- Email: [email protected]
Transcultural nursing research with schizophrenics
hf.
J. Nurs. Stud. Vol. 15, pp. 135.142. Pergamon Press Ltd.,
1978. Printed in Great Britain.
00224878/78/0801-0135
W2.tXVO
Transcultural nursing research with schizophrenics * HELEN E. KLEIN, D.S.W., MARLENE M. MOSBERGER, R.N., TYLER B. PERSON, B.S. and RITA E. VANDIVORT, M.S.W. Missouri Instituteof Psychiatry, 5400 Arsenal Street, St. Louis, Missouri 63139, U.S.A.
Increasingly today, care givers are being asked to evaluate the services rendered to clientele. The requirements of documentation by institutions of appropriate quality and quantity of services, such as required by Professional Standards and Review Organizations (Goran, Roberts, Kellogg, Fielding and Jessee, 1973, are putting growing pressure on clinicians, both in medical and psychiatric settings, to justify the methods used in practice. As a consequence, research supporting the success of certain clinical techniques is more frequently being called for by the professionals in the field. Research to indicate quality of services is required particularly in psychiatric settings, where both diagnosis and treatment are more difficult than in a strictly medical setting to clearly demonstrate and monitor. The deinstitutionalization movement in mental health has emphasized rapid community placement of the hospitalized mentally ill to avoid a person becoming overly dependent on a care giving institution, as well as to avoid institutional stay without an appropriate level of treatment. Yet, to effectively apply the model and assure quality treatment requires that professionals understand social variables favorable for successful community outcome. Purpose
This article presents a nursing substudy included in a 5 yr Transcultural Study in Discharge of Schizophrenics carried out in Missouri and Turkey by the Missouri Institute of Psychiatry. The purpose of the overall study was to identify social, psychological, and environmental variables significantly associated with patients’ adjustments in the community and if it occurred, readmission to hospital. The nursing substudy examined selected variables of professional care of the patient in hospital; physical environment of home and hospital; and social, religious, and recreational activities at home and hospital. The underlying premise was that the greater the change required of patients in their everyday pre-illness behavior or environment to meet hospital standards and routines, the ‘Funded in Dart by USPHS Grant MH 18934. 135
136 HELENE.
KLEIN, MARLENEM.
MOSBERGER,
TYLER B. PERSONAND
RITA E. VANDIVORT
favorable the ultimate outcome would be for community adjustment discharge.
less
after hospital
Method The study was carried out at Bakirkl)y State Hospital, Istanbul, and at seven Missouri Division of Mental Health hospitals and mental health centers located throughout the state. Of the 369 patients, 52 were urban and 42 rural Turks; 66 were urban and 63 rural black, and 66 urban and 80 rural white patients in Missouri. Sampling was by consecutive admissions. Local clinical psychiatrists gave the treatment and were blind to the research design thus eliminating bias in their decisions on treatment, discharge, or readmission. A primary diagnosis of schizophrenia was required, and patients with other types of mental illness, gross medical and neurological disorders, lobotomies, and mental deficiency were excluded. Length ‘of illness was between 1 and 10 yr prior to current hospitalization, and age range between 20 and 50 yr. Both men and women were included. Both American and Turkish patients were at least second generation residents of their respective countries. During hospitalization, patients received major tranquilizers which included phenothiazines, butyrophenone derivitives, thioxanthene derivatives, and molindone; the drug and dosage was doctors’ choice. All patients receiving insulin shock, electric shock, psychosurgery, or psychotherapy as a major therapy were excluded. Ancillary therapies such as facilitative social services, and occupational, recreational, music, educational, and industrial therapies were permitted as needed. Data were collected through in-person interviews with patients and families by nurses, psychiatrists, and social workers at patients’ hospital admissions, discharges and at 1 yr post hospital follow-ups in the community. Statistical analyses included MucciardiGose Cluster Algorithm, chi-square, multivariate regression, and step-wise regression depending on which questionnaires were being analyzed. The data showed that both Turkish and Missouri patients’ illness was statistically similar in symptomathgy and intensity and both had similar social functioning ‘at worst’, i.e. at admission. Treatment for both was similar as required by the research design; and both were similarly improved at discharge. The Nurses Observation Scale for Inpatients (NOSI) was used to measure ward behavior at date of discharge, and no statistically significant differences were found between Turkish and Missouri patients as a whole nor between any of the six ethnological subgroups except for Missouri white urban patients alone, who were more likely to be rehosnitalized if the patients were in the Negative Ward Behavior Group at discharge (x’ = 5.9733, df 1, P < 0.025 > 0.01, c = 0.2881). Both Turkish and Missouri patients had statistically similar discharge readiness ratings on the Hogarty Discharge Readiness Inventory (DRI). At follow-up 1 yr after discharge there was still the similarity of symptomatology and severity. These data showed that illness for Turkish and Missouri patients was statistically similar and thus suggested the variables associated with rehospitalization lay in the social environment. Complete reporting of the study including hypotheses (Klein and Itil, 1973), questionnaires and rating scales, interrater reliability (Person, Klein, Hyman and Cook, 1978), description of patient samples, and the total unpublished findings are available in the final NIMH report (Klein, 1976). Partial published findings, exclusive of those in this article, may be found in Klein, Person, Itil and Cetingbk (1978).
