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Patients' and parents' views of admission to an adolescent unit

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ABSTRACT: Reilly, J. (2006) Patients' and parents' views of admission to an adolescent unit. www.nursingtimes.net.

ABSTRACT: Reilly, J. (2006) Patients' and parents' views of admission to an adolescent unit. www.nursingtimes.net.

AIM: This study investigated the views of young people and their parents about admission to the adolescent psychiatric unit at the Bethlem Royal Hospital in south-east London. The aim was to ascertain whether their views on issues such as treatment, decision-making and restriction of liberty were accurate.

METHODOLOGY: The sample consisted of 10 young people (four female, six male) aged 12-18 and their parents. Participants were given a questionnaire within 2-7 days of admission, which contained 40 statements about admission to the unit on a five-point scale from strongly disagree to strongly agree. Half the statements were inaccurate and half were accurate.

RESULTS: The study found significant results for some areas under investigation, but non-significant results were found where both parents and young people had inaccurate perceptions of admission to the adolescent unit. Therefore, both parents and young people had more accurate perceptions of admission to the adolescent unit than inaccurate.

CONCLUSION: This study suggests that although there are some accurate perceptions about admission to an adolescent unit, further education is needed in some areas.

'The actual people I met weren?t violent that I think they are violent, that comes from television, plays and things. That's the strange thing, the people were mainly geriatric - it wasn't the people you hear of on television. Not all of them were younger. None of them were violent but I remember being scared of them, because it was a mental hospital.' (Participant, Glasgow 2000).

Since the publication of the National Service Framework for Mental Health (Department of Health, 2000) mental healthcare providers have been under increasing pressure to provide and improve services for young people with mental health problems. Approximately 40% of young people are affected by mental illness at some time in their life (West, 1997) and 14-18% of these have moderate to severe mental health problems (Bird, 1999). However, many young people are reluctant to use the specialist services offered to them, or quickly cease contact (Gough, 1998; McKay et al, 1996; Triseliotis et al, 1995).

Although many health promotion and education programmes for young people have been set up to tackle stigma and negative connotations associated with mental health problems, many young people who come into contact with psychiatric services still appear, in my clinical experience, to hold negative views around mental illness.

Previous research on young people?s views on mental illness (Holyoake, 1999; Chesson 1997) has focused mainly on children (aged 5-12) and their views about people with mental illness and psychiatric hospitalisation. This study aimed to investigate these views in adolescents, a group that so far appears to have been under-investigated.

Beliefs about mental illness

Mental illness has long been associated with stigma and negative stereotypes. In a survey by the Royal College of Psychiatrists (1998), 70% of people believed that individuals with schizophrenia are violent and unpredictable. However, research has not found mental illness to be a reliable predictor of violence and the majority of people diagnosed with mental illness are never aggressive to others (Monahan, 1992). In reality, members of the public have a higher chance of winning the lottery than of being a victim of violence perpetrated by someone with mental health problems (Gunn, 1993).

While there have been a number of cases in which people with mental illness have perpetrated violent crimes, such stories have often been reported in a sensational way by the mass media. Such reporting contributes to developing and maintaining public stereotypes of people with mental illness in general (Bolton, 2000; Angermeyer and Mattschinger, 1996; Wahl, 1995; Philo et al, 1994). Positive images of people with mental illness rarely gain media attention to help to create a more balanced view of them.

Day and Page (1986) rated 103 newspaper reports in Canada concerning people described as mentally ill. The reports generally conveyed negative stereotypes - characterised by dangerousness, unpredictability, dependency and transience - resulting in the implicit portrayal of people with mental illness as a homogeneous group with no positive social identity. Similarly, Signorielli (1989) analysed the portrayal of people with mental illness in TV drama over 16 years. They were more likely to be portrayed as bad than good and also more likely than other characters to be 'failures'. Examinations of media portrayals in various countries and using different analysis methods have consistently reported that depictions of mental illness are overwhelmingly negative (Wahl, 1995; Philo, 1993; Hyler et al, 1991).

Unsurprisingly, media organisations reject the notion that they are responsible for perpetuating harmful stereotypes, claiming they are mirroring the values and beliefs of our society (Bolton, 2000).

In 1984 Roth and Roth undertook the first systematic survey of children's concepts of their own psychiatric hospitalisation and found that children aged 6-12 years did not have specific concepts of their problems or the roles of staff. Instead, their understanding was stereotyped and general. Over time as psychiatric hospitalisation progressed, the children?s understanding of their problems and role of staff improved.

