Satisfaction of family members with inpatient psychiatric care and its correlates: a national survey in China

The satisfaction of patients and their families is an important quality indicator of hospital healthcare [1]. Since patients’ families are key stakeholders and important participants of the healthcare process, monitoring and improving family satisfaction is both relevant and necessary. Measuring the satisfaction of family members and how they perceive the care provided to patients may help improve hospital healthcare quality [2, 3]. For mental health care, the involvement of family members in patients’ care is very important for treatment and recovery, sometimes of critical importance [4‐7]. This is even more so as most Chinese families are expected to be involved in patients’ healthcare, including important decision making [8, 9]. A 2001 WHO Report recommends that psychiatric patients’ family members should be involved in mental health planning and practice, especially in the treatment process [10]. One study showed satisfied family members improved the treatment for psychiatric patients and are of the utmost importance for the mental healthcare evaluation [11].

Although quite a few studies have been published regarding parents’ satisfaction with inpatient psychiatric care [12‐16], few studies have focused on the satisfaction of family members with the inpatient psychiatric care of adults. In 2002, Gigantesco et al. interviewed 265 relatives of psychiatric patients in Italy to measure their satisfaction, and they used a self-developed 11-item questionnaire, including information on services, environment privacy, involvement in the treatment program, etc. They invited all family members who had visited inpatients to participate and 105 relatives of psychiatric inpatients were recruited. The overall satisfaction level was 69.2%. The most reported reason for dissatisfaction was the lack of information about treatment. They found being female was associated with less satisfaction among relatives. Other factors, such as relatives’ age, relatives’ education level (> 8 years or not), or a patient diagnosis of psychosis, were not associated with dissatisfaction among relatives [17]. In 2013, Macinnes et al. interviewed 63 carers of forensic inpatients via telephone in United Kingdom, and they also used a self-developed 8-item questionnaire, including information provided by the service, involvement in care, ward environment, discharge plans, among others. They found that the overall satisfaction was 78%. Similar to the findings of Gigantesco et al. (2002), delivering appropriate information was strongly associated with carers’ satisfaction. Additionally, they found that parents were more dissatisfied than other carers [18].

Dourado et al. (2018) evaluated the satisfaction of 80 Brazilian family members for psychiatric inpatient service. They used the Brazilian Mental Health Services’ Family Satisfaction Scale, which was made up of eight quantitative questions. The instrument was designed on a 5-point Likert scale, and it included questions about satisfaction with various aspects of health care, such as treatment results, reception, staff competence, and privacy protection. They found the mean overall satisfaction score was 4.05/5, or 81%, indicating a high satisfaction level. They found no significant association between family satisfaction and participants’ sociodemographic variables, such as age, educational level, and kinship degree [19].

So far, only two such studies have been published in China, investigating the family satisfaction of psychiatric patients. Shi et al. (2004) surveyed 249 family members of psychiatric inpatients in Shanghai. They used the revised mental health service scale, which contained 58 items, including involvement in the treatment, information about services, friendliness of mental health professions, listening skills, privacy protection, etc. They found 77.1% of participants were satisfied and the most important reason for dissatisfaction was their lack of involvement in patients’ treatment decisions [20]. However, this study did not include many important variables related to hospitalization (such as length of stay, costs, treatment, etc.) or hospital-level variables. In 2010, Zhang et al. surveyed 196 family members in Hangzhou city (the capital city of Zhejiang province in east China) about their satisfaction with nursing services in a psychiatric hospital. Using a 24-item questionnaire, including questions about nursing skills, psychological nursing, environment, service etiquette, etc., they found the overall satisfaction level was 84% with significant differences in sex, educational background, and home income. Male sex, lower educational background, and lower home income were all associated with higher satisfaction [21]. Similar to the first one [20], the two surveys only focused on the family members without considering factors related to the patient involved or the inpatient treatment. Furthermore, those instruments were designed for families only and were not appropriate for patients.

Based on the above, it is important to develop a brief and reliable instrument that can be used by both patients and family members, to measure the level of satisfaction with inpatient psychiatric services. This survey was designed with the following goals: (1) To develop a brief and reliable instrument to measure patients’ and families’ satisfaction with psychiatric inpatient care; (2) To examine the differences among various hospitals and regions; (3) To examine the correlates with family satisfaction, including patient factors, treatment-related factors, and hospital-level factors. We hope the data may offer some insight into factors contributing to family members’ dissatisfaction and ways to modify them, ultimately improving the quality of patient-healthcare.