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Findings Hypotheses included in the nursing substudy are given below along with the findings on each hypothesis. Many of the variables studied were selected from current clinical nursing practice in psychiatric settings because most of these practices have not heretofore undergone structured testing. Hypothesis one concerned the physical milieu in hospital, and variables studied were habits of personal hygiene, clothing, sleep, food, and privacy. Personally as well as professionally, certain values are set on routine habits such as eating, sleeping, cleanliness, privacy. In Turkey, for example, hospital facilities prevent many patients from bathing and changing to clean clothing as frequently as they are accustomed to do at home, and families often take patients home on visits to provide these. In one study at Bakirkby Hospital, nearly one-third of the families gave this as a major objective of home visits and indicated they wanted doctors and administration to provide better bathing facilities (Atman and Polvan, 1971). In Missouri, some rural patients without indoor bath and toilet facilities at home found the hospital setting more convenient for personal hygiene. With such variances in patients’ home environments, it was not surprising that findings in the study showed significance for some subcultures and not for others. In regard to bathing, Missouri blacks were less likely to be rehospitalized if prior to illness and hospitalization they customarily bathed more than once per week (x2 = 9.4454, df 3, P < 0.025 > 0.01, c = 0.2612). Missouri whites were more likely to be rehospitalized if hospital routine required daily bathing during hospitalization (x2 = 17.4136, df 2, P < 0.001, c = 0.3264). For other subgroups including Turks, there were no statistically significant findings. * Brushing of teeth was significant for only one group, Missouri whites, in which fewer patients, who had brushed their teeth daily during hospitalization, were rehospitalized (x2 = 9.4062, df 3, P< 0.025 > 0.01, c = 0.2460). All Missouri patients who cleaned their nails only monthly were more likely to be returned to hospital after discharge (x’ = 11.4353, df 3, P< 0.025, c = 0.1998), and Missouri white urbans who cleaned their nails daily were less likely to return (x2 = 7.9654, df 3, P < 0.05 > 0.025, c = 0.3282). For all other groups care of teeth and nails was non-significant; and for all groups care of hair was non-significant. The most easily recognized self care in hospitalized patients is shaving for men and use of cosmetics by women. Turks who shaved as often as they thought necessary (PRN) rather than on a regular schedule prior to illness had more favorable community outcome after hospital discharge or’ = 10.3990, df 3, P < 0.025 > 0.01, c = 0.3156) while those urban Turks who shaved more than once weekly had less favorable outcome (x2 = 9.5080, df 3, P < 0.025 > 0.01, c = 0.3932). By contrast, Missouri rural men who shaved more than once per week fared better (x2 = 9.7510, df 4, P< 0.05 > 0.025, c = 0.2527). When urban Turks shaved more than once monthly while hospitalized, rehospitalization was less likely (x2 = 8.4824, df 3, P < 0.05 > 0.025, c = 0.3730). Similarly to Turkish men’s shaving habits, all Turkish women who used cosmetics prior to illness as often as they thought necessary (PRN), or more than once daily,*had more favorable community outcome after leaving the hospital k’ = 11.5026, df 3, P < 0.01 > 0.005, c = 0.3302). Favourable outcome was also associated with use of cosmetics more than once weekly *In the variables
report below, all variables not explicitly were tested on all subgroups.
reported
on specific
subgroups
are nonsignificant;
all
138
HELENE.
KLEIN,
MARLENE
M. MOSBERGER,
TYLER B. PERSONAND
RITA E. VANDIVORT
while in hospital for urban Turkish women (x2 = 6.1760, df 2, P < 0.05 > 0.025, c = 0.3258). Missouri rural yomen who used cosmetics no more often than once per month while in hospital were more often rehospitalized after discharge or’ = 7.9133, df 3, P< 0.05 > 0.025, c = 0.2290). A comparison was made for each individual patient on the above personal hygiene variables to see how much modification, positive or negative, in habits was required between their usual home habits prior to illness and while hospitalized to conform to hospital routines. Among Missouri rehospitalized patients 97 (92%) had made from 1 to 7 changes (mean 2.49) and among those not rehospitalized 154 (91 @/‘o) had made from 1 to 7 changes (mean 2.78). Among Turkish rehospitalized patients 31 (100%) had made from 1 to 7 changes (mean 4.16) while among those not rehospitalized 61 (97%) had made from 1 to 7 changes (mean 3.05). Obviously hospitalization even under flexible nursing care requires personal change for most patients; only 26 patients out of the total of 369 patients experienced no change in their habits of personal hygiene. Clothing was another variable examined as part of patients’ personal hygiene. In both countries most patients wore their own street and sleep clothing. A very few were provided with hospital clothing, but since that provided was of the same style as the patients’ own clothing, this made no significant differences for patients. More important was how frequently Missouri patients were able to change to clean clothing. Those who changed more than once per week while in hospital were found to be rehospitalized less often Or’ = 7.9739, df 3, P < 0.05 > 0.025, c = 0.1679); this was also for the Missouri urban if while groups. The Missouri whites had a greater chance of rehospitalization hospitalized they changed to clean clothing only PRN, i.e. ‘as needed’ Or’ = 7.1736, df 2, p < 0.05 > 0.025, c = 0.2164), but Missouri white urbans were less frequently rehospitalized when they changed daily or” = 9.0750, df 2, P < 0.025 > 0.01, c = 0.341.7). Of both rehospitalized and not rehospitalized Missouri patients, one-half were requird to change their clothing habits. In Turkey 32% of those rehospitalized changed their clothing habits in hospital compared to only 24% of those not rehospitalized. Change in use of clothing habits was not as frequently experienced as change in other types of personal hygiene. Privacy varies greatly between different cultural groups, so data were collected to show if patients had been accustomed at home to usually being alone, spending some time alone, and never being alone, and whether in hospital they were able to continue their accustomed degree of privacy. The findings were non-significant for outcome on all groups. Close observations of patients showed that those wishing privacy will find some means of securing this even in crowded hospitals, while more gregarious ones take advantage of crowded wards to make more friends. On an individual comparison only 9% of Missouri rehospitalized patients and 10% of non-rehospitalized patients had had less privacy in hospital than at home; but in Turkey 45% of both groups had less. Sleeping arrangements were considered a special kind of privacy. All Turkish patients who shared a bed prior to hospitalization 01’ = 6.0447, df 2, P < 0.05 > 0.025, c = 0.2458) or urban Turks who shared a bedroom with one other after discharge (x2 = 8.1358, df 3, P < 0.05 > 0.025, c = 0.3678) were less likely to be rehospitalized. Many who shared beds or bedrooms shared them with their spouses. All Missouri patients had more favorable community outcome if they shared a hospital room with one to four others (more frequently true for urbans) or more than ten others (more frequently true for rurals) (x2 = 8.6608, df 3, P < 0.05 > 0.025, c = 0.1747). There were very few private
