Complaints and Satisfaction of Patients in Psychiatric Hospitals: The Case of Israel.

The main objective of the research is to advance knowledge in the field of patient experience. First, the research provides a classification of verbal responses by patients to an open-ended question (using content analysis) into distinct categories of concerns and complaints; and second, it examines (using regression analysis) the extent to which different types of complaints exert a differential impact on the level of patient satisfaction. The content analysis reveals that patient voice extends across a wide variety of issues, including complaints regarding physical conditions of the facility, quality of food, cleanliness, caregiver attitudes, availability of medical staff, lack of communication with staff, malpractice, and lack of privacy and respect. Linear regression analysis reveals that patients who complained about the hospitalization experience, especially complaints about interpersonal relations, are less likely to express satisfaction regarding hospitalization. The findings underscore the importance of patient's complaints for understanding patient satisfaction (or dissatisfaction) with hospitalization. Patients' complaints, especially in the area of interpersonal relations, are found to be consequential for the patient level of satisfaction.

Introduction

The article joins previous studies on patients experience by examining the impact of various types of complaints made by patients in psychiatric institutions on the levels of satisfaction. The contribution of this research is 2-fold. First, it classifies patients’ verbal responses regarding the hospitalization experience into distinct categories of concerns; and second, it examines the extent to which different types of complaints impact satisfaction. By doing so, the article delineates the major areas of patients’ concerns and contributes to a better understanding of the sources for patient satisfaction in psychiatric wards.

Researchers have long used close-ended satisfaction questionnaires (1 -3), verbal responses to open-ended questions, and mixed methods to assess patient evaluations of quality of care (4 -9). The growing body of research on the topic reveals that satisfaction is influenced by demographic attributes such as age and gender (10) and tends to decline with socioeconomic status (10 -12). Likewise, the likelihood of expressing criticism increases with socioeconomic status (13,14). Curiously, whereas the literature on patient satisfaction with medical care in general wards is steadily growing, only a few studies have examined the sources of patients’ experiences and satisfaction with treatment in psychiatric wards (15 -20). The present research contributes to this body of research.

The studies that focus on patients’ experiences in psychiatric wards suggest that they tend to voice dissatisfaction; raise concerns regarding specific aspects of the hospitalization experience, such as the need for the improvement of interpersonal relationships; and complain about lack of sensitivity to individual needs, limited information, and lack of effective communication (16 -18). In addition, patients often complain about increasing boredom as a result of limited physical activity. They also complain about the lack of physical security during hospitalization (19).

The data for the present analysis were obtained from the 2017 Survey of Psychiatric Wards conducted by Israel’s Ministry of Health. The data set includes information on patients’ attributes as well as measured indicators of patient satisfaction with the hospitalization experience. In addition to the satisfaction scores, the data provide verbal answers to an open-ended question soliciting patients’ voiced opinions of their treatment. The combination of closed-ended satisfaction measures and verbal responses to the open-ended question provides a unique opportunity to examine the differential impact of various types of complaints on satisfaction.

Previous Studies

The small body of studies on the hospitalization experience in psychiatric wards can be divided into 2 streams of research. The first stream focuses on the determinants of the level of satisfaction with treatment (15 -20); the second stream deals with the nature of voiced complaints made by the patients (16 -18). Similar to findings reported by studies in general hospitals (10 -12), researchers found that the level of satisfaction with treatment in psychiatric wards is associated with sociodemographic attributes of patients as well as with the conditions of the hospitalization. For example, Greenwood et al (21) found that females, younger patients, and those detained were less satisfied with their hospitalization than other patients. However, Greenwood et al (21) found no significant relationship between ethnicity and level of satisfaction. Bird and colleagues(22) identified higher satisfaction scores among older patients and lower satisfaction scores among patients with higher levels of education. They also found lower levels of satisfaction among patients who had experienced involuntary admission (23 -25). Likewise, patients in locked wards were less satisfied than patients in open wards (26). According to Längle et al (15), patients who were less satisfied with their relationships with the staff were less satisfied with the medical decisions ultimately taken. Researchers also observed that patients tend to provide more positive responses when the interview was conducted near the time of discharge (27, 23), possibly due to anticipation of discharge.

