OJHAS Vol. 10, Issue 1:
Related Stress Among Patients Admitted to a Psychiatric In-patient Unit
Latha KS, Associate Professor, Department
of Psychiatry, Kasturba Hospital, Manipal-576 104, India,
Ravi Shankar BG, MSW trainee, Karavali College, Mangalore, India.
Address for Correspondence
Manipal-576 104, India.
Latha KS, Ravi Shankar BG. Hospital
Related Stress Among Patients Admitted to a Psychiatric In-patient Unit
in India. Online J Health Allied Scs.
Submitted: Jul 13,
2010; Suggested revision: Oct 3, 2010; Resubmitted: Oct 5, 2010;
Accepted: Mar 20, 2011 Published: Apr 15, 2011
The psychiatric patient’s
attitudes towards hospitalization have found an association between
patient perceptions of the ward atmosphere and dissatisfaction. The
aim of the study was to determine the aspects of stress related to hospitalization
in inpatients admitted to a psychiatric facility. Fifty in-patients
of both sexes admitted consecutively to a psychiatric unit in a General
Hospital were asked to rate the importance of, and their satisfaction with, 38 different
aspects of in-patient care and treatment. Results showed that the
major sources of stress were related to having a violent patient near
to his/her bed; being away from family; having to stay in closed wards;
having to eat cold and tasteless food; losing income or job due to illness,
being hospitalized away from home; not able to understand the jargons
used by the clinical staff and not getting medication for sleep. A well-differentiated
assessment of stress and satisfaction has implications for the evaluation of the quality of psychiatric care and
for the improvement of in-patient psychiatric care.
hospitalization; Ward atmosphere; Patient satisfaction
for psychiatric patients is often necessary when it is determined that
their behaviors are acutely dangerous to themselves or those in their
environment.(1,2) Hospital imposes a special environment in which
the meanings of behavior can be easily misunderstood. The consequences
to patients hospitalized in such an environment- the powerlessness;
depersonalization, segregation, mortification and self-labeling seem
undoubtedly counter-therapeutic and stressful.
related to hospitalization may be diverse - due to poor resources (financial
or lack of caregivers to stay with the patient) or some variables related to the
ward environment. Further, it may be related to having to interact with the
various professionals and their inexperience to deal with such situations. These
factors singly or in combination may become a hindrance for effective treatment
The assessment of patients'
satisfaction with medical services
has been a rapidly developing area of research for almost 20
years.(3-7) However, the assessment of
patients' satisfaction with psychiatric clinics has only
recently started to come into
is conceptualized as a milieu where there is an experience of trauma
.The experience of being a client in a locked inpatient psychiatric
unit can be considered traumatic (12,13) which invoke in consumers a
response of fear, helplessness,
distress, humiliation, or loss of trust in psychiatric staff.
Robins et al
(2005) in a semi structured qualitative interviews with 27 randomly selected
mental health consumers treated in a psychiatric setting about the descriptions
of adverse events experienced while receiving treatment reported two
incidents related to the hospital setting including the fear of physical
violence and the arbitrary nature of rules. The second set related to
interactions with clinical staff including depersonalization, lack of fairness
In a study of
the relationship between patients' perception of the real and ideal ward
atmosphere and their satisfaction. Patients in locked wards perceived more anger
and aggression and patients subjected to coercive measures perceived less
autonomy and practical orientation.(15,16)
In a Finnish
psychiatric hospital that explored the factors associated with satisfaction
patients were quite satisfied with their care. Of seven different satisfaction
areas, they were most satisfied with staff–patient relationships, and reported
most dissatisfaction in the areas of information, restrictions, compulsory care
and ward atmosphere/physical milieu. Younger and female patients were less
satisfied with staff–patient relationships than older patients and men.(17)
To the best of our knowledge,
there are no studies in our set up related to the factors contributing
to stress/ dissatisfaction associated with psychiatric hospitalization.
The overall aim of this study was to identify those areas of
hospital treatment that patients consider important and/or satisfactory/ unsatisfactory.
