So~. Sc~. & Mcd. Vol. 12, pp. 49 to 51. Pcrg~tmon Press 1978, Printed ila Great Britain.

PATIENTS AND HOSPITALS: A STUDY OF THE ATTITUDES OF STROKE PATIENTS

DAVID CHRISTIE* a n d LORRAINE LAWRENCE'~

The University of Melbourne Department of Medicine, The Royal Melbourne Hospital, Victoria 3050, Australia

Abstrac~Sixty survivors of a cerebrovascular accident were interviewed at approximately six months after the acute episode. Their attitudes towards the teaching hospital in which they received initial care were assessed by a method developed and tested in a pilot study. These attitudes were not associ- ated with social class, residual disability or length of stay, but were strongly related to age and sex. With increasing age men regarded the hospital environment less favourably; changing attitudes towards doctors being a major contributor. In the case of women this trend was reversed, increasingly positive attitudes being associated with increasing age. Twelve non-English speaking subjects viewed their hospi- tal experience less favourably than the others. Technical skills of medical staff were highly regarded by most, but their ability to communicate and relate to stroke patients was often thought to be inadequate.

I N T R O D U C T I O N

The efficiency of a hospital service may be monitored in various ways but concern usually centres upon hos- pital processes and measures of outcome. Less atten- tion has been paid to patients' views of the hospital experience, although in a good service the importance of meeting both emotional and physical needs is recognised. In the case of cerebrovascular disease, slow recovery and frequent residual disability render the survivors particularly liable to feelings of neglect within the medical care system. Stroke patients were selected to develop and test a method of assessing attitudes of patients to the hospital in which they received their initial care.

MATERIALS AND M E T H O D S

The Royal Melbourne Hospital is a 600 bed general hospital and a major teaching unit of the University of Melbourne. A prospective study of 170 consecutive patients admitted with a clinical diagnosis of stroke was carried out, subjects being followed for six months or until death had supervened[l] . The present report deals with the 60 survivors (38 men, 22 women) who, approximately six months after ori- ginal admission, had been shown by preliminary tests to be capable of understanding and participating in interviews. They were seen in their homes and inter- preters were used for the twelve people who did not speak English.

Preliminary field work showed that patients viewed the hospital in terms of doctors, nurses and a third broad category consisting of other hospital personnel, equipment and "hotel facilities". Favourable and un- favourable attitude statements were collected by con- versing with a variety of hospital patients and their own expressions were used where possible. Scoring was on a 5-point Likert scale [2], the neutral or un- certain point being scored 3; the scores for unfavour-

* Clinical Epidemiologist. + Medical Social Worker.

S.S.M. 12/1A D

able statements were reversed so that at all times a high score indicated a favourable attitude.

A pilot study was conducted on twelve stroke sur- vivors from another hospital and each interview was tape recorded; this allowed subsequent testing of scoring reliability. Statements of low reliability were discarded and the final model consisted of 42 state- ments, 7 negative and 7 positive in each of the cate- gories of doctors, nurses and other aspects of the hos- pital. The statements were listed in random order.

A means of weighting each of the three components by its perceived importance was devised. When the attitude statements had been scored, each subject was given a frame-board containing 16 green wooden blocks. Each subject replaced green blocks with red and blue blocks in such a way that the final pattern of red, blue and green represented relative importance of doctors, nurses and other aspects respectively. The mean number of blocks assigned to categories by the whole group was used to weight the section scores for each subject.

RESULTS

The distribution of weighted hospital scores, re- scaled as percentages is shown in Fig. 1. It is skewed

5 0 - -

2 0 - - i

m

le L

"-] I 0 - - ~ \ 30 40 50 60 70 80 90

Weighted hospitol scores, %

Fig. 1. Distribution of scores indicating attitudes to the hospital held by 60 stroke patients.

