The Role of Consumer Satisfaction in Psychiatric Care
by Lara Denysyk
This literature review uses past studies from PsycInfo and other medical and psychiatric peerreviewed journals to examine the importance of patient perceptions in a psychiatric inpatient unit, as well as ways to improve these perceptions. More specifically, it looks at the role of customer service in psychiatric inpatient units and how customer service relates to quality of care, patient education, and general atmosphere on the psychiatric ward. Research has shown that personalizing treatment for the patient and utilizing their feedback can create better treatment adherence and improve treatment outcomes. Studies on patient perceptions are lacking, and further research regarding patients with different mental health illnesses in psychiatric inpatient wards is recommended.
Keywords: patient perceptions, psychiatric, inpatient, consumer satisfaction
At the Patient Centered Care Department at New York University’s Langone Medical Center, patient advocates record and respond to patient concerns. Most hospitals employ patient advocates for the sole purpose of improving patient care and perceptions of hospital treatment. Patient perceptions are vital to health care work, as positive perceptions of psychiatric inpatient units can improve patients’ cooperation with their treatment, and ultimately their outcomes. Advocates play a crucial role in treatment by encouraging improved perceptions among patients.
At Langone Medical Center, the patient advocates do rounds among many of the hospital departments. While psychiatric patients are able to meet with patient advocates, many times they are not able to discuss their issues on a daily basis. This practice, which is a common occurrence at many hospitals, leaves psychiatric patients without a consistent opportunity to air their grievances and request better treatment. One of the primary responsibilities of a patient advocate is to provide patients with an opportunity to discuss concerns regarding their treatment with a third party outside of their direct care team.
Rather than giving preferential care to certain types of patients based on their own personal opinions and perceptions, patient advocates should make it a priority to treat all patients with the utmost care and concern. The practice of ignoring psychiatric patients ultimately affects their perceptions of the hospital and their treatment, which in turn affects their treatment outcomes.
It may be that encouraging patient advocates to do daily rounds with psychiatric patients will increase patient perceptions of the hospital ward, and research suggests that these perceptions may actually improve patient outcomes. Patients’ perceptions of their illness can predict their treatment course, and changing negative illness perceptions can aid in recovery and coping in mental health care by increasing adherence to treatment (Witteman, Bolks, & Hutschemaekers, 2011). It is important to study patient perceptions in psychiatric inpatient care so that the patient is more willing to cooperate with his or her treatment team, which will, in turn, hopefully improve recovery outcomes and achieve a higher level of treatment success. This literature review will examine the importance of consumer satisfaction and patient perceptions in mental health care. More specifically, it will discuss how patient reports on quality of care, patient education, and the atmosphere on psychiatric wards influence their perceptions of hospital care. Finally, it will investigate the ways in which these perceptions may affect patient health outcomes.
The idea of consumer satisfaction as an important factor of care is a relatively new concept for America’s healthcare system. Consumer satisfaction measures the quality of service that consumers receive (Cleary, Horsfall, & Hunt, 2003). Patients’ perceptions of their treatment play a large role in their levels of satisfaction. One of the earliest definitions of mental health consumer satisfaction is the extent to which the treatment fulfills the client’s desires, wants, and wishes (Lebow, 1982). It is important to measure the quality of a healthcare service because a patient’s perspective and experiences are essential to his/her achieved outcomes, which are the criteria for overall treatment success (Howard, El Mallakh, Rayens, & Clark, 2003; Rosen & Proctor, 1981). Rosen and Proctor (1981) define an outcome as a state that is directly caused by clinician intervention or factors of the intervention itself. Symptom reduction, social and work functioning, satisfaction of services, and perceptions of well-being are all measures of treatment outcomes (Docherty & Streeter, 1996). However, researchers continue to face the issue of determining how to measure consumer satisfaction. The World Health Organization has determined as many as eight aspects of consumer satisfaction pertaining to healthcare: autonomy, choice, communication, confidentiality, dignity, quality of basic amenities, prompt attention, and access to family and community support (Brunero, Lamont, & Fairbrother, 2009). In contrast, Brunero, Lamont, & Fairbrother (2009) found only three aspects of patient perception in psychiatric units that predicted overall satisfaction. These aspects were: happiness with the service that workers provided, confidence with the support received after discharge, and feeling safe while on the ward (Brunero et al., 2009). In addition to the challenge of determining which aspects of the healthcare system to assess, researchers must contend with an over-reporting of positive satisfaction among patients using existing consumer satisfaction surveys.