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rooms for patients in either country. In Turkey 26% of the rehospitalized and 22% of the not rehospitalized patients had shared a bed with another prior to hospital admission, and in Missouri 13Vo of the .rehospitalized and 29% of the not rehospitalized. Over half of both rehospitalized and not rehospitalized patients in Missouri had to change their pattern of sharing sleeping quarters with others, while in Turkey 13qo of rehospitalized persons compared to 29% of non-rehospitalized did so. With one exception, the change was to sleeping with more persons in the room while in hospital, which further limited the privacy to which they were accustomed. Where normal activities are limited for some time, as in an institutional setting, eating often assumes great importance to people. These 369 patients were hospitalized from less that two weeks to more than three months with 107 for less than one month, 115 one to two months, and 147 two months to over three months. Snacking between meals while at home was common in both countries; however, in Missouri most change in snacking while at the hospital was about evenly divided between giving up and taking on the pattern of snacking while in Turkey with few exceptions, those who changed their pattern gave up snacking while in the hospital. The proportion who changed snacking patterns was about the same in both rehospitalized and not rehospitalized groups in both countries-about 40% among Missouri patients and just over 40% among Turkish patients. The data showed that for Missouri white patients who did not snack prior to hospitalization outcome was better<($ = 5.5954, df 1, P < 0.025 > 0.01, c = 0.1921) and for Missouri white urbans who did not snack in hospital (x2 = 4.2900, df 1, P < 0.05 > 0.025, c = 0.2470). All Turks who ate a well balanced -diet prior to hospitalization had a better outcome after discharge (x2 = 4.7777, df 1, P < 0.05 > 0.025, c = 0.2199) as did Missouri whites (x2 = 4.0718, df 1, P < 0.05 > 0.025, c = 0.1647). In Turkey 45% of the rehospitalized group of patients and 25% of the not rehospitalized group ate better balanced diets while in hospital than at home; in Missouri 32% of rehospitalized vs 26% of those not rehospitalized ate better. Another change observed was whether eating was done alone or with others. Turks more frequently than Missourians ate alone at home. During hospitalization 16% of Turkish rehospitalized and 19% of not rehospitalized and less than 2% of both Missouri groups made changes in these patterns, almost all in the direction of eating more often with others. Only rarely in either country were hospital meals served privately to patients. Eating alone or with others was statistically nonsignificant for all patients. It was thought that patients who felt happier at home than in hospital would be more apt not be rehospitalized than those who were happier in hospital, but this proved to be true only for Missouri urbans 01’ = 5.8958, df 1, P< 0.025 > 0.01, c = 0.2068). Hypothesis two compared the amount of participation in social and recreational activities in hospital with those at home. All Turkish women were less frequently rehospitalized if their major role before illness was homemaker &’ = 9.3904, df 3, P < 0.025 > 0.01, c = 0.3014). All Missouri patients were less frequently rehospitalized when they engaged in family group recreation during hospitalization, e.g. visiting relatives, parties, card games, picnics, singing, etc. (x2 = 4.9900, df 1, P < 0.05> 0.025, c = 0.1335). Missouri black urbans were less likely to be rehospitalized when they engaged in community activities outside the family, e.g. social clubs, sporting events, dancing, political and civic events, prior to illness (x2 = 4.2202, df 1, P < 0.05 > 0.025, c = 0.2452), and when they engaged in prescribed hospital therapies during hospitalization 01” = 7.3419, df 1, P < 0.01 > 0.005, c = 0.3164). Dating was a variable applicable only in
140 HELENE.
KLEIN, MARLENE
M. MOSBERGER,
TYLER B. PERSONAND
RITA E. VANDIVORT
Missouri because dating is generally not culturally accepted in Turkey except by a few westernized urban fa_milies. Missouri urbans less often returned to hospital if they engaged in dating or marriage prior to illness (x2 = 4’5039, df 1, P < 0.05 > 0.025, c = 0.1816) and also Missouri whites who engaged in dating during hospitalization ($ = 5.1780, df 1, P < 0.025 > 0.01, c = 0.1851). The two countries provided an interesting contrast in regard to earning capacity during the year preceding hospitalizationz; in Turkey patients had less likelihood of rehospitalization if they had no earnings (x2 = 7.6915, df 2, P < 0.025 > 0.01, c = 0.2750), while among Missouri patients, there was less likelihood if there were earnings k* = 8.3854, df 3, P< 0.05 > 0.025, c = 0.1720). Hypothesis three related to the level of training of the staff giving nursing care and/or physical management of the patient. In Turkey if both psychotropic medications or’ = 9.1277, df 3, P< 0.05 > 0.025, c = 0.2975).and other medications (x2 = 16.2519, df 2, P < 0.001, c = 0.8389) were administered by non-professional attendants, less rehospitalization occurred. Statistical associations never explain causal connections; but the fact that in Turkey non-professional attendants are permitted to change medications as soon as they see a need, rather than waiting for a doctor’s orders for a change as in United States, led the researchers to wonder if this quicker medication change contributed to more favorable outcome. Hypothesis four related to opportunity for and extent of religious observance in hospital and at home. For Missouri whites outcome was more favorable when religious services were provided inside the hospital, i.e. rather than attendance in the community (x2 = 12.0165, df 2, P < 0.005 > 0.001, c = 0.2758) and when these services were attended only once per week (x2 = 8.4554, df 3, P < 0.05 > 0.025, c = 0.2340). For Missouri blacks outcome was more favorable when patients prior to illness usually prayed once daily rather than more often (x2 = 8.0219, df 3, P< 0.05 > 0.025, c = 0.3925) and when their families encouraged them to continue religious worship in the hospital (x2 = 12.0163, df 1, P< 0.001, c = 0.3292). All Turkish patients had more favorable outcome if their families did not attend services (x2 = 13.7699, df 4, P < 0.01 > 0.005, c = 0.3575); and Missouri white urbans when their family did not pray daily (x2 = 6.1891, df 2, P < 0.05 > 0.025, c = 