Patient, Their Relative and Nursing Staff Perception of Ward Atmosphere in Psychiatric Hospitals in Jordan

Abstract

A literature study of the existing research on Ward atmosphere has been taken up. The Ward atmosphere scale was found to be one of the best in the field employed by a number of researchers. The same has been suggested for usage in the current context as well. The indicators in the existing research that point to the success and the failure of such studies are also taken up. The situation in the Jordanian hospitals is also studied and the possible outcome is also brought out. Ward Atmosphere Scale as suggested by Moos et al, has been studied in more detail indicating the subscales and the results that are obtained in the earlier researches. Also, the importance of every subscale is also discussed in the respective sections.

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Introduction

Hospitals are the life providers of the modern world. They are the places where life is born as well as death occurs. This makes hospitals an important place in the life of every human being. The role played by the hospitals is vital in ensuring that the life of the person is not threatened and he or she is able to cure her when put under its care. This care at the hospital is provided by the wards. While the wards are the dispensers of the medical treatment for which the person lands up in the hospitals, wards are also the places that motivate a person to live on or de-motivate him to resign to death. This is particularly and acutely so in the case of psychiatric wards. When the diseases for which the treatment is provided to the patient are least understood, naturally the support provided is also more worrisome. And that is reflected in the case of psychiatric illnesses that plague human society.

In every civilized society, there have been different forms of hospitals and rejuvenating centers. There have been regaining centers that had helped the person to regain his health in the wards of the hospice. In all these cases, the wards play an active role. The upkeep and the atmosphere in the ward is a major motivating factor for the patients and their relatives to look forward to deliverance from the trouble they are going through. The same is also true with the staff. The staff also gets motivated to work if the ward atmosphere is encouraging. Therefore, a study on the methodologies of maintaining a motivating ward atmosphere is imperative. This has been undertaken in the current exercise. The study centers primarily on the ward atmosphere in psychiatric hospitals in Jordan. To add to the study a detailed literary review has been carried out on all the available literature in this regard. Information has been gathered from journals and manuals for this purpose to know the science behind the ward atmosphere and to understand the relationship that exists between the ward atmosphere and the patients. The study also focuses on the relationship between the ward atmosphere and the curing percentage or curing factor. This measure would help us arrive at a conclusion on how the ward atmosphere could be improved.

The major thrust is in the ward atmosphere at the psychiatric hospitals in Jordan. This study would help in identifying the lacunas in them as well as steps that should be taken to ensure the conditions become better.

A Psychiatric Facility – then and now

Psychiatric hospitals have their genesis in the infamous Bethlem Royal Hospital of London (popularly called Bedlam). One can now see where the word probably originated from. The scene that a visitor could observe on a normal day within a psychiatric ward would be one of general chaos and confusion. Most of the time, there were patients moving around aimlessly, wondering why they were being confined to their beds. Very rarely you would find understanding hospital staff who thought it was necessary to pay complete attention to what patients wanted. There was no doubt that if a person entered a hospital with just a minor psychological disorder, the atmosphere in a ward would ensure that his condition deteriorated even further.

Today, the scenario has changed quite a bit. The reason for this change is not just the technological advances that have been made, but also the change in attitudes that are generally in place in the health industry. Since hospitals are now bustling commercial centers where there are professionals eager to hawk their skill and expertise, every effort is taken to ensure that the patient is made to feel as comfortable as possible. It must be also mentioned here that the level of comfort that a patient enjoys in a hospital is directly proportionate to the amount of money that he or she is willing to spend on medical expenses.

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The ward environment has an overbearing impact on the treatment provided to the patients. Moss (1974) demonstrated that the patients who were provided with a clean environment and with clear program objectives tend to recover faster than the ones who were not in such a system. Moss Scale that he employed indicated that the hospitals which responded to a high WAS scale had a greater autonomy provided to the patients and they were open to discussions. However, in other cases where the WAS scale was lower, the patients were more submissive to the staff of the hospital and did not discuss their issues openly. This meant that their problems were not quickly sorted out as in the earlier case.

In a similar study conducted by Middleboe (2001), one hundred and one patients were asked to take the WAS study. During this study, they were asked to respond to the WAS questionnaires in both real and ideal forms. The patients recorded their feedback about both the open and closed units in the wards. Middleboe used a Good Milieu Index (GMI) as developed and suggested by Moos. Based on this study, Middleboe could conclude the following:

  1. Patients in the locked wards seem to perceive higher anger and aggression.
  2. They also perceived lesser autonomy and practical orientation.
  3. The support, order, and organization predicted higher satisfaction among patients.

Psychiatric Care – the Jordanian angle

In the year 1988, a national program for mental health was discussed at a national workshop that was held in Amman. This was indeed a big leap forward for a country like Jordan, where political strife and war are common household terms. The program aimed at increasing the awareness among the public on the need to pay more attention to mental disorders and to ensure that people with mental sicknesses are referred to specialists at the earliest.

Apart from the National Centre for Mental Health, there are two other public mental hospitals in Fahis and Na’our; the Royal Medical Services has allocated forty beds specifically for mentally ill patients. Apart from these hospitals, there are quite a few private health clinics and daycare centers for the mentally ill. (EMR, 2001) Most of these health care centers have facilities that equal some of the best in the world. With centers for every imaginable illness that you can think of, doctors in Jordan are a much sought-after lot. In spite of all these technological advancements in the health facilities provided in this country, there is still a big lacuna when it comes to Wards for mentally challenged people.

