Isr J Psychiatry Relat Sci Vol 45 No. 3 (2008) 201–209
Relative Perceptions of the Needs of Inpatients with Schizophrenia and Schizoaffective Disorders Alexander Grinshpoon, MD, MHA, PhD,1,2 Michael Friger, PhD,3 Eyal Orev, RN, MA,4 Shifra Shvarts, PhD,5 Ze’ev Kaplan, MD,4 Moshe Z. Abramowitz, MD, MHA,1 and Alexander M. Ponizovsky, MD, PhD1 1
Mental Health Services, Ministry of Health, Jerusalem, Israel Tirat Carmel Mental Health Center, Ministry of Health, Tirat Carmel, Israel 3 Epidemiology and Health Services Evaluation Department, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel 4 Beersheba Mental Health Center, Ministry of Health, Beersheba, Israel 5 Department of Health Systems Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel 2
.
Abstract: Background: Although there is a consensus that mental health services should be provided on the basis of need, the concept of client needs differs substantially among professionals, patients and involved family members. The aim of the present study was to identify the needs of patients repeatedly hospitalized with schizophrenia and schizoaffective disorders and to compare them with the needs rated by their nursing staff and relatives. Method: Using the Camberwell Assessment of Need (CAN), we surveyed 52 consecutive voluntarily re-admitted inpatients aged 18– 65 fulfilling the ICD-10 criteria for schizophrenia and schizoaffective disorders. Analysis of variance and post-hoc t¬test single comparisons were performed to examine the between-groups differences in the number of unmet needs rated by patients, clinical staff and family members. Results: Significant differences in the perceptions of the patients and staff occurred in only 6 of the 22 CAN domains, with the patients rating higher the needs for “information on condition and treatment” and “benefits,” and the staff member rating higher the patients’ needs for “intimate relationships,” “safety for others,” “self-care” and “daytime activities.” The analogical differences occurred between the patients and their relatives in the same need areas. Conclusions: Comparing the needs assessments from different perspectives provides a powerful means of patient evaluation and is potentially valuable information for care planning.
Introduction The importance of needs assessment for service development has been widely recognized (1–6). Although there is a consensus that mental health services should be provided on the basis of need (7), the question arises, “Who defines the needs?” Surely the concept of client needs and the measurement of needs differ substantially among professionals, patients and involved family members. Given that need is a socially negotiated concept with no single “correct” perspective, it is essential to examine differences between patient and professional views (8). Such differences may occur for a number of reasons; they may reflect differences caused by illness processes (for example, lack of insight due to psychotic
illness), or differences determined more directly by social perspectives (for example, lower social expectations for patients living in poverty). Concern about unrealistic patient demand for limited services may result in lower staff rating of need. Several empirical studies have focused on the associations between ratings of needs made by patients and staff (3, 5, 9, 10). Ochoa and colleagues (9) identified the most common needs of people with schizophrenia who live in the community and analyzed how those needs differ when evaluated by staff or by patients. Using the Camberwell Assessment of Need (CAN) (11) they found that staff detected a significantly higher number of needs than patients did. The most frequently detected needs by both patients and staff involved psychotic symptoms, house upkeep,
Address for Correspondence: A. Ponizovsky, MD, PhD, Mental Health Services, Ministry of Health, 2 Ben Tabai St., 93591 Jerusalem, Israel. E-mail:
[email protected]
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PERCEPTIONS OF NEEDS OF INPATIENTS WITH SCHIZOPHRENIA
food, and information on condition and treatment. In addition, more often than the patients, staff detected needs involving company and daytime activities. The concept and measurement of needs differ greatly, not only between professionals and patients, but also between patients and involved family members. Foldemo and colleagues (12), using the CAN to assess needs of outpatients with schizophrenia and interviewing their parents and staff about the patients’ needs, found that the patients rated the severity of needs lower than parents and staff did. The needs ranking between patients and parents, and patients and staff, showed significantly lower correlation than it did between parents and staff. Unlike patients, the parents rated more unmet needs in the categories of physical health and money. Korkeila et al. (5) examined the CAN structure of needs among outpatients with schizophrenia as identified by the patients and staff regarding the patients’ quality of life, level of functioning and psychiatric symptoms. Factor analysis identified five factors for patients and four factors for staff in the questionnaire on ratings of needs. There were significant