0.2928). Missouri blacks, however, had less favorable outcome if their families did not have a religious affiliation (x2 = 8.7196, df 3, P < 0.025 > 0.01, c = 0.2516). All Turks included in the study were Moslem while Missourians were Catholic, Protestant, or had no affiliation. In Turkey, there was more change of religious practices between home and hospital within the rehospitalized group (35%) than within the not rehospitalized group (17%) on attending services and also in saying prayers (salat)-29% for rehospitalized and 19% for not rehospitalized. Among Missouri patients while the percentage of change on services and prayers was considerably higher than in Turkey, there was almost no difference between rehospitalized and not rehospitalized groups. In Turkey what change was noted was largely in the direction of less religious observance in hospital than at home while in Missouri this was less remarkable with many patients observing religious practices more often in hospital than home. These findings suggest a somewhat negative correlation between religious worship and favorable community outcome, but these patients were schizophrenic and often religion plays a part in the symptomatology. On the positive side, the findings support pastoral programs within psychiatric hospitals. Almost all families were visited one or more times in their homes for data collection. A comparison was made of the physical attributes of the hospital and the patients’ home on
TRANSCUL TURAL NURSING RESEARCH WITH SCHIZOPHRENICS
141
amount of space per person, heating in winter, cooling in summer, toilet and bath facilities, quality of furnishing, safety of neighborhood, and the cleanliness, healthfulness, and esthetic qualities of the building and grounds. The data collector made a professional judgment of whether hospital or home had greater adequacy. All these physical attributes were nonsignificant for all groups in both countries. While data was not collected in Turkey on the month out of hospital in which these patients reached maximum improvement during the year following discharge, in Missouri 61% (N = 64) of the rehospitalized group and 13% (N = 22) of those not rehospitalized showed their peak community adjustment during the first month of discharge while only 2% (N = 2) of the rehospitalized vs 29% (N = 49) of those not rehospitalized reached their peak during the twelfth month. The mean number rehospitalized peaked by the second month and those not rehospitalized by the seventh month. In the rehospitalized group only a small proportion (22%) continued showing improvement during the remaining months of the year, but among those not rehospitalized, nearly one-half (46%) reached their peak during the last quarter. Criteria for community adjustment was from KAS-R Community Adjustment Scales (Katz and Lyerly, 1963), and judgments of peak month was made by relatives at follow-up. The data suggests that good community adjustment may come slowly and gradually for patients.
Conclusion
The findings in this study show that some variables of nursing care of schizophrenic patients in hospital and the social, religious, and recreational activities of the patients are statistically associated with patients’ community adjustment and rehospitalization. This association is not as strong as is often believed in clinical practice, and usually the association is true for only certain cultural subgroups and not uniformly for all. The implications for practice are that, insofar as practical, hospital routines can be a positive adjunct to treatment if the routines are flexibly enforced in relation to the patients’ own cultural patterns. To assume that what is helpful to some will be helpful to all is fallacious, and to enforce routines indiscriminately may be a disservice. Family and community influences as well as illness play a role in hospital readmissions, thus nursing follow-up care needs to be extended to include the relatives and significant community members as well as the patient him or herself. The findings further suggest that physical attributes of the hospital and the home do not matter as much as is often imagined. The implications of this are two fold: one, administrative planning of buildings can be de-emphasized in favor of other variables in patient care; and two, discharge of patients to homes in economically deprived areas need not concern staff as much as it does. Likewise in discharge planning, employment and earning capacity of patients may or may not play a role in community readjustment depending on the subculture in which the patient lives. Patients’ professed happiness or unhappiness with hospitalization usually has little Influence on the outcome for the patient, and awareness of this may help nursing staff to meet patients’ complaints with more equanimity and less defensiveness. In making professional decisions heavily influenced by cultural values, it is preferable to base these on the patients’ cultural patterns rather than on the value judgements of staff. There is a need for more cross-cultural reporting, e.g. Primeaux (1977), and Kniep-Hardy and Burkhardt (1977), on American Indian culture. and for more research, particularly within
142 HELENE,
KLEIN, MARLENE
M. MOSBERGER,
TYLER B. PERSONAND
RITA E. VANDIVORT
our own many subcultures in United States, to test out clinical beliefs and practices to provide baseline knowledge for program planning in both medical and psychiatric care and treatment. Customs and procedures from other countries may also provide new and better methods for care here if understood and judiciously adapted. References Atman, M. and Polvan, N. (1971). Study of Bakirkoy hospital patients and families. Unpublished paper presented National Conference Neuropsychiatry, Ankara, Turkey, 1971. (Summary in English, NIMH Annual Report MH 18934-03). Goran, M. J., Roberts, J. S., Kellogg, M. A., Fielding, J. and Jessee, W. (1975). The PSRO hospital review system. Med. Cure 13 (4), Suppl. April l-33. Katz, M. M. and Lyerly, S. B. (1963). Methods for measuring adjustment and social behavior in the community. Psychol. Rep. Southern Universities Press, Monogr. Suppl. 4-v13 (13), 505-535. Klein. H. E. (1976). Final NIMH reoort MH 18934. unmtblished. USPHS-NIMH. Clinical Research Branch. Klein; H. E. and Itil, T. M. (1973). Study of the discharge-of schizophrenic patients in Turkey and United States, in International Collaboration in Mental Health. Brown, B. S. and Torrey, E. F. (Eds). United States Department of Health, Education, and Welfare, National Institute of Mental Health, Washington, D.C., U.S. Government Printing Office, pp. 94-99. Klein, H. E., Person, T., Itil, T. M. and Cetingok, M. (1978). Family and community variables in adjustment of Turkish and American schizophrenics. Comp. Psych. In press. Kniep-Hardy, M. and Burkhardt, M. A. (1977). Nursing the Navajo. Amer. J. Nurs. 77 (1), 95-96. Person, T. B., Klein, H. E., Hyman, A. and Cook, N. T. (1978). Transcultural interrater reliability. J. Sot. Ser. Res. l(2). Primeaux, M. (1977). Caring for the American Indian patient. Am. J. Nurs. 77 (1), 91-94.