It would be right to say that ward atmosphere and ambiance are given a lot of importance only in huge hospitals where the patients run up exorbitant bills. In other words, exclusive medical care is available only to those who can afford it. This is true of both psychiatric and non-psychiatric medical care in Jordan.

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What happens to all those people who are in dire need of help and cannot afford it? Do they continue to exist on the fringes of society, victims of a war they wanted no part in? Do they keep getting branded as lunatics who cannot be integrated into mainstream society? All these questions and much more are debated in a country like Jordan that gets drawn into political imbroglios, in spite of trying its best to avoid it.

In the midst of all this, it is very difficult for people to gain access to psychiatric health care centers because of the relatively high costs. The hospitals that they can afford to go to, do not offer very much psychiatric care. Without any option available to them, most of these refugees and people living in near penury, prefer to go to local NGOs like CARE, where they are given a decent amount of attention. This is a trend that indicates that mental health should be given priority in a country like Jordan.

A report presented by the Senior Advisor of WHO Regional Office for the EMRO(Eastern Mediterranean Regional Office), Dr. Ahmad Mohit, in October 2006 gives an in-depth analysis of the problems that plague the healthcare services in general and the mental healthcare services in particular in countries like Jordan. There is a concerted effort by the governments of many Middle-East countries to develop Mental Health Programmes and involve the people in promoting awareness about mental sicknesses and their treatments. There is also an effort to provide all the drugs required to treat various illnesses like Schizophrenia, Parkinson’s disease, and many other psychological disorders. (Mohit, 2006)

In a country like Jordan, most of the people who come to hospitals have never till now accepted the fact that their mental health is something that needs to be taken care of. In their opinion, going to a doctor when you are physically unwell is not just natural, but also the right thing to do. Mental illness, on the other hand, is a totally different story. In a country where male means power, accepting the fact that a man might be mentally ill is virtually unthinkable. It is totally unacceptable to the Jordanian psyche.

It is only in the recent past that people have started to look at this scenario with new perceptions. They have begun to realize that mental health is as important as physiological health and that the same has to be treated if the need arises. Therefore, since this taboo-like situation is slowly changing, the need for more and better health care institutions is felt quite strongly.

The problem here is one of inadequate infrastructure for treating the mentally ill. There are not enough hospitals and adequately-equipped psychiatric wards to house these patients. It is very common to find people who have been through some very traumatic situations, coming to a mental health facility in Jordan for help. Post Traumatic Stress/Symptom Disorder is a common problem that one can see with war victims (Ajdukovic, D 1990). Identifying the problem is just as difficult as treating it. There are patients who come to a hospital complaining of things that they keep hearing or seeing; most of the time these are imaginary and not real at all. On the brink of becoming schizophrenics, these people are a danger both to themselves and to those around them.

Jordan has about 80 psychiatrists including the twenty in the health ministry, ten in academics, 37 in the private sector, and the rest in other areas of work. There are about 10 psychologists registered in Jordan; of these, two have doctorates in the subject, three have masters and the rest have bachelors’ degrees to support their careers. There are 180 psychiatric nurses to support this medical personnel and another 24 social workers to help them in addition. There are more than 300 educational psychologists who are working in association with the education ministry and these are also involved in the mental health of the people. In addition to this, every medical undergraduate spends about 120 hours on psychiatry specifically on clinical training and internship (Jordanian Ministry of Health Annual Report 2005).

The biggest psychiatric hospital in Jordan is the National Center for Mental Health. The men’s ward in the hospital consists of three acute psychiatric units and two sub-acute psychiatric units. There is a separate unit for chronic patients. The women’s ward also has an acute psychiatric unit and two chronic units. In most cases, patients to the wards are admitted voluntarily. This means that the patients may choose to leave the hospital if they want. There is nothing that bars them from leaving the hospital. Though of course, the hospital does suggest to the patient what should be their action; to stay or to get discharged. Patients also come with a criminal background. In this case, it is involuntary and the patients are housed in the wards depending upon court decision or are detained by the police under criminal law.

This hospital has ten psychiatrists who work along with one hundred and twenty nursing clinicians. Three social workers and nine psychologists also help them maintain the hospital and work for the patients. And it can house 250 inpatients.

Apart from this, Al Rashid Hospital is located at Abu Nusier in the north of Jordan. The countryside provides a fine backdrop for the patients to recover faster and better. The hospital provides much more care than the larger one and is more modern in its work. The major services that the hospital provides include crisis intervention, home services twenty-four hours a day. There are separate wards for men and women taking care of psychological rehabilitation services. The hospital has 120 beds and is manned by ten psychiatrists. There is over thirty-four nursing staff as of a date in the hospital to assist the doctors. Three social workers and an equal number of psychologists are also working in the hospital. A full-fledged hospital with all modern facilities starting from kitchen to ECT treatment facilities all make this hospital one of the leading psychiatric care centers in Jordan. This has also developed into a place for psychiatric study and research. The hospital trains nurses and psychiatrists for Jordanian needs.