Research suggests that, in general, it is characteristic for consumers to report high quality satisfaction on surveys regardless of the quality of the services that they actually received. Kaplan, Busner, Chibnall, & Kang (2001) exposed overreporting of positive satisfaction in hospital settings, showing that both children and parents were likely to report high satisfaction with the child’s stay in the psychiatric unit even after having conflicts with some of the clinicians. Through exaggerating their satisfaction, patients may be attempting to minimize their cognitive dissonance; customers would like to believe that they chose the right service, and to admit that they received inadequate service is dissonant with their perception of themselves as wise consumers (Kaplan, Busner, Chibnall, & Kang, 2001). Thus, in their efforts to believe that they made the right choice in terms of healthcare, they rate the hospital more favorably (Kaplan et al., 2001). Kaplan et al. (2001) also found that in terms of reporting problems on the unit, those children and parents who complained of staff abuse reported levels of problem improvement similar to those who did not report abuse, suggesting that overall satisfaction is not dependent on perception of problem improvement. Research should explore the implications of these findings for various populations in order to determine exactly how problems on the ward interact with levels of satisfaction. The discrepancies that occasionally occur between problems with treatment and levels of patient satisfaction highlight the importance of accounting for all aspects of care, such as problems with staff or first time admission.
Researchers found that patients for whom it was their first admission into a psychiatric inpatient unit had much lower overall satisfaction than long-term or repeat patients (Berghofer et al., 2001; Brunero et al., 2009). First time patients may feel shocked upon encountering other patients with severe mental disorders (e.g., psychosis or schizophrenia), and may wonder if their illness is ‘as bad’ as that of the other patients (Berghofer et al., 2001). First admission is also associated with negative perceptions of the unit’s comfort and cleanliness (Brunero et al., 2009). The unit may be comfortable and clean for a hospital, but patients for whom it is their first time staying in a hospital, it may be relatively worse than their own homes. This association suggests a role for expectations in predicting satisfaction levels, as first time patients will have markedly different expectations for their experience on the ward than repeat patients, who understand what the experience will entail. Clinicians and hospital staff can use this data to determine ways to increase patient satisfaction levels.
Hospitals can dramatically raise patient satisfaction levels with small changes to their psychiatric units. Something as simple as providing a magazine and a bottle of water for patients at intake could reverse their negative perception and render them more open to treatment (Brunero et al., 2009). First time patients may also rate their satisfaction lower if they did not receive an explanation of their rights and responsibilities upon admission to the unit (Brunero et al., 2009). Psychiatric inpatient units should have written information readily available to the patients due to some patients’ inability to retain spoken information based on their mental health status (Brunero et al., 2009). However, these policy improvements may not be enough to improve overall patient perceptions. One study found that even when hospitals provided patients with a comprehensive booklet, patients often felt that the clinicians did not fully explain their reason for admission (Brunero et al., 2009). This again illustrates a discrepancy between consumer expectation and the clinical service delivery, which can have negative effects upon the patients such as misunderstanding one’s diagnosis or lacking confidence in their potential for positive mental health outcomes (Brunero et al., 2009). Small changes on the part of clinicians and hospital staff can greatly affect patient satisfaction levels. For example, education regarding their mental illnesses and reason for admission can increase a patient’s adherence to his or her treatment plan and lead to better outcomes. Hospitals should focus on these kinds of structural improvements in their psychiatric wards in order to encourage better patient outcomes.
