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promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
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A Client and staff satisfaction survey of an Eating Disorders Team
Ms Julie Potts, Dr Justine Turner, Eating Disorders Team, Princess Margaret Hospital for Children
Chantel Fleming, Dr Peter Gibbon, T.R.E.E., Princess Margaret Hospital for Children
Professor Brett McDermott, University Department of Paediatrics, Princess Margaret Hospital for Children

Introduction
Communication
Information
Interaction with staff
Improving treatment
Conclusions

A Client and Staff Satisfaction Survey of an Eating Disorders Team

A multidisciplinary Eating Disorders Team was established at Princess Margaret Hospital for Children in 1996. Since that time it has treated over 300 children and adolescents with Anorexia Nervosa, Bulimia Nervosa or Eating Disorders Not Otherwise Specified. A survey of eating disorders patients, their parents and health care professionals was conducted during March 2000. Completed surveys were obtained from 21 patients, 25 parents and 29 health care professionals, including medical, nursing and allied health staff.

The survey instrument was designed by members of the Eating Disorders Team and the Senior Research Officer of the Psychological Medicine Clinical Care Unit. It consisted of parallel forms for each respondent group and was designed to collect both quantitative and qualitative data. Aspects of the service assessed by the survey included communication on the ward, the amount and type of information patients and parents should receive, quality of interactions with staff, and potential improvements to the services provided by the Eating Disorders Team.

This paper primarily details the findings drawn from the qualitative responses, with reference to the quantitative results where relevant. It provides insights into the perceptions of each of the three groups surveyed, and compares and contrasts those perceptions where appropriate. All responses to the quantitative items were recorded on 5-point Likert scales on which 1 represents a low level of agreement with the questionnaire item and 5 a high level of agreement.
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COMMUNICATION ON THE MEDICAL WARD

Whilst more than half of the patients (57.1%) indicated that a doctor usually informed them about decisions affecting their medical care, their written responses indicate that they feel more comfortable in approaching the dietitian regarding medical issues. Two respondents indicated that doctors are perceived to be "a bit intimidating and some made you feel stupid", or that they felt "very inferior" to the doctors who treated them. Among the parents, two mentioned being made to "feel a nuisance" or not having calls returned when trying to access information about their children. A third stated that "no information is ever offered unless requested. No short or long term advice has been offered, it must always be sought.". These responses indicate a need for medical staff, particularly doctors, to consider the quality of, and the processes around, their communication with patients and their parents.

PROVISION OF INFORMATION

Respondents were asked whether enough information was provided to patients and their parents, and whether the information was easy to understand. The results indicate relatively high levels of satisfaction with the amount of information provided and with ease of understanding across all three respondent groups. However, staff were significantly more satisfied than either patients or parents with the amount of information provided, F(2,72) = 4.26, p <.05, and reported significantly higher levels of ease of understanding, F(2,72) = 3.99, p <.05.
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ENCOURAGEMENT TO SEEK INFORMATION

Patients and parents report very little encouragement to seek more information about the medical care. Staff report significantly higher levels of encouragement, F(2,71) = 21.88, p <.001.

The quantitative results, whilst useful, provide only a very basic insight into the perceptions of the respondent groups. An examination of the qualitative data, consisting of respondents’ written answers, provides further valuable insights.

USEFUL INFORMATION FOR PATIENTS

Respondents were asked to indicate the type of information that they thought should be provided to patients. Patients report that information about the condition, details of their progress and medical treatment, expected goals of the treatment and strategies for coping outside the hospital were important. They also identified positive information regarding others who had recovered from an eating disorder as a valuable resource. One patient expressed her feelings thus - "Give people some hope. When I was there (in hospital) all I could see were people that were back again and again.".

Parents identified hospital rules, details of the illness and reasons for treatment strategies and their anticipated outcomes as being important information for patients. They also identified information relating to the long term effects of malnutrition as being important, and, as did patients, identified access to a recovered anorexic as a useful experience for their children. Parents also indicated that the process of providing information to patients must be undertaken with sensitivity.

The staff responses indicate more pragmatic concerns. In addition to information regarding the patient’s medical condition and progress they identified as being important information relating to admission goals, daily care goals, ward rules and expectations and changes to the management plan. Staff also identified as necessary information relating to patients’ rights to privacy. Several staff members also suggested that providing consistent information to all staff and patients would decrease the potential for patients to "play staff off against each other".
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USEFUL INFORMATION FOR PARENTS

Respondents were asked to identify information that would be useful to patients’ parents. Patients indicated that information about their illness, treatment and progress, details relevant to their age group and an anticipated discharge date would be useful to their parents. However, a small number of patients indicated that no information should be given to their parents, whilst one thought that "information that tells them (parents) about how parents sometimes contribute to pushing people into the state of an eating disorder" should be provided.