The National Center for Rehabilitation of Addicts provides specific psychiatric treatments for de-addiction. This primarily caters to the short-term residency of about 60 patients including adolescents who might have got addicted. The hospital is equipped to treat any of the addictions including drugs and alcohol. Three psychiatrists and a host of qualified nurses aid the patients to get them de-addicted. Apart from these hospitals, the military hospital, a part of the Royal Jordanian Medical Services, also provides psychiatric services to primarily take care of the problems faced by the soldiers and people in services. Located in Amman, the hospital has 20 beds for males and another 10 beds for females. Most of the doctors in this hospital are trained in the UK for psychiatric treatments earlier. Though now, the staff is trained in the hospital itself and they are sent to the UK for additional training.

Ward Atmosphere

Although psychiatric patients are treated as ‘in-patient’ in hospitals, the ward atmosphere plays a vital role in their recuperation. The rooms in which the patients live and their ambiance are very important for the therapeutic roles it offers. Most often the atmosphere of the hospital itself has more say in the rejuvenation and recuperation of ‘in-patients’ than anything else.

Moos (1989) developed a Ward Atmosphere Scale and this is the de facto method employed by most doctors. It is basically to measure the actual, preferred, and expected treatment environments of hospital-based psychiatric programs. “As one of the Social Climate Scales, the Ward Atmosphere Scale (WAS) has been widely used in clinical settings and program evaluation. It helps by comparing client and staff perceptions, monitoring program changes over time and promoting program improvement. It also provides accurate information about perceptions of different programs and encourages staff to become involved in program planning and design. It measures involvement, support, spontaneity, autonomy, practical orientation, personal problems orientation, anger and aggression, order and organization, program clarity, and staff control” (Moos 2007).

Ever since this scale was developed a lot of work has been done to evaluate and improve the ward atmosphere so that it is conducive for the patients (Vernis & Flaherty 1978, Friss 1986a, 1986b, Melle et al. 1996, Eklund & Hansson 2001a, 2001b, Rossberg & Friss 2004). The concept of ward atmosphere can vary between each patient since each patient’s perception is different. Also, it has been studied that the nursing staff’s perception also varies in contrast to the patient’s viewpoint. It is to be noted here that the patients and the nursing staff are in the same hospital for different reasons (Archer & Amuso 1980).

More recently a study conducted in a hospital has proved this. “Consequently, it appears that the ward atmosphere is more important for patient satisfaction than for staff satisfaction. It is important to consider the different roles and viewpoints of patients and staff, each of whom is on the ward for different reasons. Most notable is that, unlike most of the patients, staff members can leave the ward after their shifts and may withdraw from the ward milieu if they experience it as too stressful. Thus the ward atmosphere is likely to be more important for patient satisfaction than for staff satisfaction” (Rossberg & Friss 2004).

In the eighties, a researcher in psychiatry (Friss 1986a, 1986b) studied the different needs of the patients and their perception of ward atmosphere and came to this conclusion “Thirty-five short term wards were evaluated with the WAS and a good milieu index. The results indicated that psychotic and non-psychotic patients need different types of atmosphere. Psychotic patients seem to benefit primarily from a milieu with a high level of Support, Practical orientation and Order and organization, and a low level of Anger and aggression, whereas non-psychotic patients seem to benefit most from a milieu with a high level of all subscales except for two: the level of Staff control ought to be low and the level of Anger and aggression ought probably to be intermediate.”

The ward atmosphere provided at the Jordanian hospitals was not modern in the large National Center for Mental Health. However, the rest of the hospitals were built with the aim of providing modern facilities to the patients in line with the practices in the west. Therefore, every aspect of the Ward atmosphere is taken care of by the Hospital. Typically, the Al Rasheed Private Hospital is constructed in the countryside so that it provides a serene atmosphere that ensures the patient gets an atmosphere that is curative. Large buildings, freely walking areas, and the freedom to check out if the patient does not like it; all make the hospitals more and more in line with the needs of modern psychiatric treatments. The hospitals are also open for assessment of their atmosphere to ensure that the patients receive the best treatment.

Ward atmosphere is not only made of the programs that are put in practice. It is also affected by the design and the architecture of the buildings and the wards in the hospitals. Timko (1995) introduced successfully the Physical and Architectural Characteristics Inventory (PACI) in many programs including drug abuse and substance rehabilitation programs. The study revealed the relationship between the overall environment and treatment effectiveness. This was primarily for the in-patient treatments that were provided to the patients and the impact of the environment and the ward atmosphere on the conditions were amply brought out. These were used in designing the Al Rashid hospital and that certainly has a positive impact on the patients undergoing treatment at these locations.

In the case of the drug abuse and substance rehabilitation cases, a modified study was used by the researchers (Timko 1995). Residential Substance Abuse and Psychiatric Programs Inventory (RESPPI) concentrates on four major aspects of treatment provided: Physical features of the buildings, policies, and services provided by the hospitals, patient characteristics, and the treatment climate. Whereas the treatment climate is dependent on the staff, the physical features of the buildings include the architecture and the settings it is set in. Policies and services are decided by the overall specifications and brief provided to the hospital and the management decisions. The patient characteristics are more oriented towards the patient’s requirements and therefore, more individualistic. RESPPI is more an adaptation of MEAP (Multiphase Environmental Assessment Procedure) as proposed by Moos and Lemke (1994). This procedure was originally made to measure the extent of influence the residential care settings in a hospital or hospice have on older adults.