associations between the sum scores constructed from the factors and measures of functioning level and symptoms. Unlike previous studies using item-by-item comparisons that emphasized differences between patient and staff ratings, this study also found similarities in the structures and in the associations between the identified sum scores and measures of symptoms, functioning level and quality of life. Macpherson and colleagues (10) used an epidemiological representative sample of patients with psychosis and an abridged version of the CAN (CANSAS) to rate staff and patients’ perceptions of need. Results showed that unmet need was rated most highly in social and relationship domains by both patients and staff. Levels of agreement between patient and staff ratings were found to be “substantial” in all domains except for safety to others, where agreement was “fair” and in which staff perceived higher risk than patients. The authors explained the higher patient-staff ratings concordance in their study than previously reported by the fact of the use of staff that knew patients well and therefore may
have been influenced in their assessment of need by awareness of patients’ perceived need. Thus, findings from the reviewed studies present a consistent picture (6, 7, 13–16). The number of needs identified by staff and patients is broadly similar, with a tendency for staff to identify slightly more needs. However, the domains of need identified can differ substantially. There is more agreement between staff and patients when assessing domains of need with a relatively defined service response (e.g., accommodation) than those without (i.e., intimate relationships). There is more disagreement on unmet needs (domains with current serious problems, irrespective of help given) than on met needs (where there are no/moderate problems in a domain due to help given). However, most studies reviewed have investigated non-institutionalized patients and were conducted by researchers rather than the patients’ key workers. In the study reported here, we sought to target precisely the population that frequently returns to the hospital from the community and determine whether their re-admission is associated with unmet needs unrelated to the underlying mental illness. In this way, one can better address the problem of readmission and reduce unnecessary hospitalization. The specific aim of the present study was to identify the needs of patients repeatedly hospitalized with schizophrenia and schizoaffective disorders and to compare them with the needs rated by their nursing staff and relatives. Knowledge of relative perceptions of the needs could aid in negotiating the discrepancies among patients, staff and relatives, and thus could be the start for reducing non-illness related reasons for rehospitalization. Treatment and rehabilitation programs could thus be better tailored for the individual according to this input.
Method Research setting The setting for this study was a state psychiatric hospital in Beersheba. The mental health center has 270 beds distributed as follows: 20 for adolescents, 90 chronic and 160 acute patients. The hospital serves a catchment area with a mixed lower and middle-income population of 700,000. Unemployment is high.
ALEXANDER GRINSHPOON ET AL.
Nearly 50% of the inhabitants are from one of the minority ethnic groups (Bedouin Arabs) or Russian Jewish immigrants from the former Soviet Union. Table 1. Sociodemographic and clinical characteristics of the sample (n=52) Characteristic
N
%
Gender male 34 65.4 female 18 34.6 Age group, M±SD, years 38.1±10.8 21–24 6 11.5 25–34 16 30.8 35–44 13 25.0 45 and over 17 32.7 Marital status single 32 61.5 married 8 15.4 separated/divorced/widowed 12 23.1 Education, M±SD, years 10.4±2.0 0–6 3 5.8 6–11 28 53.8 12 and over 21 40.4 Employment employed 16 30.8 unemployed 33 63.5 Religious affiliation Jewish 48 92.3 Other 4 7.7 Country of origin Israel 32 61.5 Other 20 38.5 Diagnosis ICD-10 Schizophrenia 26 50.0 Schizoaffective disorder 26 50.0 Age at first admission, M±SD, yr. 25.1±9.8 13–19 17 32.7 21–29 24 46.1 30 and over 11 21.2 Duration of illness, M±SD, moths 166.2±116.7 Total number of hospitalizations 14.4±12.4 Length of current hospitalization, days 22.2±20.0
Subjects The sample consisted of 52 consecutive voluntarily
203
admitted inpatients. The sample size was calculated to be equal the number of subjects required for the desired medium-effect size of .30 at the .05 level of significance and a power of .80 for multiple regression analysis (17). Subjects were considered eligible for inclusion in the study if they were aged 18–65, had been admitted from the community, met ICD-10 criteria for diagnosis of schizophrenia (F 20) or schizoaffective disorders (F 25), had not less than three admissions, were in the hospital not less than two weeks prior to the data collection, and were able to provide written informed consent for participation in the study. Subjects were excluded if, upon admission, they were acutely psychotic or had coexisting mental retardation, dementia or other severe brain organic pathology. The Institutional Review Board approved the study protocol. Table 1 presents the characteristics of the sample.