Research carried out within the framework of the second stream of studies operated under the premise that patient’s “voice” brings insights, sheds light, and enriches understanding of the patient experience, by tracing the sources of patients’ feelings and sentiments (20). Following the literature on “customers’ voice” (28 -30), it is reasonable to view patients as “service recipients” and the hospital staff as “service providers.” Hence, it is also reasonable to expect patients’ verbal complaints to capture patients’ true feelings. Following this line of logic, researchers studying the voice of patients in psychiatric wards highlighted several major areas of concern. First and foremost, patients in psychiatric wards stress the need for improvement in interpersonal relationships with staff members and tend to complain about lack of sensitivity to their needs (16 -18). Patients also argue that hospital staff treats them with disrespect (19). Likewise, they complain about lack of information and often believe that wrong decisions were applied in their treatment (31). In addition, patients complain of boredom as a result of minimal activity in the hospital as well as lack of physical security and fear of violence (19).

In sum, the literature reveals that satisfaction with treatment in psychiatric wards is significantly influenced by sociodemographic attributes of patients and conditions of hospitalization. The literature also reveals that patients tend to share several concerns regarding their hospitalization experience. Nevertheless, it is not clear from previous research whether and to what extent, various concerns and complaints differentially affect patient’s level of satisfaction. This is the goal of the analysis presented in this study.

Research Goal

In what follows, I delineate and classify the verbal complaints expressed by psychiatric patients into distinct categories and then estimate the extent to which various types of complaints differentially impact the level of patient’s satisfaction with treatment.

Method

The data for the analysis were collected by the Israeli Ministry of Health in 2017, through a questionnaire exploring the experience of hospitalization in psychiatric facilities in Israel. The sample consisted of 1032 patients older than the age of 18, hospitalized in 11 psychiatric health facilities (out of 13 facilities) between November 2016 and March 2017 . Data were collected through face-to-face interviews (prior to release) with 82% response rate. The survey was conducted in 4 languages according to the patient’s preference. Each hospital was weighted according to the number of patients discharged from the hospital. The questionnaire contained over 40 closed-ended questions addressing issues such as attitudes toward staff, provision of information, treatment sequence, patient satisfaction, and environmental conditions. In addition to closed-ended satisfaction questions and personal information, respondents were asked to provide comments in response to an open-ended question: “Do you have any further comments or suggestions for improvement?” By conducting a content analysis of the verbal responses, I was able to capture the essence of the responses and classify them into distinct qualitative categories of criticism.

Of the 1032 respondents, 680 (65.9%) patients provided verbal answers to the open-ended question. All verbal responses were coded and searched for common themes. They were then given a description according to their thematic content and grouped together accordingly. The verbal responses were classified into 10 broad categories, relating to the nature of the comment. The vast majority of the patients referred to 1 issue with very few expressing views on 2 or more issues. For the present research, only the first comment was analyzed, on the presumption that this comment was the most “burning issue” for the patient. The classification of the verbal comments into categories is presented in Table 1. The classified categories of the verbal responses (obtained through the content analysis) are used as predictors of the level of satisfaction.

Table 1.

Distribution of Patients’ Voice by Narrative (in Percentages) and Excerpts From the Open-Ended Responses.

