تاثیر ویژگی های شخصیتی مانند اختلالات فکری و روانی در مورد بیماران بازداشت شده با استفاده از روش های شکایات NHS در تنظیمات پزشکی قانونی

The current study examined the role of personality factors (particularly psychopathy) in the use of the NHS complaints procedure in forensic in-patients as there appears to be little literature in this field. Forty-six complainants were identified from the computerised information systems at a 60-bedded medium secure unit between April 1996 and April 2000. Scores on the Psychopathy Checklist:Screening Version (PCL:SV) in this sample were compared with a matched sample of 46 in-patients, who had not made a complaint (formal or informal) during the study period. Among the complainants few complaints were upheld. Complainants had significantly higher PCL:SV scores and higher incident rates than non-complainants. Key items on the PCL:SV that distinguished complainants from non-complainants were “grandiosity” and “does not accept responsibility”. Patient factors particularly psychopathic traits may be a much more important factor in the use of the complaints procedure in in-patient psychiatric settings than was initially envisaged. Complaints investigators need to be more aware of the influence of personality factors in patient satisfaction with care.

There is a growing interest in the use of consumer satisfaction as a measure of outcome of psychiatric care. Lebow (1982) reviewed the literature on patient satisfaction with mental health treatment and highlighted a number of methodological problems with survey based assessments including low response rates, sampling bias and reliability and validity of patient satisfaction data. Others have reported biases in the evaluation of satisfaction due to what has been labelled acquiescence (El-Guebaly, Toews, Leckie, & Harper, 1983). Complaints and compliments about services provide an alternative source of data on satisfaction. These offer the advantage of being specific in focus, important for the patient and less reactive than survey data. By reviewing unsolicited complaints and their outcome it is possible, however, to assess both the quality of care and patients' perceptions of their care (Schwartz & Overton, 1987). The current NHS complaints procedure (DOH, 1994), which can be viewed as a proxy measure of unsolicited complaints, was implemented in April 1996 to address complaints in hospital and community services using a two-stage process: local resolution (LR) followed by independent review (IR) if appropriate. Most studies on complaints focus on physical health care (Burstein and Fleisher, 1991, Curka et al., 1995 and Schwartz and Overton, 1987) and there is limited information on complaints in mental health settings (Ingram and Roy, 1995 and Pitarka-Carcani et al., 2000). Furthermore, published data generally concentrates on the nature and types of complaints generated, monitoring system failures or the profiles of professionals or institutions against which complaints are made (Department of Health, 1995, Griffiths, 1996, NHS Executive, 1996 and Reid et al., 1995). Relatively little is known about the profile of complainants other than basic demographic characteristics although it has been postulated that patient satisfaction may relate subjective attitudes to life and illness behaviour as well as systems of care (Allen, Baigent, Kent, & Bolton, 1993). Although levels of patient satisfaction in mental health settings tend to be relatively high a number of studies indicate that demographic variables such as age, sex and education do not significantly influence levels of satisfaction (Kalman, 1983 and Weinstein, 1979). Race, however, appears to have some influence with minority groups reporting less satisfaction (Larsen, Attkisson, Hargreaves, & Nguyen, 1979). There is also evidence that patient satisfaction tends to be lower in mental health rather than other health care programs (Hoff, Rosenheck, Meterko, & Wilson, 1999) and that psychiatric diagnosis and chronicity of illness are key factors associated with low rates of patient satisfaction (Lehman & Zastowney, 1983). Several studies suggest that compulsorily detained patients are more dissatisfied than those admitted voluntarily (Gove and Fain, 1977, Hansson, 1989, Kalman, 1983 and Shannon, 1976). It has also been shown that patients with poor prognosis express less satisfaction with services and treatment (Woodward, Santa-Barbara, Levin, & Epstein, 1978). In studies looking at psychiatric diagnosis an association has been shown between low levels of satisfaction and psychosis, drug abuse and suicidal behaviour (Lebow, 1982). Relatively little is known about the influence of personality factors on satisfaction. Kelstrup, Lund, Lauritsen, and Bech (1993), however, demonstrated that patients with antisocial and borderline personality disorder had significantly lower levels of satisfaction than those with affective disorder and schizophrenia. Svensson and Hansson (1994) in a questionnaire study also reported that Swedish patients with higher levels of trait aggressive nonconformity on personality measures were significantly less satisfied with the ward environment and treatment than patients who scored low on these traits. To date, there are no published studies on the nature or type of unsolicited complaints generated by patients in forensic units where care and treatment is often compulsory and protracted and would be expected to be associated with a high frequency of complaints about staff, treatment and environment. We investigated the nature and type and outcome of complaints in a medium secure unit in the north west region of England following the implementation of the NHS complaints procedure. We also investigated whether personality factors among patients (particularly psychopathic traits) played a role in the use of formal (NHS complaints procedure) and informal complaints procedures by comparing matched (age, sex, time frame) samples who did and did not complain about care and treatment during the same period. The rationale for the study was based on previous reports that personality factors, particularly antisocial personality traits (Kelstrup et al., 1993) and aggressive nonconformity traits, are associated with lower levels of satisfaction with inpatient care (Kelstrup et al., 1993 and Svensson and Hansson, 1994) in general psychiatric samples, and that co-morbid personality disorder is prevalent in forensic patients (Coid, 1992). We specifically tested the hypothesis that forensic patients who use the formal and informal complaints procedures would have higher scores on a measure of psychopathy than those who do not and that complaints in forensic settings are rarely upheld or proceed to an Independent Review Panel (IRP). We further hypothesised that subjects who use the complaints procedure are those who are generally more challenging in terms of management particularly in terms of other outcome measures such as incident rates or rates of withdrawal of self-generated complaints before formal investigation.

In light of our finding that personality factors are an important contributor to patient use of the complaints system, staff investigating complaints need additional training in the management of complaints by patients whose personality function may be a significant factor in their low levels of satisfaction with care. In light of the fact that the inability to accept blame for ones own actions or lack of insight is part of the patients' pathology, there is a need to question the appropriateness of formal complaints procedures for minor complaints that would be better managed at ward level. In some cases the formal complaints procedure clearly fosters and reinforces unrealistic perceptions of care and reduces a patient's ability to take responsibility for the consequences of their own actions, when the latter is in their own best interests. Staff working with challenging patients need to feel supported by their employers and the malicious use of the complaints procedure (such as the case we highlighted) needs to be monitored so that persistent and vexatious complainers are managed in more appropriate ways. Finally, in light of our findings future studies on NHS complaints should include a cost-benefit analysis of the impact of investigations on care delivery. Based on our findings, we suggest that future studies should be conducted on psychiatric patients in secure and non-secure settings so that the role of personality in general is examined in patients using the NHS complaints procedure.