The understanding of which might help to implement various interventions
to tide up with the stress associated with psychiatric hospitalization.
This cross sectional study
was conducted at a General Hospital. Kasturba Hospital is a 1470 bed
General Hospital serving a Catchment area approximately covering 4 districts. It is attached to a major medical college and is affiliated with the Manipal University, Manipal, India.
The adult inpatient psychiatry
unit is housed in the first floor and is independent and a closed ward.
The total bed strength is 40 for both sexes and in separate wings. There
is also an additional 15 beds within the same ward but separate wing
for substance use disorders. In addition, psychiatric patients who are
not disturbed and harmful to self or others are admitted to other open
medical wards. The bed occupancy is usually full and the average length
of stay is 12 days. Most of the patients on an average 95% are discharged
into the community and a small number are transferred to long-term facility.
The treatment and care of patients are by a multidisciplinary team.
The admission process occurs in a comfortable and in a non-threatening
atmosphere where the significant others are encouraged to stay with
the patients most of the time during their stay. Though there are particular
visiting hours, it has been flexible for maximal family involvement.
Family psycho education or therapeutic family interactions occur at
least twice during their hospitalizations as part of the treatment programmes.
It is a closed ward; however there is minimal use of seclusion and restraint.
Subjects for this study (n-
50) were patients admitted to the psychiatric unit of the hospital.
Hospitalization is often initiated to maintain patient safety while
stabilizing severe adjustment problems. Subjects ranged in age from
16-70 years and a mean of 36.8(±S.D.13.6). The response rate was 89%
(50 out of 56).
Of the 50
subjects 29(58%) were males and 21(42%) were females. It is noteworthy that in
terms of the primary reasons for admission 26 (52%) were depressed; 10 (20%)
were suicidal and 14(28%) displayed significant aggression and were considered
to be dangerous to themselves as well as to others. Most of the patients who
were included were recovered psychotics or patients with depressive disorders.
Severe depressives were excluded for the likelihood of distortions in their
responses due to their mood states; neurotic patients who had improved were also
details such as the age, education, marital status, occupation, family
details were gathered with the help of a proforma devised for the purpose
in a semi-structured interview.
Hospital Stress Rating Scale
(HSRS) (18) developed by Volicer and Bohannon (1975) was used to
elicit stressful events related to hospitalization. Holmes and Rahe (1967) (19) used a method from the field
of psychophysics to devise. The Social Readjustment Rating Scale, a
tool to measure life stress. Volicer
and Bohannon (1975)
(18) used a procedure comparative to Holmes and Rahe (19) in developing.
The Hospital Stress Rating Scale. Several investigators, (20) have used
the Volicer (1973) (21) instrument as a patient outcome criterion measure
in evaluating nursing practice, thus reaffirming that the techniques
used by Holmes and Rahe and Volicer are suitable for use in a clinical
setting. These methods were used, therefore, for the development of
this instrument. Namely, the utilization of a procedure that assumes
persons are able and willing to assign magnitude to, in this instance,
stress related to hospitalization. The Hospital Stress Rating Scale
has been widely used in other settings too such as patients admitted
in medical and surgical wards (22,23); stress in hospitalized AIDS
This is a 49-item scale designed
to explore the perception of stressful events related with hospitalization
by patients. This scale has 4 sub-scales.
There are four main categories
such as: 1. Events related to hospitalization- 11 items; Events related
to patient-staff relationship-7 items 3. Events related to ward environment-
13 items 4. Events related to special difficulties arising out of the
disease- 7 items. Each item was scored on a 3-point scale of severity
ranging from Low stress -1; medium stress-2; and high stress-3. The
total score was calculated by summing
up the scores of all items. The scoring pattern was, higher the
total score higher was the stress experienced and lower the total scores
lesser was the stress.