(Received 9 February 1978; acceptedforpublication
15 February 1978)
J. Nurs. Stud. Vol. 15, pp. 135.142. Pergamon Press Ltd.,
1978. Printed in Great Britain.
00224878/78/0801-0135
W2.tXVO
Transcultural nursing research with schizophrenics * HELEN E. KLEIN, D.S.W., MARLENE M. MOSBERGER, R.N., TYLER B. PERSON, B.S. and RITA E. VANDIVORT, M.S.W. Missouri Instituteof Psychiatry, 5400 Arsenal Street, St. Louis, Missouri 63139, U.S.A.
Increasingly today, care givers are being asked to evaluate the services rendered to clientele. The requirements of documentation by institutions of appropriate quality and quantity of services, such as required by Professional Standards and Review Organizations (Goran, Roberts, Kellogg, Fielding and Jessee, 1973, are putting growing pressure on clinicians, both in medical and psychiatric settings, to justify the methods used in practice. As a consequence, research supporting the success of certain clinical techniques is more frequently being called for by the professionals in the field. Research to indicate quality of services is required particularly in psychiatric settings, where both diagnosis and treatment are more difficult than in a strictly medical setting to clearly demonstrate and monitor. The deinstitutionalization movement in mental health has emphasized rapid community placement of the hospitalized mentally ill to avoid a person becoming overly dependent on a care giving institution, as well as to avoid institutional stay without an appropriate level of treatment. Yet, to effectively apply the model and assure quality treatment requires that professionals understand social variables favorable for successful community outcome. Purpose
This article presents a nursing substudy included in a 5 yr Transcultural Study in Discharge of Schizophrenics carried out in Missouri and Turkey by the Missouri Institute of Psychiatry. The purpose of the overall study was to identify social, psychological, and environmental variables significantly associated with patients’ adjustments in the community and if it occurred, readmission to hospital. The nursing substudy examined selected variables of professional care of the patient in hospital; physical environment of home and hospital; and social, religious, and recreational activities at home and hospital. The underlying premise was that the greater the change required of patients in their everyday pre-illness behavior or environment to meet hospital standards and routines, the ‘Funded in Dart by USPHS Grant MH 18934. 135
136 HELENE.
KLEIN, MARLENEM.
MOSBERGER,
TYLER B. PERSONAND
RITA E. VANDIVORT
favorable the ultimate outcome would be for community adjustment discharge.
less
after hospital
Method The study was carried out at Bakirkl)y State Hospital, Istanbul, and at seven Missouri Division of Mental Health hospitals and mental health centers located throughout the state. Of the 369 patients, 52 were urban and 42 rural Turks; 66 were urban and 63 rural black, and 66 urban and 80 rural white patients in Missouri. Sampling was by consecutive admissions. Local clinical psychiatrists gave the treatment and were blind to the research design thus eliminating bias in their decisions on treatment, discharge, or readmission. A primary diagnosis of schizophrenia was required, and patients with other types of mental illness, gross medical and neurological disorders, lobotomies, and mental deficiency were excluded. Length ‘of illness was between 1 and 10 yr prior to current hospitalization, and age range between 20 and 50 yr. Both men and women were included. Both American and Turkish patients were at least second generation residents of their respective countries. During hospitalization, patients received major tranquilizers which included phenothiazines, butyrophenone derivitives, thioxanthene derivatives, and molindone; the drug and dosage was doctors’ choice. All patients receiving insulin shock, electric shock, psychosurgery, or psychotherapy as a major therapy were excluded. Ancillary therapies such as facilitative social services, and occupational, recreational, music, educational, and industrial therapies were permitted as needed. Data were collected through in-person interviews with patients and families by nurses, psychiatrists, and social workers at patients’ hospital admissions, discharges and at 1 yr post hospital follow-ups in the community. Statistical analyses included MucciardiGose Cluster Algorithm, chi-square, multivariate regression, and step-wise regression depending on which questionnaires were being analyzed. The data showed that both Turkish and Missouri patients’ illness was statistically similar in symptomathgy and intensity and both had similar social functioning ‘at worst’, i.e. at admission. Treatment for both was similar as required by the research design; and both were similarly improved at discharge. The Nurses Observation Scale for Inpatients (NOSI) was used to measure ward behavior at date of discharge, and no statistically significant differences were found between Turkish and Missouri patients as a whole nor between any of the six ethnological subgroups except for Missouri white urban patients alone, who were more likely to be rehosnitalized if the patients were in the Negative Ward Behavior Group at discharge (x’ = 5.9733, df 1, P < 0.025 > 0.01, c = 0.2881). Both Turkish and Missouri patients had statistically similar discharge readiness ratings on the Hogarty Discharge Readiness Inventory (DRI). At follow-up 1 yr after discharge there was still the similarity of symptomatology and severity. These data showed that illness for Turkish and Missouri patients was statistically similar and thus suggested the variables associated with rehospitalization lay in the social environment. Complete reporting of the study including hypotheses (Klein and Itil, 1973), questionnaires and rating scales, interrater reliability (Person, Klein, Hyman and Cook, 1978), description of patient samples, and the total unpublished findings are available in the final NIMH report (Klein, 1976). Partial published findings, exclusive of those in this article, may be found in Klein, Person, Itil and Cetingbk (1978).