49

50 DAVID CHRISTIE and LORRAINE LAWRENCE

Table 1. Correlations of age of subject and attitudes towards the hospital and its component parts. Kendall's tau

Age in years correlated with: Hospital Doctor Nurse Other

score score score score

Men (n = 38) -0.28? -0.32t -0.06 y's" -0.271- Women(n = 22) +0.23 ~'s" +0.26* +0.27* +0.10 N's"

N.S. Not statistically significant at the 5~o, level. * P < 0.05. -tp < 0.01.

in the favourable direction yet the median score of 66% indicated only a luke-warm attitude to a presum- ably life-saving service. Further work was directed towards analysing these attitudes in the hope that greater understanding of the problems of stroke patients would emerge. Because of the skewed nature of the distribution and because an interval scale could not be assumed, a non-parametric approach was adopted.

In Table 1 rank correlation coefficients (Kendall's tau) have been calculated for the relationships between age and attitude scores in men and women respectively. In the case of men, there was a strong negative association between age and overall hospital score. A similar association was shown when age was correlated with attitude scores relating to doctors, and with other aspects of the hospital. No significant relationship was present between age and attitudes towards nurses. With women the trend was reversed, increasing age being associated with more favourable attitudes. This association failed to reach statistical significance in the case of overall hospital score, but did so in the subsets relating to doctors and nurses. All these relationships were maintained when non- English speaking patients were excluded from the analysis.

The degree of residual disability was classified after Rankin [3]. None of the survivors interviewed at six months was in the most severe category but 26 had definite functional impairment (grades 3 and 4); 34 patients had no disability or minor impairment only (grades 1 and 2). When attitude scores of these two groups were compared, no significant difference was present either generally or within age and sex cate- gories. Length of stay in hospital ranged between 5 and 186 days (median 25.5) yet no correlation 'was present between length of stay in the institution and

attitudes held towards it. Social class was character- ised on the 4 point Congalton scale [4] and there were no significant differences in attitudes expressed by members of social class 1 and 2, as compared with those held by members of social classes 3 and 4.

The non-English speaking group included seven Italians; the other five were Chinese, Greek, Maltese, Ukrainian and Yugoslav. For these people, hospitali- zation posed unique problems, and across the board less favourable attitudes were held. In Table 2, the median scores of the non-English speaking group are compared with the remainder, the test of statistical significance being the Mann-Whi tney U test. Differ- ences in attitude scores, significant at the 5% level, were present in all categories except that relating to doctors and here, the trend was in the same direction of dissatisfaction.

DISCUSSION

The interactions and relationships within a hospital constitute a complex field of study and the attitude statement approach was used to try to capture patients' true perceptions as opposed to "stock answers". Patients were interviewed about six months after hospital discharge and this recall technique was chosen to avoid the confounding effect of present need and dependency upon the hospital. Such recall is likely to result in modification of strong views with the passage of time but because of the absence of bias, between subject comparisons are valid. The study was restricted to stroke patients in order to control for diagnosis, but it is likely that the experi- ences of this selected group differ only in degree from those of the majority of patients in large general hos- pitals.

Table 2. Comparison between weighted scores of English speaking subjects and non- English speaking subjects using median and range: Mann-Whitney U test

Hospital Doctor Nurse Other

English 808 242 224 337 speaking (n = 48) (554`933) (190-280) (122-257) (214-414) Non- 72l* 228 N's" 211" 314' English speaking (618 8 5 7 ) (180-266) (157 2 4 4 ) (214-386) (n = 12)

N.S. not statistically significant at the 5% level. * P < 0.05.

A study of the attitudes of stroke patients 51

The distribution of percentage scores (Fig, 1), relat- ing to an overall view of the hospital experience, sug- gests that from the patients' view at least there is considerable room for improvement. Physical facili- ties do not appear to be of major importance; by relating to their own ward patients appear to adapt to the size of the hospital. Lack of privacy is outweighed by an appreciation of staff friendliness and the company of fellow patients; "hustle and bus- tle" is often interpreted as caring and efficiency. These reactions were very frequent and appeared to be inde- pendent of age, sex or ethnic origin; they are similar to those noted by Cartwright [-5] in English hospitals.