Theme/variable	Narratives	Percentage (%)	Excerpts from patients’ open-ended question
Silence/no voice	No verbal comment	34.1	–
Expression of voice	Verbal comment was provided	65.9	–
Positive voice	A verbal comment of positive nature was given	13.6	“The cleanliness is good. Fine clothes and pants…The behavior of the nurses and doctors is good, helping with something not difficult, listening to problems and questions. They never ‘closed the door for me.’”“I recommend coming to this hospital only to this ward. The treatment was really good, I had a doctor who explained to me, I cooperated, and now I have an option to go or stay. Otherwise. There are no thefts in this ward…”“All the staff are nice”
Complaints/negative comments regarding physical conditions	Level of cleanliness, adjustment of conditions to medical condition, keeping quiet at night, room/ward density, accommodation conditions, number of visitors, visitor behavior, ward restrictions	11.2	“…shower be in the evening and not in the morning and that a separation be made between the patients in a difficult situation and the patients who are less in a difficult situation.”“Maybe clean the toilets in the evening as well and not just in the morning”“Wants to allow patients to be with cell phones”“It bothers her that the rooms are locked until 12”
Complaints on caregiver relationship	Criticism of interpersonal conduct with staff members	4.3	“That the thinking of the nurses will be more correct toward me. That the attitude of the cleaners will be more appropriate…”“That the staff will treat more nicely and respectfully. (The nurses assistants). Nurses will treat better, more pleasant, nicer…”“Ensure that there are skilled assistants who have taken courses to work with the mentally ill, and then that they work in collaboration with the nurses. Make a selection between the nurses who are hired in a psychiatric ward…”
Complaints about the nature of food	Review on food quality, cleanliness and food serving	6.5	“The meals did not always arrive on time, and this bothered the patient”“Yes, a proposal that is low budget that they can implement. There will be smaller plates in the dining room and then eat less (that’s how I work) because they still gain a lot of weight from the medication…”“As for the food is not tasty and needs to be improved”“In the morning there will also be whole bread and not white bread because it is really fattening, they do not bring us sugar but white bread they do. Lunch is usually not tasty, food is processed. In addition, there is no cold-water cooler in the ward and sometimes the kitchen is closed when you want to drink.”
Complaints on medical staff availability	Comments/complaints on personnel lack/staff availability, bureaucracy, release bureaucracy, medical availability	4.6	“Bring in a larger team, more responsive. Feeling we are not being treated enough, there are only 2 psychologists”“There is a problem of manpower, feeling that there is not enough response to requests, takes a long time to process the requests.”“More time for the social worker”
Complaints on physical security and deprivation of liberty	Complaints on physical security from inpatients and staff (thefts, violence, physical restraints)	2.9	“Did not feel safe because of some of the patients…”“There are a lot of thefts in the department. Difficulty sleeping at night.”“That they will not come by force to take from home without presenting an identity card. And they will not come by force at all to take me to the hospital, I will come alone. They will not use force; all the chairs were broken…”
Complaints on medical decisions	Comments/complaints about medical malpractice, wrong diagnosis, misuse or wrong medical treatment, unqualified/professional medical care	3.5	“That (they) will gradually lower the medications I take because the medication is not good. Out of focus, nausea that will give a chance to see how I am without it. Getting too much…feels worse…No need for medication…Suffers from a diagnosis…do not agree with the diagnosis that they diagnosed me.”“I have physical and mental problems, need a clinical pharmacist because the drug instead of lowering blood pressure, the drugs raise blood pressure, need such a combination, need a strong pharmacist who will detect any reaction…I suffer from it. Many physical pills and many psychiatric pills and it Collides.”“Do not feel that there has been an improvement in the problem that caused me to be hospitalized and I have been here for almost a month.”
Complaints on communication with medical staff	Comments/complaints about the lack of proper communication/lack of knowledge/explanations, both during treatment and in the release phase	6.6	“…another suggestion—open an anonymous mailbox for all hospitalized/rehabilitated that will be a means of communication that can be sent for improvement/complaints…I know there is a complaints box where it is currently possible to file complaints but an anonymous email is more effective…”“…Feeling misunderstood”“Listening and feedback from the staff, a more detailed explanation of everything, conversations more often…”“There is a “revolving door.” The patient should be explained about the length of his stay, involve the patient in the program—what he is receiving treatment for, what the rights are, whether he deserves a rehabilitation basket/protected work…”“The patient feels that he is returning to the hospital after he is released because when he is released there is no supervision and accompaniment for the patient.”
Complaints on maintaining privacy and respect	Comments/complaints about failure to maintain privacy/physical/personal respect	3.4	“…That staff will speak more respectfully at eye level, there is no need to put any patient in a cube. Maintain human dignity Listen to what a patient feels—If a patient asks not to talk to the family about the medical condition then maintain his privacy and not violate privacy…”“There is not enough privacy when visitors come…”“There was a case of harsh and disrespectful treatment from one of the nurses in the ward…”
Complaint on leisure activity	Comments/complaints of lack of leisure activities during hospitalization	9.4	“In the ward the great suffering is boredom. It is possible with a minimum of money and effort to add more activities that will be available in the department at all times, for example, books that suit everyone, personal games, art booklets, crossword puzzles, crossword puzzles, colors…”“…chess-mat games, thinking games, some attractive activities, lectures, board games—there are many free hours and you have to fill in activities other than soup to eat in the dining room there is no activity…”“More activities should be added as well as exercise…”