Changes in the physical attributes of the buildings and the wards have contributed to changes in the behavior of the patients in case of psychiatric treatments. A change in the color and graphics displayed in the wards brought in a marked reduction in inappropriate behavior of the patients in a psychiatric ward. (Devlin 1992). Appropriate decorations and lightings were also found to have improved results in the treatment of psychiatric patients (Gulak 1991). All this indicates that the physical attributes in the ward are as important in the treatment of the patients as the treatment process itself. This has been brought out in a number of cases and studies conducted by various researchers all over the world (Gutkowski et al. 1992). The Royal College of Psychiatrists (1998) suggested that the ward design and finish should reflect the commitment and the quality of treatment that is provided in the hospital. This has been found to have a markedly improved performance in the treatment of the patients, according to them. Higher décor standards meant that the patients were more motivated and they enjoyed being together and sharing thoughts with the staff and the inmates freely.

Ward Atmosphere is also decided by the hospitals’ policies and practices. Most of these practices reflect in their programs and the way they are administered. Some of the major issues that were faced by researchers and found to have a great impact on the performance of the hospital are:

  1. Freedom to older residents in the hospital seems to provide more and better working climates for the entire group. This results in greater independence to the inmates in the hospital and they seem to have a greater voice in decision making. This tries to bring them back to normal living earlier (Rodin et al 1985).
  2. Berdes (1987) explains that privacy is another major influencing factor for the patients to have independence. This helps them draw out their own choice and control in the hospital helping them to move well with the treatment.
  3. Moos (1997) indicate that a clearly planned social activity in the hospital tends to improve the treatment results. This arises because of the large social interaction such freedom and independence seem to provide to the inmates of the hospital. Only in these cases, residents see better performance and independence to themselves. Staff also seems to find more self-direction in the hospital with such facilities and policies for inmate independence.
  4. A self-directed treatment climate where the residents themselves encourage self-direction and self-understanding on the treatment conditions will help in providing participating treatments (Timko 1995). This would help in obtaining better results from the practices that are already in vogue.

Ward atmosphere has a role to play in the treatment climate of the patients. It is, therefore, important that the ward atmosphere is not only enhanced to match the needs of the patients.

In order to enhance the climate of the ward atmosphere, physical and policy-based conditions, it is important that the ward atmosphere that currently exists is measurable. Any of the methods discussed earlier could be used for measuring the various aspects of the ward atmosphere. The scales suggested by the researchers may be used to provide a comparison across the ward atmospheres in different hospitals and their perceptions. This could also help in identifying the areas that are satisfactory for the residents and the areas that would need improvement in the hospital.

Measuring Ward Atmosphere

Measuring ward atmospheres and hospital performances was a subject of much researches. Pugh et al, (1969) proposed one of the first scales in this direction, the staff opinion scale. The Philosophy of Treatment form was proposed by Barrell Dewolfe & Cummings (1965) and the Opinions on the Mental Illness Scale by Cohen et al in 1963. The Ward Evaluation scale was first proposed by Rice and his co-workers in 1963. In this case, for the first time, patients evaluated the wards and the impact the wards had on them. In order to bring in a semblance of quantitative control on the ward, a new scale was proposed by Jackson (1969), the Characteristics of Treatment Environment Scale. This was primarily aimed at removing the vagueness in the earlier scales connected with the opinions and perceptions of the individuals. Kellam et al (1967) developed the Ward Information Form which identified the problems that psychiatric patients faced in their wards. They reported back better treatment outcomes when the patient-to-staff ratio is low, low levels of aggressive behavior, and social isolation.

Similarly, a Perception of Ward (POW) scale was designed by Ellsworth et al (1971) to identify the impact of patient involvement in Ward management in psychiatric hospitals. From this scale, Spiegel and Spiegel (1971) developed the ward climate inventory (WCI) which was more a seven-point Likert Scale. All these scales, staff, and patients rate the ward from their perception and these were primarily perception-based measurements. Based on all these factors and studies that were conducted, Insel and Moos (1974) in their effort to merge these experiences and then build on what they termed the ‘social ecology’. According to them, society and the environment had an impact on the way the patients behaved in their wards. This also had major ramifications on the treatment outcomes. By environment, they meant both physical and social environments, including architectural design of a place and psychosocial milieu. Social ecology according to Moos (1973), should be used to enhance the living standards of the people and the quality of the human environment or society.

According to Moos, there are six major methods that are related to the characteristics of the environments and have a bearing impact on the overall human functioning in society. These are:

  1. Ecological dimensions, the geographical and architectural designs, and variables.
  2. Behavior settings, those that are directly related to ecological and behavioral needs.
  3. Varied dimensions of the organization structure.
  4. Dimensions or variables that identify the behavior of every person in the social milieu collectively.
  5. Variables are identifiable to the psychosocial characteristics and organizational climates.
  6. Variables are relevant to the functional analysis of environments.

These variables are interrelated, nonexclusive, and non-overlapping. They had a noticeable and sometimes decisive impact on the performance of the individuals as well as groups.

Based on these factors, Moos and his associates developed the Ward Atmosphere Scale. This is a 100 item, 10 subscale instrument that could be administered on both patients as well as on staff. Here in this paper, we are also using them on the patient relatives to identify their perception to a greater extent, since they are also active participants in the environment that is created. This instrument was used subsequently in a number of research studies as well by a large number of researchers and the outcome was close to reality (Cronkite Moos & Fitney 1965).