TRANSCUL TURAL NURSING RESEARCH
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Findings Hypotheses included in the nursing substudy are given below along with the findings on each hypothesis. Many of the variables studied were selected from current clinical nursing practice in psychiatric settings because most of these practices have not heretofore undergone structured testing. Hypothesis one concerned the physical milieu in hospital, and variables studied were habits of personal hygiene, clothing, sleep, food, and privacy. Personally as well as professionally, certain values are set on routine habits such as eating, sleeping, cleanliness, privacy. In Turkey, for example, hospital facilities prevent many patients from bathing and changing to clean clothing as frequently as they are accustomed to do at home, and families often take patients home on visits to provide these. In one study at Bakirkby Hospital, nearly one-third of the families gave this as a major objective of home visits and indicated they wanted doctors and administration to provide better bathing facilities (Atman and Polvan, 1971). In Missouri, some rural patients without indoor bath and toilet facilities at home found the hospital setting more convenient for personal hygiene. With such variances in patients’ home environments, it was not surprising that findings in the study showed significance for some subcultures and not for others. In regard to bathing, Missouri blacks were less likely to be rehospitalized if prior to illness and hospitalization they customarily bathed more than once per week (x2 = 9.4454, df 3, P < 0.025 > 0.01, c = 0.2612). Missouri whites were more likely to be rehospitalized if hospital routine required daily bathing during hospitalization (x2 = 17.4136, df 2, P < 0.001, c = 0.3264). For other subgroups including Turks, there were no statistically significant findings. * Brushing of teeth was significant for only one group, Missouri whites, in which fewer patients, who had brushed their teeth daily during hospitalization, were rehospitalized (x2 = 9.4062, df 3, P< 0.025 > 0.01, c = 0.2460). All Missouri patients who cleaned their nails only monthly were more likely to be returned to hospital after discharge (x’ = 11.4353, df 3, P< 0.025, c = 0.1998), and Missouri white urbans who cleaned their nails daily were less likely to return (x2 = 7.9654, df 3, P < 0.05 > 0.025, c = 0.3282). For all other groups care of teeth and nails was non-significant; and for all groups care of hair was non-significant. The most easily recognized self care in hospitalized patients is shaving for men and use of cosmetics by women. Turks who shaved as often as they thought necessary (PRN) rather than on a regular schedule prior to illness had more favorable community outcome after hospital discharge or’ = 10.3990, df 3, P < 0.025 > 0.01, c = 0.3156) while those urban Turks who shaved more than once weekly had less favorable outcome (x2 = 9.5080, df 3, P < 0.025 > 0.01, c = 0.3932). By contrast, Missouri rural men who shaved more than once per week fared better (x2 = 9.7510, df 4, P< 0.05 > 0.025, c = 0.2527). When urban Turks shaved more than once monthly while hospitalized, rehospitalization was less likely (x2 = 8.4824, df 3, P < 0.05 > 0.025, c = 0.3730). Similarly to Turkish men’s shaving habits, all Turkish women who used cosmetics prior to illness as often as they thought necessary (PRN), or more than once daily,*had more favorable community outcome after leaving the hospital k’ = 11.5026, df 3, P < 0.01 > 0.005, c = 0.3302). Favourable outcome was also associated with use of cosmetics more than once weekly *In the variables
report below, all variables not explicitly were tested on all subgroups.
reported
on specific
subgroups
are nonsignificant;
all
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while in hospital for urban Turkish women (x2 = 6.1760, df 2, P < 0.05 > 0.025, c = 0.3258). Missouri rural yomen who used cosmetics no more often than once per month while in hospital were more often rehospitalized after discharge or’ = 7.9133, df 3, P< 0.05 > 0.025, c = 0.2290). A comparison was made for each individual patient on the above personal hygiene variables to see how much modification, positive or negative, in habits was required between their usual home habits prior to illness and while hospitalized to conform to hospital routines. Among Missouri rehospitalized patients 97 (92%) had made from 1 to 7 changes (mean 2.49) and among those not rehospitalized 154 (91 @/‘o) had made from 1 to 7 changes (mean 2.78). Among Turkish rehospitalized patients 31 (100%) had made from 1 to 7 changes (mean 4.16) while among those not rehospitalized 61 (97%) had made from 1 to 7 changes (mean 3.05). Obviously hospitalization even under flexible nursing care requires personal change for most patients; only 26 patients out of the total of 369 patients experienced no change in their habits of personal hygiene. Clothing was another variable examined as part of patients’ personal hygiene. In both countries most patients wore their own street and sleep clothing. A very few were provided with hospital clothing, but since that provided was of the same style as the patients’ own clothing, this made no significant differences for patients. More important was how frequently Missouri patients were able to change to clean clothing. Those who changed more than once per week while in hospital were found to be rehospitalized less often Or’ = 7.9739, df 3, P < 0.05 > 0.025, c = 0.1679); this was also for the Missouri urban if while groups. The Missouri whites had a greater chance of rehospitalization hospitalized they changed to clean clothing only PRN, i.e. ‘as needed’ Or’ = 7.1736, df 2, p < 0.05 > 0.025, c = 0.2164), but Missouri white urbans were less frequently rehospitalized when they changed daily or” = 9.0750, df 2, P < 0.025 > 0.01, c = 0.341.7). Of both rehospitalized and not rehospitalized Missouri patients, one-half were requird to change their clothing habits. In Turkey 32% of those rehospitalized changed their clothing habits in hospital compared to only 24% of those not rehospitalized. Change in use of clothing habits was not as frequently experienced as change in other types of personal hygiene. Privacy varies greatly between different cultural groups, so data were collected to show if patients had been accustomed at home to usually being alone, spending some time alone, and never being alone, and whether in hospital they were able to continue their accustomed degree of privacy. The findings were non-significant for outcome on all groups. Close observations of patients showed that those wishing privacy will find some means of securing this even in crowded hospitals, while more gregarious ones take advantage of crowded wards to make more friends. On an individual comparison only 9% of Missouri rehospitalized patients and 10% of non-rehospitalized patients had had less privacy in hospital than at home; but in Turkey 45% of both groups had less. Sleeping arrangements were considered a special kind of privacy. All Turkish patients who shared a bed prior to hospitalization 01’ = 6.0447, df 2, P < 0.05 > 0.025, c = 0.2458) or urban Turks who shared a bedroom with one other after discharge (x2 = 8.1358, df 3, P < 0.05 > 0.025, c = 0.3678) were less likely to be rehospitalized. Many who shared beds or bedrooms shared them with their spouses. All Missouri patients had more favorable community outcome if they shared a hospital room with one to four others (more frequently true for urbans) or more than ten others (more frequently true for rurals) (x2 = 8.6608, df 3, P < 0.05 > 0.025, c = 0.1747). There were very few private