In addition to the open-ended question, patient satisfaction with the hospitalization experience was obtained through the following closed-ended question: “Please rate your overall satisfaction with the treatment you received at the hospital on a scale from 1 to 10, with 10 meaning excellent and 1 bad.” This measured indicator of satisfaction is used in the analysis as the dependent variable.

The independent variables used as predictors of patient’s level of satisfaction include patient’s sociodemographic characteristics and conditions of hospitalization. The sociodemographic attributes are gender, age, and ethnic origin (Jews—majority population = 1, Others [mostly Arabs] = 0). The conditions of hospitalization (for control purposes) include hospital location (urban center = 1, periphery = 0), type of ward (open = 1, closed = 0), and consent to hospitalization (consent = 1, no consent = 0). See Table A for the distribution of the characteristics of the population.

Results

Descriptive Overview of Patients’ Views

Table 1 displays the distribution of verbal responses to the open-ended question regarding the hospitalization experience. The verbal responses reveal wide criticism of the experience across a variety of issues, including complaints regarding physical conditions (eg, sanitation, food) and complaints regarding the quality of medical service (staff availability, communication, malpractice, maintenance of privacy and disrespect). Table 1 indicates that 34.1% chose not to answer the open-ended question (“no voice/silence”), while 65.9% provided verbal answers (“voice”). It is important to note that 13.6% of the sample volunteered a positive opinion regarding their experience, whereas others expressed a negative opinion or voice concerning at least 1 aspect of the hospitalization experience.

The relatively large percentage of patients (13.6%) who voiced positive verbal comment regarding their hospitalization experience expressed gratitude to staff for their dedicated care. Patients mentioned specific physicians by name, praising them for their professional conduct. Several patients attributed improvements in their medical condition to the conduct of the professional staff.

The negative comments regarding the hospitalization experience were divided and classified into 9 categories according to the theme of the complaint. The first and most frequent theme pertains to the physical conditions of the facility. Such complaints were proffered by 11.2% of patients; they related to levels of cleanliness, adjustment of conditions to medical needs, quiet in the surroundings, accommodation conditions, and visitor behavior. Patients also expressed criticism about ward restrictions, such as locked rooms and restrictions on dining hours and shower time.

The second theme focuses on the lack or limited leisure activities and was shared by 9.4% of patients. Comments concerning leisure hours emphasized patients’ need to fill the afternoon hours with some content, suggesting that “filling the void” can exert a positive impact on mental health, by steering patients away from dwelling on their medical problems.

The third group of concerns, shared by 6.6% of patients, includes comments on lack of proper communication and insufficient explanations and/or transfer of information, not only during hospitalization but also at the discharge stages. Patients felt that they were not given important information regarding medical treatment, including instructions on how to maintain proper mental health after discharge. A similar number of patients (6.5%) criticized the quality or quantity of food as well as cleanliness, noting that the food was not tasty or healthy or adequate.

The fifth and sixth categories of concerns deal with availability of staff (4.6%) and interpersonal relations with staff (4.3%), respectively. Complaints about lack or limited availability of staff included comments regarding rigid bureaucracy, lack of medical care, long waits for consultation with the attending physician or psychologist, and brief consultations. Likewise, patients expressed a sense of disrespect by the staff (indicating that staff members were gossiping about them or laughing at them behind their backs).

