Opinions on how to define a good treatment environment in psychiatric wards have changed over the years. Since the end of the 1960s, many have tried to identify descriptors of a fruitful treatment milieu so valid goals can be established. The Ward Atmosphere Scale (WAS) is an acknowledged questionnaire designed to assess how patients and medical staff perceive the environment in the ward. Studies have shown a clear association between certain WAS subscales and treatment results (1 - 3) as well as patient satisfaction (4 - 8). In Norway, the WAS questionnaire has mostly been used in wards mainly for patients with psychosis (9, 10). Corresponding studies have not been done in psychogeriatric wards.
Material and methods
We conducted a quality assurance study in four psychogeriatric wards (A, B, C, D). Wards A and B had 10 beds each; ward C had 14 and ward D 16 beds. The majority of patients were aged 75 years or older. The patients were diagnosed with psychosis, non-psychosis or dementia without psychosis. Half of the patients on ward C were psychotic, but on the other wards only a small proportion of the patients had this diagnosis. On wards A and C, a third of the patients were demented; wards B and D had only a few with dementia. Patient turnover varied from low to relatively high. The ratio of daytime ward staff to patients lay between 0.6 and 0.7. The staff turnover was low.
Patients who were able to cooperate and day and evening staff were offered to participate and filled in the questionnaire during one week in spring 2006. Patients who needed it were helped by the staff, who had been instructed to do their best to enable patients to express their own opinions. The questionnaires were answered anonymously and background information recorded collectively for each ward, so no results could be traced back to individuals.
Ward Atmosphere Scale
This is a self-report questionnaire that, in the Norwegian revised version, contains 80 questions related to how the atmosphere in the ward is perceived. Answers are rated on a four-point scale and sorted into 11 subscales with values from 0 to 10: involvement, support, spontaneous behaviour, autonomy, practical orientation, personal problem orientation, angry and aggressive behaviour, order and organization, program clarity, staff control and staff attitude towards expressed feelings (4, 10).
Questions on satisfaction
Patients and staff also answered five questions about satisfaction: general satisfaction with the ward, with the patients, with the staff; whether the ward environment provided the chance to test out one’s skills and whether ward activities raised one’s self-confidence on a five-point scale (4). For staff, the last two questions were included in the Working Environment Scale WES-10 (5, 11).
Working Environment Scale-10
This is a self-report questionnaire where the staff answer 10 questions, on a five-point scale related to the work environment. The measure provides four dimensions: self-realization, workload, conflict and nervousness (at work) (11).
Both scales have shown satisfactory psychometric qualities (4, 11).
Data handling and statistical analysis
The WAS score, WES-10 score and satisfaction score were calculated for each ward separately and compared with the mean score from patients and staff on about 50 wards mainly for patients with psychosis in Norway. These wards were used as a reference; scores were converted to z scores (normal score) and any deviation from the reference ward mean (0 line) was presented as number of standard deviations (SDs). Scores that deviated one SD or more were regarded as clearly deviating from the reference value (includes 67 % of the variance). A t-test for independent samples (two-sided) was used to compare the WAS scores for patients and staff.
12 of 44 patients were excluded beforehand, the majority of them because of dementia. Eight refused to participate and two questionnaires were incomplete. 11 needed help with the questionnaire. In all, 22 patients and 54 staff participated in the study. The patient WAS score for order and organization was higher than that for the mean score in the wards mainly for patients with psychosis and much lower for angry and aggressive behaviour on all the four wards. Support was rated much higher than the mean on three of the wards, and staff control much lower on three of the wards (fig 1).
Figure 1 Patients’ view on ward atmosphere in four psychogeriatric wards
For most subscales, the staff score was closer than the patient score to that for the mean in wards mainly for patients with psychosis; on three wards, order and organization was much higher than the mean and angry and aggressive behaviour much lower.
Staff rated the following subscales significantly higher than patients: practical orientation (p < 0.01), personal problem orientation (p < 0.05), angry and aggressive behaviour (p < 0.001) and program clarity (p < 0.01), while the patients scored significantly higher than staff for order and organization (p < 0.05).
On all four psychogeriatric wards, patient scores for general satisfaction and for how well the patients liked the staff, was one SD or more above the mean score for patients in the reference wards, while scores for other questions on satisfaction varied.
Staff scores for satisfaction and assessment of work environment (WES-10) varied markedly, but there was no systematic deviation from the wards mainly for patients with psychosis.
We wanted to clarify whether patients in psychogeriatric wards were capable of filling in the WAS questionnaire. Five or more patients completed the questionnaires in each ward, a sufficient number to obtain reliable mean values for the wards mainly for patients with psychosis according to Røssberg & Friis (10). Some patients spent a long time filling in the questionnaire and patients with slightly reduced cognition had difficulty understanding the questions. However, with help and a strong emphasis on motivation, many still managed to complete the study.
It is reasonable to believe that the psychogeriatric wards have a higher level of order and organization than the wards mainly for patients with psychosis. Their work is more predictable, as they do not have to accept acute admissions. Emphasis is placed on order in the daily routine with a set rhythm and concrete activities, partly out of consideration for the early cognitive decline in a number of patients.
A lower level of angry and aggressive behaviour also seems plausible. Many older people have a slower pace, less energy and reduced somatic health. As a result, they may appear less threatening or express their anger in a milder form. Furthermore, disagreements with demented patients are more often regarded as confusion and lack of understanding rather than as real conflicts. It is probably noteworthy that aggressive patients are first admitted to the emergency department and only moved when they have become more stable.
Patients in three of the psychogeriatric wards reported a much lower level of staff control, whereas the mixed ward (C) differed little from the wards mainly for patients with psychosis. Ward C had more compulsory admissions which is known to involve more disagreements about rules and control.
Psychotic patients probably consider the staff more often as negative and controlling because they lack understanding of their disease. In other studies the patient score was much higher than the staff score (9, 10) and we find it interesting that this was not the case in the psychogeriatric wards.
A high patient score for support is a less robust, but nevertheless interesting finding. One can imagine that psychotic patients are less able to comprehend the support given them or that older patients are given another type of care, a type that is more easily recognized as support.
The treatment environment is affected by many factors. Friis found that the proportion of psychotic patients and the patients’ mean age were the factors most strongly associated with the patients’ WAS score (12). The background variables most strongly associated with the WAS scores on psychogeriatric wards, however, warrant a separate study with many more participants.
The psychogeriatric patients’ higher score for satisfaction with the staff and the wards in general is striking. Their generation possibly appreciates care more than younger patient groups. Moreover, the patient scores for order and organization, angry and aggressive behaviour, support and staff control deviate from the reference mean (0-line) in directions that correspond well with patient satisfaction according to findings in the reference wards (4, 5, 8). These variables are considered to be among the most important for patient satisfaction on wards for mainly patients with psychosis and can be expected to be important on psychogeriatric wards as well.
Our conclusion is that the WAS questionnaire can be used on psychogeriatric wards with good help from the staff. The psychogeriatric wards had a higher degree of order and organization and patient satisfaction and a lower degree of angry and aggressive behaviour than in wards for mainly patients with psychosis. The low number of participants on each ward should be taken into consideration. This study needs to be followed up by studies of ward atmosphere, satisfaction and work environment in more psychogeriatric wards.