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rooms for patients in either country. In Turkey 26% of the rehospitalized and 22% of the not rehospitalized patients had shared a bed with another prior to hospital admission, and in Missouri 13Vo of the .rehospitalized and 29% of the not rehospitalized. Over half of both rehospitalized and not rehospitalized patients in Missouri had to change their pattern of sharing sleeping quarters with others, while in Turkey 13qo of rehospitalized persons compared to 29% of non-rehospitalized did so. With one exception, the change was to sleeping with more persons in the room while in hospital, which further limited the privacy to which they were accustomed. Where normal activities are limited for some time, as in an institutional setting, eating often assumes great importance to people. These 369 patients were hospitalized from less that two weeks to more than three months with 107 for less than one month, 115 one to two months, and 147 two months to over three months. Snacking between meals while at home was common in both countries; however, in Missouri most change in snacking while at the hospital was about evenly divided between giving up and taking on the pattern of snacking while in Turkey with few exceptions, those who changed their pattern gave up snacking while in the hospital. The proportion who changed snacking patterns was about the same in both rehospitalized and not rehospitalized groups in both countries-about 40% among Missouri patients and just over 40% among Turkish patients. The data showed that for Missouri white patients who did not snack prior to hospitalization outcome was better<($ = 5.5954, df 1, P < 0.025 > 0.01, c = 0.1921) and for Missouri white urbans who did not snack in hospital (x2 = 4.2900, df 1, P < 0.05 > 0.025, c = 0.2470). All Turks who ate a well balanced -diet prior to hospitalization had a better outcome after discharge (x2 = 4.7777, df 1, P < 0.05 > 0.025, c = 0.2199) as did Missouri whites (x2 = 4.0718, df 1, P < 0.05 > 0.025, c = 0.1647). In Turkey 45% of the rehospitalized group of patients and 25% of the not rehospitalized group ate better balanced diets while in hospital than at home; in Missouri 32% of rehospitalized vs 26% of those not rehospitalized ate better. Another change observed was whether eating was done alone or with others. Turks more frequently than Missourians ate alone at home. During hospitalization 16% of Turkish rehospitalized and 19% of not rehospitalized and less than 2% of both Missouri groups made changes in these patterns, almost all in the direction of eating more often with others. Only rarely in either country were hospital meals served privately to patients. Eating alone or with others was statistically nonsignificant for all patients. It was thought that patients who felt happier at home than in hospital would be more apt not be rehospitalized than those who were happier in hospital, but this proved to be true only for Missouri urbans 01’ = 5.8958, df 1, P< 0.025 > 0.01, c = 0.2068). Hypothesis two compared the amount of participation in social and recreational activities in hospital with those at home. All Turkish women were less frequently rehospitalized if their major role before illness was homemaker &’ = 9.3904, df 3, P < 0.025 > 0.01, c = 0.3014). All Missouri patients were less frequently rehospitalized when they engaged in family group recreation during hospitalization, e.g. visiting relatives, parties, card games, picnics, singing, etc. (x2 = 4.9900, df 1, P < 0.05> 0.025, c = 0.1335). Missouri black urbans were less likely to be rehospitalized when they engaged in community activities outside the family, e.g. social clubs, sporting events, dancing, political and civic events, prior to illness (x2 = 4.2202, df 1, P < 0.05 > 0.025, c = 0.2452), and when they engaged in prescribed hospital therapies during hospitalization 01” = 7.3419, df 1, P < 0.01 > 0.005, c = 0.3164). Dating was a variable applicable only in
140 HELENE.
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Missouri because dating is generally not culturally accepted in Turkey except by a few westernized urban fa_milies. Missouri urbans less often returned to hospital if they engaged in dating or marriage prior to illness (x2 = 4’5039, df 1, P < 0.05 > 0.025, c = 0.1816) and also Missouri whites who engaged in dating during hospitalization ($ = 5.1780, df 1, P < 0.025 > 0.01, c = 0.1851). The two countries provided an interesting contrast in regard to earning capacity during the year preceding hospitalizationz; in Turkey patients had less likelihood of rehospitalization if they had no earnings (x2 = 7.6915, df 2, P < 0.025 > 0.01, c = 0.2750), while among Missouri patients, there was less likelihood if there were earnings k* = 8.3854, df 3, P< 0.05 > 0.025, c = 0.1720). Hypothesis three related to the level of training of the staff giving nursing care and/or physical management of the patient. In Turkey if both psychotropic medications or’ = 9.1277, df 3, P< 0.05 > 0.025, c = 0.2975).and other medications (x2 = 16.2519, df 2, P < 0.001, c = 0.8389) were administered by non-professional attendants, less rehospitalization occurred. Statistical associations never explain causal connections; but the fact that in Turkey non-professional attendants are permitted to change medications as soon as they see a need, rather than waiting for a doctor’s orders for a change as in United States, led the researchers to wonder if this quicker medication change contributed to more favorable outcome. Hypothesis four related to opportunity for and extent of religious observance in hospital and at home. For Missouri whites outcome was more favorable when religious services were provided inside the hospital, i.e. rather than attendance in the community (x2 = 12.0165, df 2, P < 0.005 > 0.001, c = 0.2758) and when these services were attended only once per week (x2 = 8.4554, df 3, P < 0.05 > 0.025, c = 0.2340). For Missouri blacks outcome was more favorable when patients prior to illness usually prayed once daily rather than more often (x2 = 8.0219, df 3, P< 0.05 > 0.025, c = 0.3925) and when their families encouraged them to continue religious worship in the hospital (x2 = 12.0163, df 1, P< 0.001, c = 0.3292). All Turkish patients had more favorable outcome if their families did not attend services (x2 = 13.7699, df 4, P < 0.01 > 0.005, c = 0.3575); and Missouri white urbans when their family did not pray daily (x2 = 6.1891, df 2, P < 0.05 > 0.025, c = 0.2928). Missouri blacks, however, had less