Patient Reports on Quality of Care
Quality of care is one factor affecting patient perceptions. Quality of care in a psychiatric setting is a multidimensional concept, and is therefore difficult to define (Hansson, 1989). One method of operationalizing quality of care is to separate it into an empirical component (i.e., the reality of the care) and a normative one (i.e., the ideal of the care) (Donabedian, 1980). However, one should be wary of such generalizations due to the distinctive characteristics of psychiatric care, namely, the use of the patient and professional relationship as a therapeutic tool (Schroder, Ahlstrom, & Larsson, 2006). While quality of care in psychology can have specific dimensions that are necessary for positive treatment, it is important to remember that certain aspects of this care (i.e., the patient-therapist relationship) are not always conducive to easy and reliable measurement.
The care setting plays a role in patient perceptions as well. In other words, patients in a psychiatric setting can have different perceptions of what is important in their care as compared to patients in somatic care settings. Specifically, patients in a psychiatric setting considered the cognitive aspect of their care most important, while somatic patients ranked task-oriented aspects such as technical and medical care as the most important (Schroder et al., 2006). Clinicians should account for and attend to differences between what psychiatric and somatic patients deem most important in their treatment.
In order to determine how these patient care perceptions differ, Schroder, Ahlstrom, & Larsson (2006) conducted a qualitative interview study with twenty psychiatric patients regarding their perception of the quality of care they received in an inpatient psychiatric setting. The researchers discovered five categories of good quality of care: clinicians respect the patient’s dignity, the patient feels secure with regard to care, the patient was able to participate in the care, the patient recovered, and the quality of the care environment itself (Schroder et al., 2006). The authors concluded that the planning and evaluation of care should include patients’ perceptions of the quality of psychiatric care.
Another interesting finding of Schroder et al. (2006) was that most of the psychiatric patients wanted help in reducing the sense of shame that resulted from their diagnosis. Surprisingly, no other study on quality of care shared this finding. Shame can affect patient care by hindering a patient’s willingness to seek help. Today’s society stigmatizes mental illnesses to such a degree that patients often see asking for help as a sign of weakness. By addressing the shame that patients can feel while receiving treatment for a mental illness, clinicians can improve the patient’s perception of the quality of care. One patient describes his/her experience with patient care in a psychiatric inpatient unit:
Depression and psychosis are so powerful, you feel so weak and defenseless – so it’s extra important that the staff treat you right, you’re so easily hurt. All it needs is a brusque tone of voice, or that you see they haven’t been listening to what you’ve been saying – and there you are, feeling even more guilty, putting the blame on yourself, more desperate and unhappy than ever. So especially in psychiatric care it’s very important that you’re seen and listened to, I think (Schroder et al., 2006, p.97).
Like the patient quoted above, many of the other participants in this study agreed that it is especially important in a psychiatric unit to have highly trained staff that are easy to talk to (Schroder et al., 2006).
In addition to having highly trained staff who know how to deal with psychiatric problems, patients wanted continuity in their doctors so that they would not have to “tell their story all over again,” which can add to insecurity in psychiatric care, more so than in other types of care (Schroder et al., 2006, p.97). The experience of having to re-explain their mental health history to each new doctor may make patients feel ashamed, overwhelmed, and insecure about how the doctor will react. This does not occur often with somatic care. The patient–clinician relationship is an incredibly important aspect of treatment, and having multiple doctors compromises and complicates those relationships.
Patients also agreed that they would like doctors to include them in the development of their treatment plan and comprehensively explain their condition and treatment process:
I mean, I didn’t know a thing, I’d never heard of compulsive thoughts or actions. I thought: ‘What’s happening? I’m going mad.’ But when I got the chance to talk to the psychologist and he described it and explained it, I had some understanding of it and could work on it. It didn’t frighten me any more once I’d got proper answers to my questions (Schroder et al., 2006, p.98).
Explaining the patient’s condition, possible care plan, and potential outcomes can put the patient at ease and potentially allow the patient to become more active in his or her treatment (Schroder et al., 2006).