After going through the literature
and identifying the probable stresses/satisfaction related to psychiatric
hospitalization, some of the items were included for example ‘staying
in a closed ward’, ‘having someone near your bed who is destructive/
violent/ depressed’, ‘not getting medication for sleep’ and ‘side
effects of medications- drowsiness, dryness of mouth, tremors, giddiness
and other discomfort’. Some of the items relevant to hospitalization
in general were retained. The events related to patients who were serious,
medically ill, and not applicable were eliminated and some of the sentences
were changed or rephrased to suit the chosen sample. Overall, we had
a scale with 38 items, which was thought to be of relevance in our set
The scales was
translated in the local language by a professional in the field fluent in both
languages and later back translated, later verified by another expert. Ambiguous
words were changed. All the items were found to be culture free. Of the 49
original items only 38 were included as the rest was not specific to the
patients being treated in the psychiatric ward. This again was done in
consultation with the experts.
In an attempt
to measure patient satisfaction, formal scales though allows for ease
of administration, contain relatively few items and risks
losing potentially important information
and may not represent any advantage over asking patients a global
question such as ‘Were you satisfied with treatment?’.(13) Hence, an open-ended
question was asked to elicit any other areas with which patient were not
Social support assessment:
Social support network and other stressors- two questions were related to elicit
information about social support network from friends and relatives. The number
of relatives and friends with whom they had enduring relationships and were in
regular contact were included. There was an open-ended question about
stressors-whether the patients experienced any significant stressors in the last
6 months and if the answer was in the positive further details were elicited to
know the nature of the stressor.
of coping strategies was made using a self- report coping scale. This measure
was designed to examine the common strategies used based on Roth &
Cohen (1986) approach/avoidance model of coping.(25) the approach
scale assesses support seeking and problem solving strategies, whereas
the avoidance scale reflects emotional distancing and/or attempts to
ignore the problem. Eight options were presented and patients who had
more than one mode of coping were asked to indicate the same. The number
and nature of strategy employed were taken into account.
Institutional Ethical clearance
was obtained for the study. Patients and their relatives were explained
about the purpose of the study and their willingness to participate
was taken. Confidentiality was assured. After their consent was taken,
a social worker who was familiar with the protocol met for 30 minutes
the patient in the in-patient unit 3-4 days after the hospitalization.
During this time, the patient completed paper-and-pencil questionnaires
related to hospital-related stressors, coping and social support. Demographic
and other clinical information was also collected in a semi-structured
interview with the patient and relative.
The data were
tabulated and descriptive analysis was carried out. Independent t test
and chi square was carried to find the statistical significance across
genders on hospital stress scales and coping.
Sociodemographic characteristics: The Sociodemographic
characteristics of both the genders are shown in Table 1.
1: Sociodemographic Characteristics of the Sample
the sexes about 48% were from within the district and the remaining
hailed from the neighboring districts and states. The sample comprised
of 58% married while 40% were single and the rest widowers. Religion-wise
distribution followed the general population – Hindus-82%; Christians- 14%; and
Muslims- 4%. The educational
backgrounds of the sample were 94% were literate; 6% did not have any
formal education; 62% had either high school or collegiate education
and one-third primary. 54% resided in urban and the rest from rural
or semi-urban localities. The mean age
of males were 37.5(S.D. 11.9) and females 35.9 (S.D. 15.8)
distribution also revealed that nearly a third of the patients of both genders
were in the fourth decade of their life. Majority of males were between 31-50
years – 62.1% compared to females who were either 21-30 -33.4% or 41- > 50 years
Majority of the
males were employed in various institutional set-ups-62.1%; 24% were
agriculturists; 6.9% students and 6.9% were unemployed. Among the females 76.2%
were homemakers; 4.8% agriculturists and 20% employed in other sectors. There
was none who was retired from service.
Among both genders 60% hailed
from non-nuclear families, here both extended as well as joint families
were clubbed and the rest from nuclear families. In both the sexes
the patient him/her self was the head of the family-32%; father in 24%;
spouse in 18% and in the rest either the sibling, mother or some one
Among the male
patients the main bread winner was the patient himself 38%; fathers 24% and
other 38% on the other hand among females the breadwinners were either the
spouses in the married and fathers in those who were single.
