THE PSYCHIATRIC REVOLVING DOOR PHENOMENA.

A QUATITATIVE STUDY TO DETERMINE PATTERNS OF READMISSIONS,

STRUCTURED STUPPORTS AND CHARACTERISTICS OF CLIENTS WHO
EXPERIENCE READMISSIONS AT CHESHIRE PSYCHIATRIC AND
REHABILITATION CENTER.

BY

AYIREBI ISAAC

A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT FOR A FIRST

DEGREE IN NURSING PROGRAM.

2014.
 DECLARATION

I declare that this research is my own work and has not been taken from the work of others save
and to the e that such work has been cited and acknowledged within the text of my work
submitted as part of a Bachelor of Nursing degree programme in Garden City University
College, under the supervision of Miss Dzigbodi Kpikpitse, Head of Nursing Department.

DEDICATION

I dedicate this work to my wonderful Rita Ayirebi and the Clients who so generously shared their
experiences with me and provided valuable information that will assist others in coping with
psychiatric conditions.

ACKNOWLEDGEMENTS

This piece of work would have been virtually impossible without the assistance and
encouragement of certain individuals. I am therefore deeply indebted to show my appreciation
to them.

My special thanks go to the Almighty God who by His mercies and love gave me the grace to
conduct this study.

I am also indebted to extend my sincere gratitude to the all the clients who gave their consent and
partook in the study. Without their participations the objectives of this research would not have
been achieved.

My heartfelt gratitude goes to Miss Dzigbodi Kpikpitse, my Supervisor who is also the Head of
the Department of Nursing, Garden City University College, for her valuable guidance, teachings
and corrections throughout this research and for making this research a successful learning
experience.

My thanks and great fullness is also given to the head of the Cheshire Psychiatry and
Rehabilitation Center, and nurses all the other staffs members for their warm reception and
support throughout the study.

Finally, I thank the authors and publishers whose textbooks provided treasured information used
in writing this piece.
In Ghana, the Ankaful Psychiatric Hospital in the central region has a total number of 250 beds.
Four percent of the total numbers of hospital beds in the hospital are allocate to children and
adolescents (Annual report Ankaful 2012)

Invariably, there is overcrowding in the state psychiatric hospital due to insufficient beds
resulting in patients sleeping on mats and mattresses spread on the floor. This is worsened by the
relapse of patients to the already congested facility. Further there is easy spread of disease due to
the overcrowding. At Ankaful psychiatric hospital the average length of stay of admitted patients
in 2005 was 82.2 days whilst psychiatric hospitals like Pantang increased to285 days within the
same period.

The Mental Health and Poverty Project (MHaPP) study by Dr. Victor Doku, Dr. Akwasi Osei
and others shows that, in 2007, 520 patients were said to be ready for discharge at Accra
Psychiatric Hospital remained there. One of the reasons appears to be the stigma attached to
mental disorders, which results in families and caregivers abandoning their relatives at the
psychiatric hospitals. It is likely that lack of community support and rehabilitation services also
contributes. As well as noncompliance to medication regimen. There is a strong myth about
people who happen to take psychiatric medications or are admitted to the psychiatric facility here
in my country. The canker is so severe to an extent that people refuse to seek medical treatment
even at the outpatient department due to the stigma attached to one being seen at the psychiatric
facility. They would travel far distance to visit other medical facilities. Whereas supposedly they
could have received the same care or better at the psychiatric outpatient department. As such
there are patients who have been in and out of the hospital so many times that they prefer to stay
in the hospitals. One patient for instance at the Ankaful Psychiatric Hospital has stayed there for
over twenty years occupying a single bed. This brings into mind the number of patients that
would have received care if the said patient was well, that’s good discharging plans and good
social supports were available.
The mental health and poverty project study conducted in Ghana, in 2007 demonstrated that due
to lack of community support and rehabilitation services discharged patients are unable to return
to their communities. This issue indicates that the community is unprepared and unwilling to
receive and support discharged mental patients. It therefore, becomes almost impossible to lead a
normal live in the community following discharge from a psychiatric hospital. It implies that,
patients will relapse and be readmitted to the hospital.
It has been reported that 60% of the total admissions in Ankaful psychiatric hospital are
readmissions (annual report 2012, Ankaful Psychiatric Hospital).
The mental health and poverty project study conducted in Ghana, in 2007 demonstrated that due
to lack of community support and rehabilitation services discharged patients are unable to return
to their communities. This issue indicates that the community is unprepared and unwilling to
receive and support discharged mental patients. It therefore, becomes almost impossible to lead a
normal live in the community following discharge from a psychiatric hospital. It implies that,
patients will relapse and be readmitted to the hospital. The policy of the ministry of health of
Ghana now is to shift focus of mental treatment from specialist institutional care in the large
mental hospitals, to community services and general health care settings throughout Ghana. The
new mental health bill which was passed in 2012 strengthens community mental health services,
helping those who need care to be more easily identified and managed. This presupposes that the
lengthy stay of patients in the hospitals have become shorter. However it is sad to note that
mental health facilities to those discharged patients in the community are nonexistence,
therefore, discharged patients relapse and are readmitted to the hospital as reported that 60% of
the total admissions in Ankaful psychiatric hospital are readmissions (annual report 2012,
Ankaful Psychiatric Hospital).
Despite all medication and psycho- educational treatments given to patients the following still
make them relapse as the clients complained about the poor community adjustment following
discharge from the psychiatric homes. Again noncompliance to medication, stigmatization due to
poor psychoeducational empowerment of the public also contributes to the relapsing of the
client.
A study conducted in Cheshire psychiatric and rehabilitation center located at Kwadaso, by me
in 2014, the town which is a sub-metros of Kumasi Metropolis Assembly. The town lies in the
western part of Kumasi Metropolis. I employed a descriptive design because it points out
situations as they exist and also brings out the need for change. The study population consisted
of 30 adult clients at the Cheshire Psychiatric and rehabilitation center without active psychotic
conditions at the time of the study.