Just as patients would like doctors to include them in the development of their care plan and keep them informed about their treatment process, family members often want these same privileges. Here lies the potential for conflict, as family members tend to hold conflicting values, priorities, and goals from their ill relatives (Lasalvia et al., 2011). These differences typically stem from patients placing more emphasis on daytime activities and independence, whereas family members prioritize symptom reduction and intensive medical support (Lasalvia et al., 2011). Research suggests that family members and staff do share views on how to solve patients’ problems, which is a promising finding that provides encouragement to involve family members more often with treatment (Lasalvia et al., 2011). Therefore, family can help staff with supervising medication, encouraging their relatives to participate in rehabilitation programs, and providing a nurturing environment for recovery (Lasalvia et al., 2011). While the combination of clinician, patient, and family perspectives regarding patient care can often lead to conflict, research supports the extra effort required to surmount these obstacles. The amalgamation of all three perspectives offers a more comprehensive view of how staff and patient interactions operate within real-world mental health services (Lasalvia et al., 2011). This benefits the patient by taking their perspectives regarding day-to-day activities into account, while also focusing on the symptom reduction that is so important to clinicians and family members.
Patient education, along with other psychosocial interventions, is a crucially important approach to help patients manage their illness (Hatonen, Suhonen, Warro, Pitkanen, & Valimaki, 2010). Patient education involves teaching patients about components of their mental illnesses such as prevalence, risk factors, and prognosis. The general public has a poor level of knowledge regarding mental illnesses such as depression, and when a member of the general public becomes a psychiatric patient, this ignorance translates into negative beliefs about his/her diagnosis (Petrie, Broadbent & Kydd, 2008). These negative beliefs can in turn negatively affect a patient’s knowledge of his/her illness and adoption of active coping skills (Petrie et al., 2008). However, patient education programs must take into consideration the individual needs of patients (Hatonen et al., 2010). One patient described what he would like in his treatment:
You want the dialogue to work, you want to take in what’s said to you and really think about it and try to live that way, which may mean changing. When you feel it’s really working, you think what a good thing it is. You want an open dialogue where the staff understand your problem, understand how you feel, and keep the conversation going forward (Schroder et al., 2006, p.98).
This patient, as well as many others, would like a more personalized treatment approach. One method of personalizing treatment is using information technology (IT), a technique that many patient education intervention programs currently utilize. In the IT patient education modules, patients learn about mental illnesses and available treatments. Patients see this technology as useful because it offers self-paced learning as well as a shorter time commitment than traditional patient education programs. One patient described the benefit of shorter education sessions, highlighting the fact that long, drawn out education programs often tire out the patients whereas shorter sessions allow them an opportunity to rest (Hatonen et al., 2010, p.338). The IT approach to patient education provides individualized learning at the patients’ convenience. Unfortunately, some of the patients believed that while the information they receive in patient education sessions was important, it did not help them with everyday coping (Hatonen et al., 2010). Though IT use for patient education shows great promise, some changes are necessary in order for it to fully help patients and improve outcomes. Patients suggested that the education modules include interactive features and utilize more pictures and videos (Hatonen et al., 2010). Such improvements would address patient concerns concerning the individualization of standardized IT modules.
One method of individualizing patient education is to utilize illness perception interventions. These programs have grown out of Howard Leventhal’s theory that in order to understand and cope with health threats, individuals form common-sense beliefs about their illness (Petrie et al., 2008). The process of understanding their symptoms and illness drives the patient’s emotional and coping responses and may lead to more help seeking and improvement in perception of their illness (Petrie et al., 2008). Illness perception interventions are an important aspect of patient education and treatment because patients who believe that their treatment is effective tend to better keep to treatment and rehabilitation programs (Petrie et al., 2008). Initial studies have shown that illness perception interventions are applicable to many different common mental health disorders including schizophrenia, non-affective psychotic disorder, bipolar disorder, anorexia nervosa, psychotic or personality disorders, depression, and anxiety (Petrie et al., 2008). Further research should attempt to determine how illness perception interventions differ among various diagnoses.
When researchers utilized illness perception interventions among hospitalized bipolar and schizophrenic patients, they discovered that patients with different diagnoses wanted to learn how to come to terms with their diagnosis and deal with the medical model as it applies to symptomology and treatment. Additionally, they expressed a desire to separate their illness from their identity, understand the social dimensions of their new label, and differentiate the current self from past experiences (Petrie et al., 2008). However, illness perception interventions are most effective when the patient is in remission from psychosis, and can make better sense of his or her illness (Petrie et al., 2008). In order to apply illness perception interventions to improve mental health outcomes, clinicians should focus on increasing adherence to therapy, reducing inappropriate service use (repeat patients), and improving family and other significant relationships (Petrie et al., 2008). By focusing on these areas, clinicians can improve mental health outcomes for patients through education. With this improved knowledge, patients develop a greater understanding of what they can do in order to improve their mental illnesses.