Middleboe (2001) reports after a study at one of the Dutch psychiatric hospitals that had both locked as well as open units, that there was a difference in perception of the visitors as well as the patients on how the ward was influencing them. In addition, his study also indicated that the staff too had a difference in perception as well. With reference to the patients and their perception, he employed both WAS Real and Ideal Forms that would bring out their expectations of a Ward as they considered ideal and what was really existing in their hospital. In addition to this, he also employed a satisfaction questionnaire. Out of the three different forms available on the WAS scale, actual, expected, and preferred, two of them were employed in this case; the actual and the preferred.

A similar study was conducted using the COPES (Community Oriented Program Environment Scale) to judge the extent to which the clients were satisfied in a psychiatric – rehabilitation unit (Eklund & Hanson 2001). COPES is a rating scale. It has got 10 different subscales which are measured using the questions that are posed to the respondents. Moos (1988) says that the scale has acceptable levels of internal consistency and face validity. The survey taken by Eklund & Hanson indicates a client satisfaction of 3.8 on a scale where maximum satisfaction is marked at 5.0. It was found that a similar study conducted by another group using the WAS scale by Friis & Rossberge (2001), corroborated the results identified earlier. 640 staff members and patients in 42 wards were involved in the process. Questionnaires were provided to these people in line with the WAS scale and the same is then reworked to lead to the conclusion obtained by Eklund and Hanson (2001). The results that they obtained for the WAS scale under order and organization sub-scale correlate with patient satisfaction.

The other common scale that can also be used in measuring ward atmosphere could be the work environment scale. This is a standard scale used to measure the work environment in industries and hospitals and other locations to check the extent of satisfaction the environment provides to the workers in the company. WES-10, as it is commonly known, is a self-reported questionnaire, measuring four subscales. (Friis & Rossberg 2001). This scale is more a viewpoint of the staff rather than that of the patients. However, it measures to what extent the happenings in the hospital and the ward, affect the performance of the staff. Better the staff performance, better the performance of the processes adopted and they could turn out to be more effective.

Ward atmosphere also provides for building relationships and friendships inside the hospital and among the inmates. This would ensure that there is more swift development happening. A quantitative measure of these happenings is possible. Normally called the helping behavior in the patients, this is found in patients forming new friendships; promote self-esteem among the patients and their effectiveness in solving problems and issues that arise. Moos and Sidman (1973) produced a seventy-item helping scale for patients in nine programs.

A number of factors seem to influence the overall performance of the programs that are planned for the hospital. Ward atmosphere is a broad word covering various factors and environmental issues in the hospital.

Factors influencing ward atmosphere

Organization of the Hospital

A number of factors influence the ward atmosphere. Arrington and Haddock (1990) report that for-profit organizations seem to deliver less when compared to those with not-for-profit settings. This made them come to the conclusion that institutional context is critical in the extent of service provided by the hospital. However, this seems to have an alternate effect as well. Some of the for-profit organizations seem to provide additional facilities to the niche group of people they are dealing with (Culhane & Hadley 1992). Similarly, the importance provided to the structure and organization of the hospital is also very low. Gulak (1991) observes that the design of the hospital was more in line with the ease of administration and monitoring, ease to clean, and such similar hospital administration requirement rather than for the betterment of the patients. The type of organization, the structure of the building including its architecture and design does have an influence on the patient’s curative factors.

Size of the organization

The size of the organization, the number of patients in the hospital were found to have a negative influence on the patients. At the same time, more the staff seems to add a positive influence on the curative nature of the patients. It was found when the number of patients in every group or program was lessened, the program seems to have a positive effect on the patients (Nissen 1985). Hellman et al (1985) observe that the larger size of the hospital and the number of patients in every program had a far negative influence on the patients when it really mattered. Smaller the size, he found it to have a positive impact on the patients.

At the same time, if there are trained nurses and staff, the impact of the large size is mitigated to a great extent. This seems to have a positive impact on the patients. However, in one of the research projects reported by Friis (1986), the larger the size more positive was the impact particularly when it was organized well. Despite this, it can be taken smaller sizes have a more positive impact on patient recovery (Timko & Moos 1996). In addition to this, Moos (1996) and Friis (1996) further substantiate that the staff size when it increases provides a positive impact on the patients.

Physical Structure and the architecture

The effect of the physical structure and the architecture of the hospitals have been measured using a number of scaling mechanisms. The Physical and Architectural Characteristics Inventory (PACI) proposed by Timko (1996) provided for various features such as the location of the facility, community services, social interaction facilities, supportive features for physically disabled, aids to spatial and temporal orientation, security and safety features and space allowances for the residents and staff activities. Particularly for psychiatric patients, the settings of the environment, appeal, and comfort seem to have a positive impact. Latvala et al (1999) report that the physical attributes of the hospital also had a positive effect on the staff. Staff morale improved and unscheduled absences from work decreased a lot. There was also lower violence in the wards and the patients displayed lesser anger (Lubin 1989).

