m e n t s abou t t h e s e i s s u e s from pa t i en t s who enjoyed g rea t e r par t ic ipa t ion in the l imit set t ing for the acu te ward. The concern about visiting and phone privileges again may be par t ly caused by undue rigidity on the par t o f the staff. In fact , the rules about visiting and tele- phoning have been a l te red in the new Michigan M e n t a l Hea l th Code recent ly in- s t i tu ted which, for ins tance , does allow several phone calls upon admission.

The fact tha t t he r e were only seven c o m m e n t s on food was r a the r s tar t l ing, s ince diet was such an issue in therapy , at ward meet ings , and dur ing free t ime. In the rapy it brought up emot ions o f car ing, dependency , depr ivat ion, and hosti l i ty. Its use in cortversat ion as a topic seemed to be an effort to c o m m u n i c a t e about these emot ions to the staff. Prac t ica l efforts were even made to a l t e r the menus rout inely and ethical ly. By follow-up these emot iona l l inkages with hospi tal diet had pract ica l ly d isappeared .

T h e pa t ien ts ' compla in t s about the physical env i ronment of the wards were

638 ,ALLEN AND BARTON

para l le led by the authors observa t ions and shou{d be c l ea red up a f te r the plans for remodel ing h a v e been comple ted . T he pat ients express ing feelings about confine- men t were p robably re la ted to the fact that pa t ients who were in good control o f thei r own impulses felt imposed upon by being locked on a ward with those who were potent ia l ly suicidal or wanted to run away and were the re fo re in need of the conf inement . This is par t icu la r ly a p rob lem for univers i ty and genera l hospi tal psychia t r ic wards where facilitiez m a k e two options possible: e i t he r of locking everyone in or not admi t t ing any pat ients requir ing s t r ic t restr ic t ions. A third op- tion might be renovation to include a smal l locking subuni t .

The m a n y serious concerns over the pa t ien ts ' disposit ion points to what m ay be qui te a c o m m o n p r o b l e m : tha t disposit ions a re glossed Over by ward s ta f f in thei r rush to get the pat ient over the worst o f his s y m p t o m s by decreas ing his psychic pain through psychotherapy , diversion, and medicat ions . The recent Pa t ien t Bill o f Rights emphas izes tha t the pa t i en t ' s cont inuing hea l th ca re requirements / fo l low- ing d i scharge should be planned.~4 The pat ients a r e n o w s ta t ing tha t they wish to be involved in the planning and want sufficient in format ion about the opt ions to m a k e a l ea rned decision. They a re rightly ask ing tha t the relat ives be involved in disposit ion p lanning also. S ta f f routinely neexl to be involved in disposit ion p l an - ning as the pat ient requests , not only because they could share their exper t i se gained f rom their background discipline, but also beca~tse o f their f i r s thand knowl- edge of the pat ient . The s ta f f addit ional ly need to m a k e separa t ion f rom the de- par t ing pa t ien t more m a n a g e a b l e for themse lves psychological ly by facing the dis- position p lanning issues and ta lking them through.

Polarity

The polar i ty o f a pa t i en t ' s a t t i tude toward hospi tal izat ion at each phase of ca re (admission, d ischarge, and follow-up) may have differing degrees o f f reedom of expression. At admiss ion it may be positive i f the pat ient is want ing help, hurt ing, or feeling helpless . O the r s m a y express thei r a t t i tude as neu t ra l so as not to ap- pear too eager or too antagonist ic . The i r relat ives m a y of ten tip the ba l ance and insist upon the pat ient being admi t t ed , and the pat ient acquieses. Those fi~w who might openly show thei r negat ive feelings e i ther would then be commiLted, con- vinced by relat ives or examin ing physic ians , mere ly protes t (but passively get admit ted) , or do not ge t admi t t ed at all (and hence, would not be included in this study).

By d ischarge , the express ion o f positivity may be gene ra t ed out of feeling bet- ter , want ing to please, or want ing to appea r well enough to leave though not real ly feeling so. Those express ing neu t ra l feelings m a y have cont inued difficulties with ambiva lence , expression of feelings, or serious reservat ions about being able to m a k e it. Those express ing negat ive feelings may not have found the hospi tal izat ion helpful and a re s ta t ing so. O t h e r s with negat ive feelings who might be leaving against medica l advice m a y have felt they had got ten enough out o f the hospi tal- ization but felt the s ta f f was keeping them overly long. ~5 Thus , the rel iabil i ty o f the pa t ien t ' s repor ted a t t i tude at admiss ion and d i scharge was felt to be ques t ionable in this s tudy and para l le led what had previously been reported, a-~ This suggests a cont inued ques t for c rea t ing a da t a collection environment to allow more hones t report ing o f a t t i tudes by pat ients at these two phases o f care .