Table 2 shows the events reported by both the genders, which were stressful
related to their hospitalization. In the study patients responded to only 19
items (19 out of 38) as being of high stress, there were no events reported
which was of moderate stress and the rest was not stressful. Hence, only
these 19 items were taken up for analysis. There was none who reported any
events, which were stressful to the open-ended question.
Distribution of the Events of Stress in Different Domains
Events of Stress
related to hospitalization
away from home
||2 (9.5) |
in hospital because of illness
the reasons for treatment
for sure what illness you suffer
told about the diagnosis
eat cold and tasteless food
far away from home
||3 (14.3) |
and doctors use words you do not understand
medication for sleep when you need it
to ward environment
stay in closed wards
stay in bed /ward all the time
of the unusual smells around you
seriously ill patient beside you
disturbed/violent/depressed pt near you
enough money to pay bills
stranger sleep in the same room/ward
difficulties arising out of disease
about loosing income/job due to illness
when not expecting
about family members being far away
Distribution According to the areas of Stress - Gender-wise
Areas of Stress
related to hospitalization
arising of disease
In the present study on an
overall, males reported more number of events in all the 4 domains i.e.,
88 events in comparison to females who reported around 40 events which
was significant. (F-2.77, df-1, p<.001)
In the subscale
i.e., events related to hospitalization males reported events such as being
hospitalized far away from home (17.25% ); being put in the hospital because of
illness- (13.8%); not knowing the reasons for their treatment (13.8%); not
knowing for sure what illness they have- (13.8%); not being told about their
diagnosis-(13.8%); having to eat cold or tasteless food- (10.3%).In the
females events related to hospitalization such as not knowing when to expect
things will be done-(14.3%) and having to eat cold or tasteless food-(!4.3%).
The Fisher’s exact test showed that there was no significant difference between
males and females on this subscale.
In subscale i.e., events related
patient - staff relationship males experienced stress of having nurses
or doctors using words that they did not understand - (10.3%); and not
getting medication for sleep when patients need it- (10.3%). The females
did not perceive any stress in the second sub scale of patient- staff
relationship and was not significant.
In the events
related to ward environment males reported stress of having to stay in closed
wards - (27.6%); having to stay in bed or in the ward all the time- (24.1%);
being aware of unusual smells around the patients - (24.1%); having a patient
near who is destructive / violent - (20.7%); having beside a seriously ill
patient - (20.7%) not having enough money to pay for hospitalization (20.7%).
Among females events such as having a patient near you who is destructive
/violent / depressed -(19%); having a seriously ill patient beside you -(23.8%);
having to stay in the ward all the time -(33.3%); having to stay in closed
wards- (38.1%). This subscale was again not significant.
related to special difficulties arising of the disease, males expressed their
stress of thinking about losing income or job because of illness (27.6%); Sudden
hospitalization when they did not expect it (13.8%); worrying about family
members being far away from patient (10.3%). The special difficulties
arising of the disease experienced among females was related to worrying about
family members being away from them in (9.5%); and sudden hospitalization when
they were not expecting it (19.%) this was not significant.
There was the presence of significant stressors in the last 6 months. Stressors
were reported by both the genders i.e. 58%. While among males, 65.5% compared to
47.6% in females. The most common stressor was death of close relative-31.6% in
males and 50% in females; losses 52.6% in males and 20% in females.
Social support networks: The findings indicated that
a higher proportion of the male patients reported having relatives
6 to more than 10 – 65.6% compared to females where 81.0% had 2-5
persons in their network of social relationships. The network of friends
also was higher among males 51.8% had friends about 10, whereas among
females the network was 3-5 in 52.4%.
Coping strategies:The Pearson chi square
test showed that there was a significant difference between males and
females in the nature of coping. For instance males consulted relatives
or counselors more often than females and significant at <.05; or
resorted to use of substances such as caffeine, nicotine or alcohol(X2
.3.60, df-1, p<05). Females indulged in sleeping when faced with
stress than males and significant .p <.01 level.
Distribution of Nature of Coping Gender-wise
caffeine/ alcohol/ smoking
Some persons reported more
than one option; *p<.05; **<.01
It was observed that more than one coping strategies were employed by some
patients. The finding shows 38% of the patients utilized two strategies while
58% of the patients utilized three strategies to cope with problems.