Inpatient psychiatric units act as intensive care areas that mainly treat patients with psychotic disorders in cases of acting out, relapse, or suicidality (Middelboe, Schjodt, Byrsting, & Gjerris, 2001). These units also serve as an early rehabilitation to prepare patients to resume daily living activities after they are discharged (Middelboe et al., 2001). It is especially important to listen to the patients and their perceptions of the treatment climate as these perceptions can influence many aspects of the recovery process, including drop out rates, involvement within the community on the ward, and satisfaction with treatment (Timko & Moos, 1998). Patients perceive an ideal ward as one containing support, order, organization, and allowing for autonomy (Middelboe et al., 2001). When patients judged the staff and program as providing support and encouraging involvement and spontaneity, patients engaged in group discussions more often during treatment (Timko & Moos, 1998). Patient engagement in treatment can be beneficial to mental health outcomes as well as social outcomes.
From this framework, Timko & Moos (1998) suggest that programs should encourage patients to make gains in practical skills while relating those gains to treatment and recreational activities. Patients who participated in such programs were better functioning, more active in the ward community, and used recreational services more often (Timko & Moos, 1998). However, no matter how ideal a program may be, patients with severe psychiatric impairment will have poorer outcomes, functioning, and activity (Timko & Moos, 1998). Clinicians may actually harm these patients by assertively trying to get them to participate. Such assertive attempts may be over-stimulating for patients with severe psychiatric impairment and may lead to further psychopathology or hospital readmission (Timko & Moos, 1998). Therefore, clinicians should encourage patients to participate in activities on the psychiatric unit, but only up to a certain point, as some severely impaired patients will not respond well to that much pressure or overstimulation.
By increasing quality of care based on patient perception, psychiatric patients may be more receptive to treatment and outcomes may improve. Focusing on consumer satisfaction in the mental health field can yield many positive results, as patient satisfaction predicts treatment compliance, which ultimately leads to improved outcomes (Middelboe et al., 2001). Patient advocates should make it a priority to treat psychiatric patients just as they would treat their patients with physical illnesses. By giving psychiatric patients the opportunity to discuss concerns with their treatment, clinicians can make changes and treatment outcomes can improve.
Current research on patient perceptions provides many implications for the improvement of hospital procedures. First, it is important that doctors include patients in the development of their treatment plan. Professional education should include knowledge about patient’s shame and stigma regarding treatment (Schroder et al., 2006). Staff in psychiatric inpatient units should actively work to foster agreement with patients, as this relationship may encourage feelings of responsibility within patients (Lasalvia et al., 2011) Such responsibility may lead to better adherence to treatment and reciprocally strengthen the therapeutic alliance, ultimately leading to greater effectiveness of the intervention. Understanding the negative perceptions that the patient holds towards treatment can help clinicians be more sensitive to the patient’s difficulties during recovery. Clinicians should also be aware of setting too high expectations for patients, such as expecting them to make significant progress in a short amount of time or to actively participate in activities on the ward before they feel ready. Researchers found that clinicians can foster better results for their patients if they focus on achievable goals and ways to reach them rather than simply setting high expectations (Strating, Broer, Van Rooijen, Bal, & Nieboer, 2011). Unfortunately, research on patient perceptions is lacking. Future studies should examine whether perceptions vary by each particular mental illness, and which techniques are most effective for each diagnosis. By creating a more nuanced picture of how different patients respond to different treatments, healthcare professionals can not only improve patient perceptions of hospital care, but ultimately their overall treatment outcomes.
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Lana Denysyk is a senior in the Applied Psychology program. Her main professional interests include finding effective mental health interventions and increasing access to mental health care. After graduating, Lana will be attending Columbia University's Mailman School of Public Health to pursue her Master's of Public Health degree.