Previous studies have shown that parental understanding of child psychiatric services is limited (Garralda and Bailey, 1989; Plunkett, 1984; Burck, 1978) and poor communication has been highlighted at both outpatient and inpatient level.

Chesson (2000) attempted to establish how children and their parents view psychiatric input, its functioning and consequences and whether they share similar perceptions in a study of children aged 6-12 and their parents prior to, during and on discharge from a psychiatric unit. The children showed many inaccurate perceptions of the unit itself, the roles of the different professionals and the daily activities on the unit. The children also had a limited understanding of why they had come into hospital. Surprisingly, Chesson (1997) found that 35% of the parents did not know why their child had been admitted to hospital. They also had difficulty in understanding the treatment their child was receiving and in providing broad definitions of the roles of many of the professional staff.

In addition to the stereotypes that exist about mental illness and admission to hospital, young people have been found to hold stereotyped views on the roles of staff (Eiser and Patterson, 1984; Holyoake, 1999).

Holyoake (1999) interviewed 13-17-year-olds about an adolescent psychiatric inpatient unit, focusing on the roles of staff. The young people recognised that a hierarchy existed within the multidisciplinary team and some had stereotyped views about the roles of staff - they believed doctors make all the important decisions affecting care, while nurses make the beds and serve dinner.

The study

Aim

The aim of this study was to investigate young people's and parents' views on admission to a psychiatric unit. The study was similar to that by Chesson (1997) although it looked at adolescents aged 12-18 and their views on roles, treatment, decision-making, restriction of liberty and communication.

It investigated the following hypotheses: Hypothesis one: Young people and their parents have inaccurate perceptions of admission to a psychiatric inpatient unit. Hypothesis two: There will be a relationship between young people and their parents? views about admission to an inpatient psychiatric unit.

Design/methodology

The study used a questionnaire with 40 quantitative questions on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree) and qualitative investigation. The questionnaire, which was administered both to young people and to parents, contained 20 accurate statements and 20 inaccurate statements about decision-making, roles of staff, communication, treatment and restriction of liberty. The accurate statements were drawn from job descriptions about staff roles and decision-making within the hospital, and from hospital and adolescent unit policies on communication, treatment and restriction of liberty. The inaccurate statements were opposites of the accurate statements and inaccurate comments that had been made in previous studies. The qualitative parts of the questionnaires were follow-up questions to the answers given by participants.

Questions were counterbalanced so accurate and inaccurate statements alternated. The independent variable under investigation was the perception of young persons and parents of admission to an adolescent unit. The dependent variable was the accuracy of responses to the statements on the questionnaires.

Sample

The study used an opportunistic sample, which was necessary as not all young people admitted to the unit and their parents agreed to participate. Emergency admissions (acutely psychotic) and young people who were too distressed on admission were excluded from the study. The sample consisted of 10 young people (four girls and six boys) aged 12-18 years (mean 16 years), who had a range of problems such as social phobia, depression, psychosis and manic depression. Questionnaires were given to which ever parent attended as some parents were single parents. If two parents attended, they were asked to fill out a questionnaire together.

Ethical considerations.

Ethical approval was gained from the hospital committee at the Institute of Psychiatry, London. Participants were given information sheets about the study to gain their informed consent to participate and informed that they could withdraw at any time.

Results

The results of this study have shown that young people and their parents have more accurate perceptions of psychiatry than previously assumed. The young people had a higher mean score on accurate statements at 3.76 (range 3.25-4.2) than inaccurate statements at 2.82 (range 1.90?3.50), which suggests they had more accurate views of an inpatient admission to hospital than was hypothesised. The standard deviation for accurate statements was closer to the mean value than the standard deviation for inaccurate statements.

A dependent samples t-test was used on the results, which showed a significant difference between the young people's responses to accurate and inaccurate statements, in which they agreed with more accurate statements than inaccurate. T = (9) 4.719, 0.002

Parents had a higher mean score on the accurate statements 3.85 (range 3.45-4.40) than inaccurate 2.87 (range 1.95-3.60), which suggests they had more accurate than inaccurate views of admission to an inpatient psychiatric unit.

Again, the standard deviation is closer to the mean value than the standard deviation for the inaccurate statements, suggesting that the mean was a good representation for accurate statements made by the parents but not so accurate for inaccurate statements.

A dependent t-test was used and showed a significant difference between parent's responses in agreeing more with accurate statements than inaccurate statements: T = (9) 3.98; 0.004.

The results also showed a link between young people and their parents? views in some of these areas.

A Pearson's product moment correlation was carried out on the results of this study. The results of these will be discussed below.