In the present
study, females were younger, tended to be single with less number of years of
education in comparison to males. It can be speculated that in women with a
rural background, marriage is considered a significant life event that is to be
conducted at the appropriate age. Parents consider that it is their commitment
to arrange for their daughter’s marriage at all odds and hence might be seeking
psychiatric consultation in the early phase of the illness.
that majority of the males were the head of the family and main breadwinner,
as most of the families in India is based on patrilineal descent.(26)
It is father-centered or father-dominated families.
The study indicated
that most of the males reported stress of being hospitalized far away
from home and in both sexes stress of worrying about family members.
This was supported with previous research which shows that patients
encountering unfamiliar environment away from family and admitted against
their wishes.(27) In present study about 52% of samples reported that
it was inconvenient to stay away from home as most of males were either
head of the family and main bread winner. Being hospitalized amounted
to loss of income and being from small families the overall management
could not be allocated to anyone within the family especially where
the children were still young. In addition, it was the hospital policy
that a family member stayed with the patient during the hospital tenure.
Some of the
males experienced stress like being put in hospital because of illness
and sudden hospitalization when they did not expect it. This often happens
when hospitalization becomes mandatory for patients who are destructive,
violent or uncontrollable and in such instances relatives have to take
decisions regarding hospitalization.
found that that psychiatric hospitalization is often necessary when it is
determined that their behaviors are acutely dangerous to themselves or for those
in their environment.(1,2)
also indicated that the stress for males is associated with not knowing
the reasons for their treatment, not being told about their diagnosis.
On the other hand, the stress for females was related to not knowing
when to expect things will be done. The reasons for this may be two
fold as a high proportion of both genders had education up to high school
or less. Therefore, they were probably not having enough knowledge about
the nature of their illness, its course and outcome. Secondly, they
may have been ignorant of the medical procedures and hospital policies.
Majority of them hesitated to clarify their doubts with the mental health
professionals and distanced themselves from them. As a result, their
misconceptions, queries and doubts remained unclarified.
The study has
recognized that males and females experienced stress of having to eat
cold and tasteless food. This is particularly relevant in view of the
patients as they came from far off places and had to be dependent on
hospital canteen. Patients came from different places and cultural backgrounds,
their selection of diet, cooking styles varied and hence became a source
also showed that males were being stressed about the patient-staff relationship
where they expressed that they were bothered about the nurses and doctors
using words that they could not understand. This may be the effects
of the language barriers, differences in dialects, accent, and usage
of technical words by the professionals. This leaves the patients and
their relatives ignorant and confused about various illness- related
information as there is no proper communication between the staff and
the patients. As noted by Cleary and McNeil (1988), (28) higher satisfaction
may be a result of better patient-physician interactions.
stressed about not getting medication for sleep when they needed it.
In most psychiatric illnesses, sleep disturbances are the most common
symptom. The prescription for sedative is suggested by doctors and not
given on the demand of the patients. In such situations due to sleep
disturbances, which might be mild or severe, patients complain of feeling
tired, dull, the next morning, which may be present throughout the day.
It is a popular belief that a good night’s sleep is basic of the needs,
which rejuvenate human beings.
In the domain
of ward environment both the genders reported stress of having to stay
in bed and in closed wards all the time. This study was conducted in
the psychiatric inpatients, which is a closed ward set-up. Here a variety
of patients are admitted with a variety of psychiatric problems- such
as suicidal, harming others, destructive, violent, or trying to escape
from the ward and for these reasons hospitalization is initiated to
maintain patient’s safety while stabilizing severe adjustment problems.
In such cases, patients are kept in closed wards under maximum staff
observation. In an earlier study by Causey (1998) (29) showed that stress
in psychiatric patients in a psychiatric setting was because of being
in a place where all the doors were locked. In another study by Drake
& Wallach (1988) (30) reflected that the ward atmosphere in the
sample he studied was considered stressful. The other reasons could
be sudden withdrawal from the routine housework for females and absence
of outside employment for males due to which hospitalization was perceived
In the sample
studied both the sexes reported stress about having a seriously ill
patient and having a patient near their bed who is destructive or violent.