Policy conditions

The policies that ruled the hospital also seem to play a very important role for the patients. The amount of freedom that was provided to the patients, the visitors, and the staff also seems to have an influence on the patients’ recovery. Rodin et al (1985) report, a larger social interaction within older patients and also in those cases, where patients were given a choice to make decisions for them, seem to have a lasting impact on the patients. Many patients also felt that privacy is another important factor that seems to provide the patients with more choice and opportunities to select (Berdes 1987), resulting in more informal strength in the minds of the patients. Timko and Moos (1996) indicate that a more self-directive and self-understanding treatment provided overall governance of the psychiatric treatment.

Based on all these factors, the Ward Atmosphere Scale designed by Moos has the following ten subscales.

Involvement This is a part of the relationship dimensions and assesses how active the patients are in their normal working and whether they have pride in doing the jobs for the common good, the overall enthusiasm, and the attitude of the person.
Support This is to measure how effective is the support the patient provides to other patients. This also measures the extent to which the staff supports the program in addition to the support extended by the doctors in the hospital.
Spontaneity To what extent is the hospital environment permissive for the patients to express their feelings towards other patients and staff in the hospital, is considered a part of the relationship dimensions.
Autonomy This is related to the treatment program and is a measure of how self-supporting and independent is the patient in his own personal affairs and with reference to their relationships with staff. This is essentially dependent on the freedom given by the hospital to the patients.
Practical orientation This is the extent to which a person is trained to take care of him or herself once he is released from the hospital and to train for the future. This would involve training for jobs and for setting up practical goals.
Personal Problem orientation The extent to which the patients’ feelings are respected. This could only result from the extent to which the patient could openly discuss their issues with other patients concerning their feelings and emotions.
Anger and Aggression The extent to which the patients are allowed to enter into an argument with other patients and the staff of the hospital; the extent to which they are allowed to openly show or display anger and other forms of anger/aggression.
Order and Organization This is a part of the system maintenance part of the scale. This is a measure of the order in the hospital and the extent to which the patients follow these. The extent to which a schedule is laid down and to what extent these are adopted in the hospital? All this would be part of the order and organization.
Program clarity Are the programs in line with the needs of the patients and whether the programs are clearly explained to the patients? To what extent are the patients have trouble understanding and practicing the program are all a measure of the program clarity.
Staff Control The extent to which the staff has to exercise control of the activities of the patient is also measured. This measures the number of times staff has to say where, when, and how a particular job has to be done at the hospital.

The above ten subscales of the WAS are used by Moos to identify the extent up to which the hospital is satisfactory. This reflects the satisfaction and the reflection of this in the success of a treatment program at the hospital. As indicated already, every one of these factors is used in all the three forms that are normally used in the WAS scale. The Form R which is the real form is a judgment by the patients and by the staff to understand and know what is the real status of the hospital from their perspective? Whereas the Form I, the patients and the staff reflect upon what is their ideal requirement? Between these two forms, consultants could infer the extent to which the patients’ current programs meet their needs. Form I should provide the ideal treatment expectation from the perspective of the patient and the staff.

Finally, a third Form E which is the form on the expectations that the people have on the programs offered by the hospital and its services is also used. This would include the expectations offered by the patients as well as by the staff in the hospital. This may not be the ideal condition preferred by the patient during the treatment or the program. This is normally done to a prospective patient and therefore, the hospital would know what are the patient’s as well as their relatives’ expectations. This would help the hospital to know whether it would meet their needs and if there is too high an expectation, then the hospital can always indicate to them about it. It can also counsel them on what to expect and what not to expect.

Three forms comprising of similar subscales are used to know the real situation as visualized by the patients and staff are used. The same questions are posed with minor variations in them as can be seen below. The third form is used only when the expected levels are to be noted. This is particularly true in the case of hospital wards and has been applied to the psychiatric wards. In cases where the feedback of the relatives of the patients or other service providers is to be noted, then the same questionnaire with subtle changes could be used. The questionnaire needs to be altered so that the questions conveying the same meaning but should be for the appropriate person.

In the case of statements that are posed to the respondents, the statements are generally, eliciting a true or false answer from the respondent. And every one of the forms has an answer key. Though there is no right or wrong answer for the question, there answers that carry a full weighted score or no score. This would help the evaluating person to identify what is the right score of that respondent. For instance, if we consider a statement like ‘New Treatment approaches are often tried in this program. This is the fifth statement in the response sheets. This is considered a part of the Practical Orientation sub-scale. And has a key of ‘True’. Every sub-scale in the Moos scale is given ten statements. But they are not given one after another but jumbled around. That is 5, 15, 25, etc., are for practical orientation sub-scale. Similarly, statement numbers 3, 13, 23, and so on up to 93, are for the sub-scale spontaneity. The following table lists a typical set of statements for some of the subscales.

Spontaneity Key
3 Members tend to hide their feelings from one another F
13 Members say anything they want to the staff T
23 It is hard to tell how members are feeling here T
33 Members are careful what they say when staff are around F
43 Members are strongly encouraged to express themselves freely here F
53 Members spontaneously set up their own activities here F
63 When members disagree with each other, they keep it to themselves T
73 Members can generally do whatever they feel like here F
83 Members tend to hide their feelings from the staff F
93 Members are strongly encouraged to express their feelings F

Similarly, for every one of the sub scales a set of statements have been suggested and the key for the same is provided. The statements belonging to a single sub scale is scattered around to ensure that there is a mix of thought processes and the responses are more truthful. This is ensured by mixing up the statements in this manner and only the person who is evaluating knows the exact sub scale statements. While evaluating, every matching answer scores one point and a mismatch scores none. That is, if the key is ‘False’ and the answer is also ‘False’ for that respondent then one point is added to the score. Only if the key and the answer from the respondent matches, the score is increased by one. If not no scores are allotted to the answer. This is a measure of the Ward Atmosphere and what is the respondent’s perception of the same.