There was a significant correlation between parents' accurate perceptions of decision-making and young people's accurate perceptions of decision-making: r = 0.636; p = <0.024.>

There was a significant correlation between parents' accurate perceptions of restriction of liberty and young people's accurate perception of restriction of liberty: r = 0.600; p = <0.33.>

Non-significant results were around accurate perceptions of roles for both young people and their parents: r = -369; p = <0.147.>

Non-significant results were also found for accurate perceptions of communication for both young people and their parents: r = -368; P < 0.148.="">

Although there were no other significant correlations, there were noticeable effect sizes in the results, which is worth mentioning.

According to Cohen (1992; 1998) r = 0.10 (small effect) or 1% of the total variance, r = 0.30 (medium effect) accounts for 9% of the total variance, r = 0.50 (large effect) accounts for 25% of variance.

A noticeable effect was noted in parents' accurate perceptions of treatment and young people's accurate perceptions of treatment: r = .495; p < 0.73.="" this="" result="" meets="" the="" criteria="" for="" a="" large="" effect,="" which="" accounts="" for="" 25%="" of="" the="" variance.="" similar="" effects="" were="" noted="" for="" inaccurate="" perceptions="" of="" roles="" by="" both="" parents="" and="" young="" people.="" there="" was="" a="" medium="" effect="" size="" noted:="" r="0.411;" p=""><0.119.>

In inaccurate perceptions of treatment, there was a medium-sized effect noted in parents and young people: r = 0.325; p = <0.180. in="" inaccurate="" perceptions="" of="" restriction="" of="" liberty="" there="" was="" a="" medium="" effect="" size="" noted="" in="" parents="" and="" young="" people:="" r="0.329;" p="">< 0.177.="" in="" inaccurate="" perceptions="" of="" communication="" there="" was="" a="" medium="" effect="" size="" noted="" in="" parents="" and="" young="" people:="" r="0.306;" p=""><0195.>

Discussion

This study investigated the views of young people and their parents about admission to a psychiatric inpatient unit. It aimed to address a number of comprehensive areas that are part of the admission process to a psychiatric adolescent inpatient unit - decision-making, the roles of staff, treatment, communication and restriction of liberty. It also addressed whether there was a relationship between the views of individual young people and their parents.

Previous research had focused mainly on the views of younger children and their parents (Chesson, 1997) the roles of staff and hierarchies (Holyoake, 1999) and general medicine (Eiser and Patterson, 1984; Brewster, 1982; Bibace and Walsh, 1980; Natapoff, 1978). There has been little previous research on adolescents' and their parents' views about admission to a psychiatric inpatient unit.

A t-test on accurate and inaccurate scores for young people and their parents found significant results for young people having accurate perceptions of admission to a psychiatric inpatient unit and for parents having accurate perceptions of admission to a psychiatric inpatient unit. This refuted hypothesis 1: 'Young people and their parents will have inaccurate perceptions of admission to a psychiatric adolescent inpatient unit'.

A correlation was performed on the results to assess the developmental influence or social learning effect that parents may have on their children's opinions. This found a significant result for parents' accurate perceptions on decision-making, supporting hypothesis 2 in this study. Therefore there was a relationship between the views of young people and their parents about who makes the decisions in the adolescent unit. Another significant result was found for accurate perceptions of both young person and parents on restriction of liberty supporting hypothesis 2. Therefore there was a relationship between the views of the young person and their parents about restriction of liberty. This would suggest that young people and their parents are aware of modern-day psychiatry and perhaps even human rights as to what is acceptable for their own safety.

To assess further the accurate and inaccurate perceptions of young people it is worthwhile to look at the qualitative data. Looking first at the questions in the category of roles, seven out of 10 young people knew that nurses would spend most of the time with them, while the younger children in Chesson's (1997) study thought teachers would spend most of their time with them. In this study, the young people knew the nurses would talk, observe and assess them and felt that nurses would talk to them about anything, 'life in general', 'any problems' and 'what I'm feeling'.

Parents demonstrated similar views, suggesting nurses would observe, interact, offer support, engage and lead them in activities. One parent offered a more sophisticated and accurate perception, suggesting nurses monitor mental states and are responsible for risk assessments. This demonstrates an understanding that nurses have a high level of responsibility in psychiatry.

As previous research suggests (Holland, 1993; Rothenburger, 1990), in this study young people demonstrated an accurate understanding of the nurse's practical role of managing the unit, agreeing with the statement: 'The nurses tell us what to do each day.' They commented that the nurses told them to 'be good', 'have medication', 'do activities' and 'go to unit school'.