Data collection procedure Initially, the investigator informed nursing staff in all acute wards of the hospital about the study aims and provided them with the inclusion/exclusion criteria for enrolling to the study. Then, suitable candidates received a full explanation of the study aims and procedures and signed written informed consent forms. Diagnosis at the previous admission and socio-demographic information were extracted from medical files. Within two weeks of the patient’s admission the investigator received the information of a candidate case and conducted a face-to-face interview. All study assessments were performed using a semi-structured clinical interview by the investigator specially trained in the CAN assessment. The average interview took from one to one-and-a-half hours to complete. Additional interviews for a staff member (usually the case manager) and the patient’s close relative or caretaker were performed separately to assess the corresponding items in the CAN. The patients themselves determined proxy status; they designated one of their parents, siblings, spouse or adult children as their proxy. Sixty-two percent of the patients chose parents or siblings as proxies, and 15% chose spouses, and 23% chose their children.
7 11 8 10 14 25 27 38 25 15 10 6 8 22 21 19 5 7 1 6 16 21
Food
Looking after the home
Self-care
Daytime activities
Physical health
Psychotic symptoms
Information on treatment
Psychological distress
Safety to self
Safety to others
Alcohol
Drugs
Company
Intimate relationships
Sexual expression
Childcare
Basic education
Telephone
Transport
Money
Benefits
Patient
Accommodation
Need domain
3
18
1
2
8
10
11
24
24
12
4
27
18
37
28
47
15
36
20
37
18
9
Staff
Total need
8
17
12
8
8
8
14
24
30
8
9
23
24
32
18
41
21
30
21
20
20
8
Relative
2
11
-
1
4
3
6
9
9
3
4
2
10
12
13
15
18
4
5
5
8
3
Patient
2
13
-
1
5
5
4
6
12
3
3
9
10
24
20
24
12
15
16
29
17
3
Staff
3
7
5
2
5
2
5
6
9
-
3
4
8
14
11
13
13
7
10
12
12
1
Relative
Met or partial met need (1)
19
5
6
-
3
2
14
13
13
5
2
8
5
13
25
12
7
10
5
3
3
4
Patient
1
5
1
1
3
5
7
18
12
9
1
18
8
13
8
23
3
21
4
8
1
6
Staff
5
10
7
6
3
6
9
18
21
8
6
19
16
18
7
28
8
23
11
8
8
7
Relative
Serious unmet need (2)
Table 2. Distribution of needs by the Camberwell Assessment of Need domain in 52 patients and their hospital staff and relatives
204 PERCEPTIONS OF NEEDS OF INPATIENTS WITH SCHIZOPHRENIA
ALEXANDER GRINSHPOON ET AL.
Measures Clinical assessment Clinical data were extracted from the patients’ medical records. These were ICD-10 diagnostic category, age at the first psychiatric admission (as proxy for age of onset of the illness) and duration of the disorder since the first admission, overall number of psychiatric hospitalizations, and the duration of the current hospitalization.
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Data analysis Differences in frequencies and means (±SD) were tested with chi-square statistics and two-tailed t¬tests, respectively. Analysis of variance (ANOVA) and post-hoc t-test single comparisons were performed to examine the between-groups differences in the number of unmet needs rated by patients, staff and family members. For all analyses, the level of statistical significance was established as p