Parents report that they want information about their child’s physical and mental condition, details of the treatment plan and details of their child’s behaviour whilst in hospital. One parent specifically mentioned the value of the parent support group -"The group sessions we had for parents were quite comforting and informative as for most parents this is a new and upsetting crisis and to relate to others was helpful.".

Staff responses again focus on pragmatic issues, such as arrangements for admission, discharge and leave, information regarding the stage of the illness, psychological progress, short and long term strategies and changes to the management plan. The staff responses also identified information concerning to the impact of psychosocial factors and family dynamics as being important for parents.
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INTERACTIONS WITH STAFF

Patients and their parents report feeling significantly less valued and respected when approaching Eating Disorders Team staff for information than do staff members when approaching other Team members, F(2,72) = 13.57, p <.001, indicating an opportunity for service improvement in the area of staff and client communication.

IMPROVING COMMUNICATION

Respondents were asked how communication on the medical ward could be improved. Patients identify a need for doctors, nursing staff and patients to have access to the same care and treatment information and for patients to be treated as people rather than as "stereotypical eating disorders cases". Patients also identify communication with doctors as being particularly problematic. They suggest that doctors should listen to patients, inform them of what is going on, speak to them directly rather than going through nursing staff and "not just bark an order and walk off".

Parents’ concerns include the need for regular feedback on the patient’s condition and improved accessibility to hospital staff. However, the majority of parent comments relate to the quality of the communication and interactions between staff, patients and parents. They suggest that staff should not appear judgmental nor "talk down to" parents and that they should supply information only in areas in which they are qualified to comment.

In contrast to the client responses, few of the staff mention strategies for improving communication with the patients or their parents. Staff responses to this question almost entirely focus on ways to improve communication among staff, perhaps confirming the perception, particularly among parents, that the quality of staff/client communication requires improvement.
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IMPROVING TREATMENT

Proposals for improving treatment varied among the three respondent groups. Patients suggest that they be given more control over their lives, for instance the ability to do normal things like brush their teeth, shower and go on home visits. Being shown more trust by the medical staff was a common theme among patients, as was the opportunity to meet recovered patients. One patient suggested that "Videos about anorexic people and how it’s bad…could shock some people who are suffering from anorexia and could make them eat more.".

Another common theme to emerge from the patient responses was that they should be given time to "sort things out" or that staff should "let people gain weight at their own rate rather than focussing on the speed of weight gain". A number suggest that nasogastric tubes should be used only as a last resort and that the focus should be shifted from weight and/or eating issues to the underlying psychological issues, the "deep down problem". There is little consensus evident among the patients in terms of practical treatment strategies. Some suggest that eating disorder patients should be brought together as a group whilst others suggest that eating disorder patients should be treated individually with no contact between them. Others maintain that eating disorder patients should be kept separate from other patients in the hospital.

Suggestions for improving treatment proposed by parents revolved primarily around issues of communication and information. For instance, parents recommend better communication with medical staff and the provision of information regarding nutrition and exercising, particularly at discharge. The also suggest development of a structured regime for the patient and family and more regular individual and family therapy. However, some parents note that therapy sessions should be conducted only when nutritional issues are resolved to the point where "the patient’s mind is able to function normally". The feeling was also expressed by some parents that the hospital could deal only with the medical issues involved and that the "mental or emotional" aspects had to be resolved by the patient.

Staff identify as potential improvements to treatment the provision of dedicated medical beds, flexibility of treatment options, the implementation of individualised programmes, improved communication among the treatment team, coordination of medical and psychological treatment strategies, consistency in handling individual cases and regular feedback on individual patients. They also identify a number of specific services for patients that could be implemented or improved. These include an Occupational Therapy programme to combat the boredom and lethargy of long term hospitalisation, establishment of a group house dedicated to the treatment and management of eating disorder patients, and outpatient programmes to assist with the transitions from hospital to home and to adult services. With respect to their own needs, staff identify adequate supervision, sufficient time to adequately care for patients and better education and training as being important. There is also a perceived need to improve the "bad feeling" that exists between nurses and patients, who may not understand that "nurses are only doing their job".
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CONCLUSIONS

This survey provides evidence of the value of obtaining qualitative as well as quantitative data when seeking consumer feedback. Whilst the rating scale responses indicate that in general patients and their parents are less satisfied with the service provided, the written responses identify specific areas of concern for each respondent group, provide insights into the differing perceptions held by the groups, and offer practical suggestions for improving the service. Key areas for improvement are identified as the quality of communication between clients and staff, consistency and accuracy of information provided to all stakeholders, and the need for a support service when transitioning patients from the hospital to their home environment or to adult services.

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Last Modified: 27-11-2002 10:11:12