Family involvement and satisfaction in patient’s healthcare is particularly important in Chinese culture, as families are almost always involved in patient care, with few exceptions [32]. To the best of our knowledge, this is the first study to evaluate family member satisfaction with psychiatric inpatient services in a nationally representative sample. We found that the satisfaction level was overall high, although significant variations existed in different regions and among different hospitals. We found that higher educational background, more psychologic treatments offered per day, and optimal professional staffing (higher doctor/bed ratio, nurse/bed ratio, and psychologist/bed ratio) were all significantly related to higher family satisfaction.

In our study, the mean total satisfaction score was 23.46/25, or 93.84%. The result indicated that the families surveyed were very satisfied with the mental health inpatient services, which is consistent with some other studies [18, 19]. Gigantesco studied 105 relatives of psychiatric inpatients in Rome, Italy, and they reported a satisfaction score of 45.7/66, or 69.2% [17]. This difference may be due to the different demographic factors between the two samples. Since the Rome sample was from a predominantly urban area, the educational levels were quite modest; only 37% of the population had attained senior high school or greater levels of education. In our sample, the family members were from the capital city of each province, and 58.25% of them had a senior high school level or greater educational background. We found a higher education was significantly associated with higher satisfaction. As mentioned in the introduction, there have only been two reports on this topic published in China. Shi et al. (2004) reported the rate of satisfied or very satisfied family members was 77.1%, but due to differences in the instrument used, it is hard to compare it with our results. Another study focused on one aspect of psychiatric care. Specifically, they surveyed the satisfaction of nursing services [21].

We found that family total satisfaction score, and satisfaction scores for hospitalization cost and doctor-patient/family communication were higher than those reported by patients in this study. This result is consistent with findings both from China and other countries [17, 20, 33].

Our results showed that the education level of relatives was significantly associated with family satisfaction; higher education level was associated with greater family satisfaction. This is somewhat supported by another study [19], which showed that family caregivers with higher education levels had higher overall satisfaction scores (but it did not reach the statistical significance, possibly due to small sample size). This finding has also been reported in the non-psychiatric setting. For example, Thimmapur et al. studied caregiver satisfaction for intensive care unit services and found that caregivers with high school diplomas were more satisfied than illiterate caregivers [34]. Our findings differed from some other studies, which showed that lower education in families was significantly associated with higher satisfaction in relatives [17, 35, 36]. Many potential factors may contribute to this divergence, with one being mentioned in several studies—the service and decision-making model. Most believe that psychiatric services are more interactive and involve more shared decision making with family members; this may explain why educated family members would participate more readily and feel more satisfied [37‐39].

We found that the provision of psychological treatment significantly contributed to family satisfaction, which is consistent with a previous report [23]. As patients and their family members are treated as customers [40, 41], and psychological treatment often focuses on listening and conflict resolution, it is not hard to understand why the number of psychological treatments for patients is significantly associated with higher satisfaction levels in both patients [23] and their families.

Not surprisingly, our findings also support a common-sense notion, that the adequacy of professional staffing is essential in service delivery and customer satisfaction. We found that higher ratios of psychiatric, psychologic, nursing staff, to bed number were all significantly associated with higher family satisfaction. While this finding is somewhat expected, it may increase awareness of this issue and motivate the government and hospital administrators to prioritize resources. Given that mental health service resources were overall insufficient and unbalanced across regions [42], prioritizing the hiring and retaining of professionals is essential.

It is worth noting that satisfaction is often affected by expectations. The high satisfaction in our study may have been due to family members’ low expectations. In the context of widespread discrimination against psychiatric patients and the poor public image of psychiatric hospitals, the patient expectation for mental health hospitals was assumed to be low [33, 43]. Measurements of expectations at baseline would help clarify this relationship.

A few limitations of this study need to be acknowledged. First, this is a cross-sectional study, which cannot uncover causal relationships. Second, the questionnaire we used in this study was locally developed, and the reliability and validity need to be more widely studied. Third, the samples were from provincial tertiary public psychiatric hospitals, and the generalizability may be limited. Forth, the data were collected on the day of discharge when both the patients and families were still at the hospital, which might lead to some measurement bias. Finally, a high degree of satisfaction (more than 90%) in our study implies a ceiling effect or/and high social desirability, suggesting a more sensitive assessment tool or an additional tool to measure social desirability may be needed in future studies.

In conclusion, we developed a brief and reliable instrument to measure the satisfaction level of family members of psychiatric inpatients. Our results show that the family satisfaction with inpatient psychiatric services overall was high in China, although significant variations existed across different regions and among different hospitals. Overall, family members seemed to be more satisfied than patients with the inpatient service. Several factors related to individual, treatment, and hospital resources were found to be significantly associated with the satisfaction of family members. Notably, the education level of the participants, psychological treatment patients received, and adequacy of mental health professional staffing were all significantly associated with higher satisfaction. These results highlight for policymakers and hospital administrators a number of opportunity areas to improve family members’ satisfaction.