Despite young people recognising the practical role of nursing, most (eight out of 10) knew that nurses did not make beds on the unit, unlike in previous research with younger children (Eiser and Patterson, 1984). Most young people thought the nurses 'kept everyone in line', 'take us outside' 'wake patients up' and 'open doors figuratively and literally', demonstrating the structure of the day and influence over young people that nurses can have.

As in previous research (Chesson, 1997) most parents thought the role of the nurse was purely to make sure their child participated in activities and how they structured their day.

Most young people recognised the hierarchy within the nursing team, as in previous research (Holyoake, 1999), agreeing with the accurate statement that: 'Some nurses are more senior than others.' They expressed that they recognised this from the badges nurses wore, their conversation with young people and the respect gained from other nurses. Parents had similar responses, with nine out of 10 commenting that they recognised hierarchy by job title, roles played, consultation regarding the child's case and by the level of information held.

More than 20 years ago, it was felt that professionals working in mental health services should no longer wear uniforms, as they created a further barrier to treatment. Most young people recognised that nurses and doctors would not wear uniforms in this unit. When asked how they would distinguish nurses from doctors, most commented on the smart appearance of doctors, wearing suits, having a more sophisticated presentation and being more academic than nurses. Parents did not make the same assumptions about doctors and nurses and expressed that they would recognise the difference between doctors and nurses by name badges or by introduction of name and role.

A small number (two out of 10) of the young people agreed with the accurate statement that the consultant was in charge of the adolescent unit. The reasoning for this was they knew he prescribed medication and kept others in line, showing the hierarchy in medicine and the power associated with this role. In response to this, one parent commented that all staff should be involved in decision-making. Other parents thought the consultant's role was to be involved in treatment, policies, deployment of staff and having 'the final say'.

Although young people recognised the hierarchies within nursing, only a small number (three out of 10) thought the consultant told other doctors what to do. One commented this would only occur in 'extreme cases of psychosis' and the 'doctors discuss with each other', suggesting a recognition that the consultant is the specialist within the team.

As previous research has found (Katzman and Roberts, 1989), a few of theyoung people agreed with the inaccurate statement that the doctors tell the nurses what to do. It appears from some of the statements made by the young people that nurses were seen as inferior to doctors. One young person felt the doctors told the nurses when a young person needs to be on one-to-one observation, although the nurses instigate this. Another person felt that the nurses would lose their jobs if they disagreed with the doctors, demonstrating the power associated with the doctor's role. As in Holyoake's (1997) study, young people felt that the doctors made decisions about treatment and nurses made only simple decisions such as what activities to participate in or what kind of treatment is needed immediately.

However, parents appeared to acknowledge that nurses are fairly autonomous in their roles and used doctors for consultation, recommendations and to discuss particular issues. They agreed that nurses help the doctors make decisions about their child's treatment as nurses spend most of the time with their child. Parents also felt nurses were able to give information on how their child is responding to treatment. One felt that nurses have a lot of input regarding treatment although two felt the doctors were responsible for making decisions about their child's treatment.

Young people agreed with the accurate statement that doctors made the decisions of discharge by talking to staff, family and the young person and observing a clear change in behaviour. Most agreed with the accurate statement that nurses had some decision-making in weekend leave. Parents agreed that nurses and doctors made decisions about weekend leave, and felt young people would be discharged when the doctors had seen that they had recovered, after meetings and in consultation with parents.

With regard to accurate perceptions about treatment, young people were aware that staff would not do anything the young person asked of them. Young people commented that the staff 'would not let me escape' or 'will not let me leave'. Parents' answers were about things that would be beneficial for the young person, such as that nurses would not 'allow him to withdraw or hurt himself' or 'do things that are not beneficial'.

Young people were aware that they may be given medication while in hospital and suggested how it might help: comments included 'it helps calm you down, relax and not [be] violent'; 'may work cos I think it's working like a placebo'; and 'may help me deal with issues'.

When asked whether they thought they would take medication for life - an inaccurate statement - some young people suggested they would take medication for the first few weeks of admission whereas others did not have a clear idea. One parent felt this was dependent on diagnosis, another said they hoped not and one suggested 4-6 months.

Most young people disagreed with the inaccurate statement that medication can be harmful; one spoke of the side-effects of some medication increasing your appetite leading you to become unfit, which can occur with some medications. All parents felt that young people may be given medication to 'reduce anxiety', suppress 'psychotic behaviour' and 'help them so they get home'. Only one parent thought medication could have side-effects after long-term use.