The seventh category of complaints is based on responses of 3.5% of the patients, who complained about medical malpractice, wrong diagnosis, and misuse of medical treatment, as well as wrongly prescribed drugs and unqualified professional care. The complaints challenged and questioned medical decisions regarding the scope and type of drug treatment, the choice of closed wards as opposed to open wards, and the diagnosis of mental illness.

A similar proportion of complaints (3.4%) constitute the eighth category, where arguments regarding lack of physical-bodily privacy were stressed. Patients complained about shortcomings and failures in maintaining privacy and a sense of disrespect on the part of the staff (3.4%). The smallest category of patients’ complaints (2.9%) deals with fear of the infringement of physical security and deprivation of physical liberty. Patients raised concerns about the sense of physical insecurity from other inpatients and staff as well as unnecessary physical restraints imposed by staff. Patients complained about thefts as well as physical violence (as contributing to a sense of insecurity and adversely affecting their recovery). On this issue, respondents advised the separation of different types of patients, according to the severity of mental illness.

Association Between Expression of Voice and Satisfaction

In order to examine the extent to which voiced complaints are associated with (dis)satisfaction, I present in Table 2 the distribution of patients’ mean satisfaction scores (on a scale ranging from 1 to 10) according to the 10 categories of voice.

Table 2.

Mean Satisfaction Score (SD) by Category of Patient’s Voice.

		Distribution of voice
Variable (SD)	All	No voice	Positive	physical conditions	Caregiver relationship	Food	Staff availability	Physical security	Medical decisions	Communication	Privacy and respect	Leisure activity
All	8.28 (2.09)	8.45 (2.06)	8.83 (1.8)	7.91 (2.23)	7.31 (2.32)	8.34 (1.8)	8.24 (2.16)	7.25 (2.4)	7.76 (2.2)	7.65 (2.2)	7.63 (2.25)	8.67 (1.6)
N	1012	348	138	113	42	67	45	28	34	66	35	96

Table 2 reveals very high mean scores (8.28 on the 10-point scale) for the level of satisfaction among patients. That is, patients reported, on average, a high level of satisfaction with their hospitalization experience. There are, however, considerable variations in the distribution of patients’ satisfaction across the different categories of voice. Satisfaction is highest (8.83) among those who provided positive responses and lowest (7.25) among those who complained about lack of physical security. Satisfaction among those who did not provide voice (8.45) is highly similar to those who expressed positive views. Level of satisfaction is considerably lower among patients who complained about lack of privacy and respect, communication problems, and relationships with caregivers. Level of satisfaction among patients who complained about food or lack of leisure activity is slightly lower than among those who expressed positive voice or no voice. Interestingly, satisfaction among patients complaining about the unavailability of staff was similar to those complaining about food and leisure activity and slightly below average (8.24). Nevertheless, this is considerably higher than among those who complained about interpersonal relationships with the staff. This, perhaps, is so because patients attributed the unavailability of staff to operational limitations resulting from lack of resources and shortage of staff rather than the misbehavior of staff.

In order to estimate the direct effect of each type of voice (net of sociodemographic attributes and conditions of hospitalization), I estimated 2 linear regression equations predicting level of satisfaction with the hospitalization experience. Equation 1 includes the patient’s sociodemographic attributes and conditions of hospitalization as predictors of satisfaction (the dependent variable). Equation 2 also includes in addition to sociodemographic attributes and hospitalization conditions, 10 dummy variables representing types of complaint as predictors of satisfaction. The estimated coefficients of the equations are listed in Table 3.

Table 3.

Coefficients (SE) of Regression Equations Predicting Satisfaction With Hospitalization.