It is but normal to be fearful as it is observed that psychiatric inpatients
often display significant degree of aggression, violent behaviours,
dangerous or threatening to others, or making loud noises. They also
tend to be impulsive and unpredictable in their behaviours. All these
seems stressful to the patients who are hospitalized.
It was an observation
in this study that males reported stress because of not having enough
money to pay for hospitalization. The result shows that in more than
fifty percent of the patients examined the monthly income was between
1000-3000 rupees. This would be a meager sum and it would be difficult
to meet all the expenses of the family with the cost of all essential
commodities increasing. As in most instances, the head of the family
was the sole earner. In such cases patients are left with no savings
and have to incur loans to meet the hospital expenses and other emergencies.
On the other hand, females reported that their areas of stress were
sudden hospitalization when they were not expecting it. It is likely
that some of the patients had come for a follow-up on aggravation of
their symptoms and on advice of the psychiatrists get hospitalized immediately
for which they are not mentally prepared. Unplanned hospitalization
results in being admitted without essential things like clothes, toiletry
or finances. The unfamiliar ward atmosphere and staff interactions add
to the stress. This is especially true in case of patients who have
been admitted for first time.
that the factors found to contribute to satisfaction include
ward atmosphere, certain Sociodemographic characteristics, diagnosis,
duration of illness, and previous in-patient treatment.(31-34)
show that both genders tried coping with the problem by consulting with
relatives, friends and counselors. It was also evident among males that
more than fifty percent reported of having more than 10 persons in their
network of friends and 93% reported having similar network size of relatives
too, on the other hand among females about 52% reported of having 3-5
persons in their network of friends and 90.5% reported having similar
network size of relatives. Usually the family and family members are
the most important primary group and persons try to confide with them
in periods of crisis. However, this again is dependent on their closeness
with their kith and kin. In a closely-knit and cohesive family unit,
this might be possible. Nevertheless, there may be many instances where
professional help is often very essential to person cope with a problem.
of the study also indicated that majority of males and females were
praying to God to cope with their problems. It is a general observation
that in times of crisis many resorts to religious coping and it have
become ingrained in our upbringing and culture too. In almost all religions
saying daily prayers, performing rituals are regularly practiced. It
was also seen in this study that males consumed excessive coffee, tea
or alcohol. It can further be thought that most of them were not educated
enough to know about the ill effects of all these beverages and some
of them had misconceptions that it reduces internal tensions and induces
sleep. Many of them were ignorant of the long term effects of consumption
of these beverages.
also pointed that females coped with problem by worrying and not trying
to find solutions. This probably could be explained as the females being
home- makers had no resources to lean upon and hence no control over
the situation. Some of them confined to the house. So there was no chance
for them to mingle with others or share their feelings.
The present study enabled to
gain an understanding of the stress related to hospitalization among
psychiatric in-patients, and their coping patterns and social support
networks. The finding of the study has implications for mental health
have to inform the patient and their relatives the reasons for their
hospitalization, referral to specialized treatment, advantages of hospitalization,
approximate plan of admission and discharge, minimum expenses of the
treatment, hospital procedures and other special benefits from the hospital
which would probably predict better treatment outcomes. Developing a
plan of care, assessment of stresses in hospitalization and understanding
patient’s background may be helpful to deal with hospital stress in
staff relationship is based on good rapport, proper communication and language.
The professionals should explain about the illness and treatment issues in
simple words and in a language familiar to the patient. Group meetings between
patients, family members and the staff would help to sort the difficulties
related of hospitalization.
In-patients' attitudes towards
their psychiatric care involves a complex relationship between
clinical and sociocultural
characteristics. In view of the multifarious problems encountered by the
hospitalized psychiatric patients, it is imperative on the part of the
multidisciplinary psychiatric team, especially the psychiatric professionals to
have a clear understanding of the various problems and stresses confronting
them. It thus becomes necessary to prepare patients for the event i.e.,
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