In all, Moos et al, have developed a very constructive tool, that has been employed a number of times to judge the ward atmosphere. Based on the tool and on the situations in the Jordanian hospital we can draw out conclusions on the state of the Jordanian hospitals.

Analysis of the data that already exists on the Jordanian hospitals and the information provided by the government of Jordan help us draw some meaningful conclusions. All of the factors has to be analyzed in order to reach the conclusive decisions on the issues cited. However, in line with the changes that are happening in the world and the contributions of the research in the specific area of work, it is becoming all the more interesting to note that the Jordanian government and the hospital governance by itself help form the hospital with these factors in mind.

Based on the information that is available in the government and the overall availability of the services in the hospital, the discussion below is done.

Discussion

WAS scale on the Hospital Wards

The hospital wards more specifically the psychiatric wards can be evaluated using the Ward Atmosphere Scale proposed and explained by Moos. Based on the sub scales the nature of the WAS scale and the possible out comes can also be discussed in the following pages. From the location of the hospitals in Jordan, the choices are very good. These locations would offer the patients a chance to recuperate. Equally so is the construction of the hospital and its architecture. If the hospitals are well designed and laid out, the impact on the patients it has is positive. This also is a great motivator for the patients to recuperate and so it is for the staff to concentrate and work as well. The extent of positive work that is carried out in the hospitals, due to such infrastructural considerations, it was found, to be closely associated with the way the building and the hospital itself is maintained. Therefore, the maintenance of the hospitals also play a very important role in the well being of the patients and in patients themselves getting well fast. Earlier work on the architectural impact on the patients by Bryan Lawson (Mar 2002) has reflected the extent of impact that these have on the patients. It was found that the time the patient spent at the nursing homes and in the hospitals came down by nearly 70%. He reports that the stay on an average because 4 days from 13 days when the architecture of the hospital was improved. This has been taken into consideration by the Moos WAS scale in the first of the sub scales, order and organization. Moos Scale reflects the work done by the earlier researchers in every one of the fields and a suitable scale has been fixed by him for the purpose.

The other sub scales such as, spontaneity, personal practical orientation and practical orientation, freedom to the patients for expressing themselves all seem to have positive impact on the recuperative effort by the patients. This is true in the case of all patients, though, it is more so in the case of psychiatric patients. In psychiatric wards, the patients have to be given adequate freedom to express themselves among other patients and with the staff in the hospital. This would help in bringing out the thoughts of the patients ensuring swifter healing of the problems that the patient might have. Using the sub scales present in the WAS all these factors can be evaluated.

In the following paragraphs, the earlier research carried out in every one of the WAS scale has been presented so that there is absolute research backing for the work carried out using the same.

Results of earlier research in psychiatric hospitals on WAS sub Scales

Involvement

Involvement of the patients and their relatives in the programs that are conducted would add more value to the program. According to Alden (1978), the interpersonal relationships between the people have had a significant impact on the treatment. This has been substantially proved in earlier researches including that of Moos et al. Patients also feel strange in a program where their involvement is limited or none. So is the case with the staff in the hospital too. The staff needs to get used to the concept of the program and the basic idea behind every one of the programs that are conducted. This would ensure that the ‘idea’ behind the program is brought about rather than mechanically implementing the program. This way, the program may not bring about the sought after result.

In addition to Alden’s (1978) findings on involvement as a factor, Howard et al (2003) present that the involvement of the patients is an important and concluding reason for treatment perception and results. This is more so, in the case of psychiatric treatments. Leavey G et al (1997) reports that ‘the patients and their relatives should be seen as partners in care’ rather than as passive recipients of treatment that is deemed fit for them; this report also stresses on the importance of the involvement and therefore, measuring involvement is critical.

Support

Support is primarily the service provided by the doctors and the staff of the hospital. This is a perception of the patients and their relatives and the staff themselves as to the extent up to which they are supported by the hospital (Sidman 1968). Support is also found to play a very important role in the treatment of the patients. Support comes up in the form of understanding of patient problems by the doctors as well as the staff. There is also the possibility that the support is also visualized as the extent of listening that the staff of the hospital do with respect to the patients as well as with the relatives of the patients. This of course is a perception factor of the patients and their relatives.

Friis (1986) did a study to identify the amount of time patients and staff spends together. Similarly, another study by Kahn Stroke and Schaeffer (1992) describes the extent of time either of them spent together and the feedback the patients were eager to give to the staff. In either of the cases, they reported reasonable quantum of time spent and also the results that delivered in the treatment of the patients. But what is the optimum time spent on every patient would rather be dependent on the patient and his or her problems. Though, the support might involve other services as well, it is more often the extent of time spent by the staff of the hospital with the patients that is really perceived by the patients and their relatives as support. It is also the quality time and not really the length of the time that is spent which brings up such perception (James A Kennedy 2003).

Spontaneity

Does the hospital allow spontaneous interaction between the patients; between patients and staff? This measure helps in knowing how far the patients react spontaneously to the situation they are in and to what extent are the staffs flexible to receive opinions from them. An interaction amongst the patients themselves will help the patient to realize better results from the treatment.