Variables	Model 1	Model 2
Constant	8.473b (.345)	8.694b (.352)
Gender (male = 1)	–.394b (.134)	–.420b (.133)
Ethnicity (Jew =1)	–.879b (.225)	–.855b (.223)
Age (years)	.019b (.004)	.017b (.004)
Consent (=1)	.380a (.154)	.307a (.153)
Closed ward (=1)	–.244 (.150)	–.211 (.149)
Location (center=1)	–.086 (.171)	–.017 (.170)
No voice	Control	Control
Positive voice	–	.349 (.204)
Physical conditions	–	–.429 (.221)
Caregiver relationship	–	–1.02b (.335)
Food	–	–.101 (.273)
Staff availability	–	–.186 (.320)
Physical security	–	–.863a (.399)
Medical decisions	–	–.629 (.362)
Communication	–	–.754b (.274)
Privacy and respect	–	−.924a (.373)
Leisure activity	–	.238 (.234)
R 2	0.51	.078
N	992	992

a P = .05.

b P < .000.

The coefficients of equation 1 indicate that Jews (b = –.879) and men (b =–.394) are less satisfied with the hospitalization experience than women and Arabs, respectively. Satisfaction tends to increase with age (b = .019) and with consent to hospitalization (b = .380). However, location and type of ward do not exert a significant effect on satisfaction. The introduction of the complaints variables to the predictors of satisfaction in (equation 2) hardly changes the coefficients of the sociodemographic variables and hospitalization characteristics. The dummy variables representing the categories of complaint reveal that satisfaction levels for patients who voiced complaints about physical conditions (b = –.534), relationship with the medical staff (b = –1.136), physical security (b = –1.19), communication (b = –.794), and a sense of respect (b = –.817) are significantly lower than satisfaction levels for patients who did not express voice. However, satisfaction levels of patients who provided positive voice are similar to those with no voice. Interestingly, although satisfaction levels for patients complaining about food, staff availability, medical decisions, and leisure activity are lower than those without voice (as evidenced by the negative sign of coefficients), the differences are not statistically significant.

Discussion

Verbal responses to open-ended questions regarding the hospitalization experience in Israel reveal a wide and detailed criticism by patients in psychiatric wards. Similar to previous studies on the topic in other countries (19), patients’ criticism and complaints extend across multiple issues, including physical conditions of the facility, food quality, cleanliness, caregiver attitudes, staff availability, communication with staff, malpractice, coercive treatments (23 -25,32), lack of privacy, and lack of leisure activities (33). The criticism can be roughly divided into 2 types: interpersonal behavioral complaints and structural-organizational complaints. The analysis reveals that complaints pertaining to behavioral aspects are more likely to decrease satisfaction than complaints pertaining to organizational limitations. Apparently, patients respond more severely to negative interpersonal relations (eg, disrespect, attitudes) than to structural limitations (eg, understaffing, cleanliness).

Similar to previous studies, this study reveals that satisfaction of psychiatric patients is relatively high (34) and that personal characteristics such as age (35), gender, ethnicity, and consent (32) are associated with satisfaction. The literature on voice expression leads to the expectation that powerful and privileged groups are more likely than others to express critical voice and dissatisfaction with service (10 -14). The findings presented here support this expectation in the context of psychiatric wards in Israel. Jews are more likely than Arabs (the minority group population in Israel) to express critical voice regarding the hospitalization experience. However, differently from previous research (34,35), women in Israeli psychiatric wards appear to be more satisfied than men with treatment and no significant association was found between satisfaction and environmental characteristics of hospitalization (26,36).

Conclusions

The analysis in the Israeli context underscores a direct link between voiced complaints and satisfaction, especially between the type of complaint and dissatisfaction. It seems that patients in psychiatric wards distinguish between the behavioral aspects of treatment and structural-organizational aspects. This distinction, in turn, has clear implication for providers of medical care. Whereas complaints and concerns regarding interpersonal relations with staff decrease the level of satisfaction with treatment, complaints about structural-organizational constraints are less consequential for patient satisfaction. Indeed, level of patients’ satisfaction with medical service is influenced, first and foremost, by the behavior of the service providers.

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Supplemental Material, sj-docx-1-jpx-10.1177_2374373521997221 for Complaints and Satisfaction of Patients in Psychiatric Hospitals: The Case of Israel by Keren Semyonov-Tal in Journal of Patient Experience