When nursing stroke patients, the accent is often upon physical aspects of care but value of sensitive communication between nurses and their stroke patients has been clearly demonstrated [6]. Some- times an inability to speak is interpreted as an inabi- lity to think and feel, a situation that prompted one man's comment "if you have a stroke, people treat you like an idiot". Generally warm attitudes towards the nursing staff were expressed. Perhaps "kind and hard working", "tough" but not "bossy", conceals a failure in communication skills because our patients did not expect nurses to talk much to them or their families, and tended to excuse any perceived inade- quacy. In general, doctors were thought to be more important than nurses in the recovery process, although 95% of patients agreed that doctors and nurses work together as a team. Positive attitudes towards members of the medical staff appear to be based on respect for technical skills because most patients found doctors "hard to get to know" and often "too busy to talk to you". Because of the pre- sumed importance of doctors in ensuring recovery, it is from this source that patients expected informa- tion about themselves, their illness and their future. Their expectations were often unmet, one women des- cribing her doctor as a "therapeutic machine" while another had more sympathy; "he is one of five to me, but I am one of two thousand to him".

Attitudes towards the hospital experience were observed to be age-related in both men and women (Table 1) and a major contributing factor, especially in the case of men, appeared to be a changing regard for doctors. Reasons for this can only be speculative in the context of the present study. Stroke often brings major change into peoples' lives and to men especially, the threat includes not only loss of status within the family but also downgrading of occupation or forced retirement. With older men these threats are more likely to materialise and it is not difficult to understand their resentment of enforced depen- dency and of the young, mostly male doctors. As women grow older they seem to fit more easily into a dependent role. An Australian study has shown that older women entering hospital are generally less anxious than younger women who are often con- cerned about household and disruption of family life. With changing work and domestic roles of women in our society, the present younger generation may

well accept dependency, in due course, far less easily than their mothers.

Since 1946, some 3 million people have emigrated to Australia and more than half have come from places other than the United Kingdom. Gordon [-8] makes the following comment: "Migrants come with hearts full of hope, but for some of them the realities of their lot in Australia require rather endurance and fortitude. Hope remains but it is for their children." Beset with stroke and dependent upon an alien hospi- tal culture, the difficulties of non-English speaking migrants are formidable. An old Italian man said that the hospital felt "like an empty space"; another had not known how to ask for a urinal; a hemiplegic man placed in a very hot bath by orderlies could neither move nor explain the problem.

The pattern appearing throughout this study is that in an age of high technology the ability, or willing- ness, of many professionals to talk with and under- stand people who are old, infirm, or "difficult" because they can't speak English, is sadly lacking in all too many cases. Corrective action has been in- itiated in Melbourne, as elsewhere in both medical and nursing education, with the introduction of for- mal teaching in the behavioural sciences. Perhaps more importantly, students are being encouraged to seek practical experience of health care in the wider community beyond the hospital. As yet there is little evidence that these new approaches have made any impact upon the traditional roles of doctors and nurses in hospital practice. With nurses, accent on physical care of patients, routines and smooth run- ning administration can run counter to the under- standing of individuals. While our medical students are selected on scientific ability alone, while courses remain essentially disease-oriented and we continue to train our students to jump a succession of examin- ation hurdles, poor communication and lack of empathy will be with us for many years to come.

Acknowledgement--This study was supported by the Hos- pitals and Health Service Commission of the Australian Government.

REFERENCES

1. Christie D. Stroke in Melbourne: a study of the rela- tionship between a teaching hospital and the com- munity. Med. J. Aust. 1, 565, 1976.

2. Oppenheim A. N. Questionnaire Design and Attitude Measurements. Heinemann, London, 1966.

3. Rankin J. Cerebrovascular accidents in patients over the age of 6--II: Prognosis. Scot. reed. J. 2, 200, 1957.

4. Congalton A. A. Status and Prestige in Australia. Cheshire, Melbourne, 1969.

5. Cartwright A. Human Relations and Hospital Care. Routledge & Kegan Paul, London, 1964.

6. Patrick G. Forgotten patients in the medical ward. Canadian Nurse 68, 27, 1972.

7. Congalton A. A. and Najman J. M. Nurse and Patient: a Sociological View. Symes, Sydney, 1971.

8. Gordon D. Health, Sickness and Society. Univ. of Queensland Press, 1976.