favorable outcome if their families did not have a religious affiliation (x2 = 8.7196, df 3, P < 0.025 > 0.01, c = 0.2516). All Turks included in the study were Moslem while Missourians were Catholic, Protestant, or had no affiliation. In Turkey, there was more change of religious practices between home and hospital within the rehospitalized group (35%) than within the not rehospitalized group (17%) on attending services and also in saying prayers (salat)-29% for rehospitalized and 19% for not rehospitalized. Among Missouri patients while the percentage of change on services and prayers was considerably higher than in Turkey, there was almost no difference between rehospitalized and not rehospitalized groups. In Turkey what change was noted was largely in the direction of less religious observance in hospital than at home while in Missouri this was less remarkable with many patients observing religious practices more often in hospital than home. These findings suggest a somewhat negative correlation between religious worship and favorable community outcome, but these patients were schizophrenic and often religion plays a part in the symptomatology. On the positive side, the findings support pastoral programs within psychiatric hospitals. Almost all families were visited one or more times in their homes for data collection. A comparison was made of the physical attributes of the hospital and the patients’ home on
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amount of space per person, heating in winter, cooling in summer, toilet and bath facilities, quality of furnishing, safety of neighborhood, and the cleanliness, healthfulness, and esthetic qualities of the building and grounds. The data collector made a professional judgment of whether hospital or home had greater adequacy. All these physical attributes were nonsignificant for all groups in both countries. While data was not collected in Turkey on the month out of hospital in which these patients reached maximum improvement during the year following discharge, in Missouri 61% (N = 64) of the rehospitalized group and 13% (N = 22) of those not rehospitalized showed their peak community adjustment during the first month of discharge while only 2% (N = 2) of the rehospitalized vs 29% (N = 49) of those not rehospitalized reached their peak during the twelfth month. The mean number rehospitalized peaked by the second month and those not rehospitalized by the seventh month. In the rehospitalized group only a small proportion (22%) continued showing improvement during the remaining months of the year, but among those not rehospitalized, nearly one-half (46%) reached their peak during the last quarter. Criteria for community adjustment was from KAS-R Community Adjustment Scales (Katz and Lyerly, 1963), and judgments of peak month was made by relatives at follow-up. The data suggests that good community adjustment may come slowly and gradually for patients.
Conclusion
The findings in this study show that some variables of nursing care of schizophrenic patients in hospital and the social, religious, and recreational activities of the patients are statistically associated with patients’ community adjustment and rehospitalization. This association is not as strong as is often believed in clinical practice, and usually the association is true for only certain cultural subgroups and not uniformly for all. The implications for practice are that, insofar as practical, hospital routines can be a positive adjunct to treatment if the routines are flexibly enforced in relation to the patients’ own cultural patterns. To assume that what is helpful to some will be helpful to all is fallacious, and to enforce routines indiscriminately may be a disservice. Family and community influences as well as illness play a role in hospital readmissions, thus nursing follow-up care needs to be extended to include the relatives and significant community members as well as the patient him or herself. The findings further suggest that physical attributes of the hospital and the home do not matter as much as is often imagined. The implications of this are two fold: one, administrative planning of buildings can be de-emphasized in favor of other variables in patient care; and two, discharge of patients to homes in economically deprived areas need not concern staff as much as it does. Likewise in discharge planning, employment and earning capacity of patients may or may not play a role in community readjustment depending on the subculture in which the patient lives. Patients’ professed happiness or unhappiness with hospitalization usually has little Influence on the outcome for the patient, and awareness of this may help nursing staff to meet patients’ complaints with more equanimity and less defensiveness. In making professional decisions heavily influenced by cultural values, it is preferable to base these on the patients’ cultural patterns rather than on the value judgements of staff. There is a need for more cross-cultural reporting, e.g. Primeaux (1977), and Kniep-Hardy and Burkhardt (1977), on American Indian culture. and for more research, particularly within
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RITA E. VANDIVORT
our own many subcultures in United States, to test out clinical beliefs and practices to provide baseline knowledge for program planning in both medical and psychiatric care and treatment. Customs and procedures from other countries may also provide new and better methods for care here if understood and judiciously adapted. References Atman, M. and Polvan, N. (1971). Study of Bakirkoy hospital patients and families. Unpublished paper presented National Conference Neuropsychiatry, Ankara, Turkey, 1971. (Summary in English, NIMH Annual Report MH 18934-03). Goran, M. J., Roberts, J. S., Kellogg, M. A., Fielding, J. and Jessee, W. (1975). The PSRO hospital review system. Med. Cure 13 (4), Suppl. April l-33. Katz, M. M. and Lyerly, S. B. (1963). Methods for measuring adjustment and social behavior in the community. Psychol. Rep. Southern Universities Press, Monogr. Suppl. 4-v13 (13), 505-535. Klein. H. E. (1976). Final NIMH reoort MH 18934. unmtblished. USPHS-NIMH. Clinical Research Branch. Klein; H. E. and Itil, T. M. (1973). Study of the discharge-of schizophrenic patients in Turkey and United States, in International Collaboration in Mental Health. Brown, B. S. and Torrey, E. F. (Eds). United States Department of Health, Education, and Welfare, National Institute of Mental Health, Washington, D.C., U.S. Government Printing Office, pp. 94-99. Klein, H. E., Person, T., Itil, T. M. and Cetingok, M. (1978). Family and community variables in adjustment of Turkish and American schizophrenics. Comp. Psych. In press. Kniep-Hardy, M. and Burkhardt, M. A. (1977). Nursing the Navajo. Amer. J. Nurs. 77 (1), 95-96. Person, T. B., Klein, H. E., Hyman, A. and Cook, N. T. (1978). Transcultural interrater reliability. J. Sot. Ser. Res. l(2). Primeaux, M. (1977). Caring for the American Indian patient. Am. J. Nurs. 77 (1), 91-94.
(Received 9 February 1978; acceptedforpublication
15 February 1978)