Only one young person agreed with the inaccurate statement that nurses would put medication in their food if they refused to take it, but 'only in extreme cases'. Most parents disagreed with this statement, although worryingly two out of 10 parents did not know the answer to this.

On the issue of restriction of liberty, most young people felt they would not be able to leave the hospital until they displayed 'a normal sense of well-being', although young people are allowed weekend leave if they are not a risk to themselves or others. Sadly, three young people felt they would have to wear a restraint jacket if they became aggressive and two did not know. This may demonstrate the perceptions of wider society that you are locked up once you enter a psychiatric unit.

The results of the qualitative answers to the statements provide further insight into accurate perceptions and inaccurate perceptions of adolescent psychiatry. Generally, it would seem that stereotypes still exist about the nurse's practical role and the doctor's role as the powerful decision-maker. Further investigation is certainly warranted in this limited area.

Although this study did show some significant results, it had some limitations. One limitation was the small sample size. At the outset of the study it was decided that a sample size of 50 would be appropriate, but the other unit that was asked to participate in recruitment of adolescents was unable to do so due to a high level of emergency admissions and staff shortages. Similarly, at the participating adolescent unit not all who were admitted were able to participate. The sample was opportunistic in nature. One reason for this was that some parents did not give consent for the child or themselves to participate. This may have been due to concern that their child was too unwell, anxieties about the admission process or the shock of finding that their child needed to be hospitalised. Therefore at the time of admission parents may not have been in the right frame of mind to fill out a questionnaire. Alternatively, parents may have felt the questionnaire could be used in a negative way, or they may have been unwilling to participate because of stigma in psychiatry or because they thought their response may affect their treatment while in hospital.

From the researcher's perspective, it was difficult to obtain a large sample because some young people were too unwell on admission to the unit. Some were acutely psychotic or depressed on arrival and it would have been unethical to ask them to participate while they were in a vulnerable state. One way of overcoming this would be ask young people cared for by outpatient community teams about their views on admission to an inpatient unit. One issue that arose with the sample was that some young people had more insight than others into admission into a psychiatric hospital. This could have influenced the results to produce a significant outcome on some variables.

One reason why some of the results were not as significant as they could be may be due to the study method. On admission the young people and their parents were given the questionnaire. In the early stages of the study some parents took it home and never brought it back, explaining they had forgotten it. This also led to a smaller size and demonstrated one of the difficulties of using the questionnaire method. To improve the response, young people and their parents were asked to complete the questionnaire on the unit. Although young people were interviewed separately, some were in the presence of their parents when they completed the questionnaire and this could have influenced their responses.

In this study seven of the parents who participated were the mothers and three were fathers. For future research it would be interesting to see if those views differed between parents as this may have affected the results.

Although this study gained ethical approval from the Institute of Psychiatry's ethical approval committee, a number of ethical issues did arise with this subject group. One is the young person's and their parent's motivation for participating. Some may have believed that declining to participate may affect their treatment. Also, young people and parents may have felt obliged to cooperate with people who are helping them when their child is at a desperate stage in their life. One parent and child were waiting for funding to be approved from their local NHS trust so the child could be treated at this hospital rather than their local psychiatric unit.

Another ethical issue with this study is interviewing young people who are unwell as they are a vulnerable group, which is why it was crucial to obtain informed consent from parents and the young person and ensure that they fully understood the study. It is important to take into account the above concerns and constraints of this study.

Conclusion

Generally, this study showed that young people and their parents had accurate perceptions of admission to a psychiatric hospital, although the qualitative information showed they still lacked insight into some areas of admission. Lack of information about roles of staff and treatment procedures were highlighted in this study.

Unfortunately lack of information can lead to stereotyped views, which are predominant in society. This study emphasises the need for further education at primary care level, for example with GPs and health visitors and in schools. More intervention packages need to be offered like those of Pinfold and Toulmin (2003) and Penn (1999), who found educational workshops with young people can have a positive impact on their views about mental health. Others (Salter and Byrne, 2000; McKeon, 1998) have argued for more stigma-prevention programmes which challenge the negative media depictions and promote a balanced and positive portrayal of mental illness in the media.

Professionals also need to take a proactive approach in objecting to media misinterpretations of mental illness. Professionals need to convince their target group about the importance of stigma and discrimination and challenge stereotypes in others and ourselves.

This study suggests that, although parents and young people may have more accurate perceptions of an admission to a psychiatric hospital than had been assumed, further research and educational intervention programmes need to take place to maintain and promote mental health and dispel fears and stereotypes that exist in society.

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