At follow-up the patients" a t t i tudes were not as d i rect ly assessed, but thei r

PA't'IENT COMMENTS ON HOSPITALIZATION 639

concerns provided d a t a about their a t t i tudes :toward the hospital izat ion a t tha t point. Only a few seemed afra id t ha t t h e interview would pose a t h r e a t of read- mission. M o s t had d is tanced themse lves f rom the e x p e r i e n c e and were candid about their feelings about the hospital izat ion. S o m e seemed to want to put the i r best foot fo rward and a p p e a r very well in tegra ted . M a n y who felt negat ively about their hospital izat ion c a m e to c r e a t e change by shar ing thei r cr i t ic isms. Only about 4,5% of the tota l s tudy popula t ion verbal ly r e fu se d to be interviewed, many of whom were negat ive about their hospital izat ion.

T h e s e t t i n g did s eem to influence the polar i ty o f the a t t i tudes . T h e r e were m o r e positively expressed a t t i tudes f rom the admi t t ing w a r d pat ients than the long- t e rm ward pat ients . This m a y have been due to the m o r e . d e m o c r a t i c , more sup- port ive qual i ty of the s h o r t - t e r m milieu, as well as the qu icker re turn to the envi- ronment for these pat ients . Even though some of the demograph i c cha rac te r i s t i c s of the two wards were significantly different , the d e m o g r a p h i c charac te r i s t i c s o f the responders , when they were lumped into positive, neut ra l , and negat ive groups , were similar. This m a y m e a n tha t the concerns expressed were universal , tha t demograph ic var iables were not the key factors . The milieu, including the s ta f f (especially s ta f f dis tancing) , was m o r e a significant fac to r as o the r studies have similarly found, z~ The o u t c o m e of the pa t ien t ' s illness m a y have been m o r e i m p o r t a n t in the express ing of pat ient c o m m e n t polar i ty than demograph i c vari- ables, as Smal l has suggested . ~

I M P L I C A T I O N S

The implicat ions f rom this s tudy a r e m a n y . Pat ient c o m m e n t s about hospi- tal ization can be elicited a t dif ferent phases o f hospital ization. The i r a t t i tude a t admission helps m a k e the decision of how and if to admit . At d ischarge , their a t - t i tude m a y assist disposition planning. A t follow-up, the content o f the c o m m e n t s may be very helpful in act ing as a ca t a lys t for change. The findings o f this s tudy, tha t the ward s ta f f need m o r e instruct ion in g roup t h e r a p y techniques , in providing more informat ion about d rug side effects , in explaining the pa t ien t ' s illness, and in elucidat ing the usefulness of the different t r e a t m e n t modali t ies , can be used for in- service educatior~, and for Students ro ta t ing through the milie~.2x. Fo r individual ward s ta f f singled out by pat ient c o m m e n t s it would be, and has been, possible to sha re the c o m m e n t s with t h e m to help them achieve a m o r e the rapeu t ic approach and one m o r e in h a r m o n y with pa t ien t -perce ived needs.

M a n y o f the compla in ts could be, and have been, b rought to the a t tent ion o f admin i s t r a to r s so tha t issues such as physical envi ronment , pa t ien t r ights , t ra ining and resea rch techniques have been changed: I t has m a d e obvious the need for dis- position planning and a f t e r c a r e legit imization in the sys t em and has concret ized the value o f the pat ients" c o m m e n t s as being able to act as ca ta lys t s for change.

O t h e r inst i tut ions m a y be chal lenged toward similar in tervent ions as well as be- ing more willing to solicit pa t ient a t t i tudes about hospital izat ion. It m a k e s obvious the need for fu r the r r esea rch about the changing a t t i tudes pat ients h a v e dur ing their hospital ization. In the past , the milieu has been shown to affect the pat ient . 7-9 I t now becomes possible, using regu la r survei lanee of pa t ien t a t t i tudes toward hospital izat ion dur ing different phases of c a r e and especially during follow-up, for the pat ient to have an effect on the sys tem, including the milieu, staff , p r o g r a m - ming, and adminis t ra t ion .

640 ALLEN AND BARTON

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