Many of the earlier researchers suggest that spontaneity is a part of the curing process. Moos & Lemke (1994) have helped the research process by providing additional information on the way the independence and spontaneity helped people. They found that more the amount of freedom provided to the people, better they were in getting substantially good treatment and they could recover swiftly. Eklund & Hansson (1997) record that the COPES (Community Oriented Programs Environment Scale) that they employed in their study also included the spontaneity of the patients in two of its sub scales, viz., quality of life and functioning in daily life. Every scale has recognized the importance of the spontaneity and this has been made a separate sub scale in the WAS scale as well.

Autonomy

Autonomy indicates whether the patient is able to take care of their needs themselves. How autonomous the patients should be is really dependent on the extent of care the patient can take care of himself or herself and that of the material and property around him or her. In his seminal talk on Autonomy for persons and non-persons, Dr. Hull (1978) remarked how courts often view mentally deranged people as non-persons and the question of providing autonomy does not arise. However, in the treatment of such people, Moos et al, recognize the need for autonomy to individuals and patients who are gaining in their mental stature and where results could be bettered if treatment is given with more autonomy.

Practical Orientation

The patients need to be trained to provide for themselves once they are out of the hospital. This could happen only if enough autonomy is given to them and at the same time, they are also trained to take care of their needs too. Patients would need practical orientation so that once they are out of the hospital they will know how to lead a decent life independently. This should ideally teach them a vocation and also help them in learning a trade that would help them to earn their living. Depending on people for their sustenance might not be a good idea once they are out of the hospital.

Even the staff of the hospital and the relatives according to earlier studies carried out feels that there should be adequate training provided to the patients in this area (Raymond Webster Feb 2006). They feel that the hospital should provide for a higher orientation towards practical learning for the patients. This would help them in bringing out self sustaining individuals out of the hospitals. This is particularly true when considering the substance misuse treatment cases (Ilgen & Moos 2006).

Personal Problem Orientation

The individual problems of the patients should be given adequate attention. This is reflected when the patients are allowed to discuss their problems with other patients and with the staff of the hospital. With personal orientation, the responses of the patients were much better over a period of time. This has been highlighted by a number of studies on personal problem orientation. Morgan (1967) reports that the personal orientation in treatments, work on improvement of the overall performance of the patient. It is, therefore, important that the self-actualization in the psychiatric patients is realized for a long term cure of these patients (Walsh et al 2000). This is also measured in the WAS scale to ensure that the metric used is complete.

Anger and Aggression

Many hospitals do not provide the open expression of anger and aggressive behavior since it is bound to affect the other patients as well as possibly the staff of the hospital. It is always for the good of the patient and for the rest, that their aggressive behavior is largely lessened. However, hospitals also view this as an outgo for the emotions pent up in the patient and by letting it out, the curing rate of the patient could improve. At the same time, dissipation of anger in a locked or closed environment might be needed for some of the patients who are basically aggressive (Mary Ann Boyd, 2005, p818-820). With this research behind them, many of the hospitals allow patient anger in open. This they feel would increase the patients to express themselves so that they are more open and overall performance of the patients could improve. But there are not many differing doctors who say that the choice of freedom to the patients, who are particularly aggressive and are bound to have anger, is at the choice and discretion of the doctors. However, Moos considers this as a part of the ward atmosphere and this is also one of the sub scales used for measuring and rating ward atmosphere.

Program Clarity

The patients, the staff and all other stakeholders in the program should have a clear understanding of how the program is progressing and the purpose of the program too (Moos RH 1997, p238). When there is a lack of program clarity the program itself is bound to fail. There are a number of occasions where who should know the program and who should not arises. The reasoning could be that, the staff might feel that the patients need not be given the entire view of why and how the program is to be conducted. Patients can be given information on how it is conducted and possibly part of the reasons behind why it is conducted. It is also possible that the staff feel that the patients may not be able to appreciate the thought that is going into such programs. Though all stake holders should have an equal knowledge in the program, taking into consideration the role of the individuals, the final choice on who should know what is decided by the staff of the hospital and the condition of the patient. However, the sub scale on program clarity provides a rating for the metric identified. Whether the metric would provide a positive turn in the performance of the hospital or not is still contended.

Staff Control

To what degree the staff administers control on the patients is an issue that rocks the psychiatric as well as the jurisprudence now and then. Staff control happens even in briefing the patients’ daily routine. Is there a need for the staff to do this every day? Or are the patients willing to learn quickly and remove staff control to a greater degree? It is true that the staff control is important in the case of psychiatric patients. Particularly, when the patient is aggressive and in the initial phase of the treatment would be wrong not to have staff control. Moos (1997) argues that every patient should have their own levels of control as required during the initial treatment and subsequently once the patient settles down. Some of the hostile patients have to be appropriately checked and measured before any other treatment is administered to the patients (Kennedy JA, 2003, p 3.12). This again is therefore, a clearly planned freedom that the patient should be provided with. It would improve the performance of the patient and therefore hasten is recovery. However, if wrongly administered this could also lead to complications. A sub scale metric would help in identifying a measure for the same and not necessarily suggest whether to increase or decrease the staff control. The decision for the same can be taken once the measure is well done.

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