The main objective was to determine the psychiatric revolving door syndrome, and the specific
objectives of the study were to answer to the following research questions; To determine patterns
of readmission, to determine structured support of patients after discharge and to determine
characteristics of patients who experience readmissions.
A structured questionnaire was used for data collection. It consisted of two sections, one section
was on the characteristics of respondents and the other was on the patterns of admissions and
readmission.

The table below illustrates the demographic data with respect to the number of admissions in
percentiles and frequencies including their diagnosis. The second section which is illustrated in
pie charts.
Characteristics Number of patients Number of admissions (%) (Frequencies)
Age 18-35 60 12
36-60 40 18

Gender Male 63.3 19

Female 36.7 11

Marital status Single 57 17

Married 23 7
Divorced 20 6

Employment status Employed 70 21

Unemployed 30 9

Occupation Students 3 1
Business folk 47 14
Engineer 17 5
Civil servant 10 3
None 23 7

Educational level No formal education 3 1

Basic education 3 1
Primary 10 3
JSS 20 6
SSS 27 8
Tertiary 30 9
Post graduate 7 2

Diagnosis Drug addict 47 14

Schizophrenia 33 10
Psychosis 17 5
Depression 3 1
From the table above, 60% of the inmates were between the ages of 18-35 years while 40% of
the inmates were between the ages of 36-60 years. From table, 63% of the inmates were males
while 37% of the inmates were females. From table, 56.7% of the inmates were single, 23.3% of
the inmates were married while 20% of the inmates were divorced. From table, 70% of the
inmates were employed while 30% of the inmates were unemployed. From table, 3% of the
inmates were students, 47% of the inmates were businessmen and women, 17% of the inmates
were engineers, and 23% were civil servants while 23% of the inmates were not working in the
description status. From table, 30% of the inmates had tertiary education, 27% had senior
secondary education, 20% had JHS education, 10% had primary education, 7% had post graduate
education, 3% had basic education while 3% had no formal education. From table, 46.7% of the
inmates are readmitted because of drug addiction, 33% because of schizophrenia, 16.3% because
of psychosis while 3% are readmitted because of depression.

FIRST ADMISSION
1-3 yaers ago 4-7 years ago 8-10 years ago

23%

67%
10%

From figure 1, 67% of the inmates had their first admission 1-3 years ago, 23% had their first
admission 8-10 years ago while 10% also

AFTER DISCHARGE DID YOU

had their first admission 4-7 years ago.
SEEK MEDICAL TREATMENT
ELSEWHERE
yes no
40%
60%

From figure 2, 60% of the inmates sought medical treatment elsewhere after discharge whiles
40% did not seek medical treatment elsewhere after discharge.
 LOCATION OF SECONDARY
TREATMENT
prayer camp herbalist native doctor

6%
12%

82%

From figure 3, 82% of the inmates sought medical treatment from prayer camps after discharge,
12% sought treatment from a herbalist after treatment whilst 6% sought treatment from the
native doctor.

NUMBER OF READMISSIONS
once twice trice quardripule more than 4

7%

20% 43%

20%
10%

From figure 4, 43% have been readmitted once, 20% have been readmitted twice, 20% have been
readmitted four times, and 10% have been readmitted three times while 7% have been readmitted
more than four times.
 REASON FOR READMISSION
non adherance to medication stigma
lack of social support lack of counseling
lack of recreational centers forced to the hospital

30% 34%

10%
3% 20%
3%

From figure 5, 34% of the inmates were readmitted because of non-adherence to medication,
30% of the inmates were admitted because they were forced to the hospital, 20% of the inmates
were readmitted because of lack of social support, 10% of the inmates were readmitted because
of stigma, 3% were readmitted because of lack of recreational centers while 3% were readmitted
because of lack of counseling for the inmates.

ANY VISIT ON PREVIOUS ADMISSIONS

yes no

7%

93%

From figure 6, 93% of the inmates said they were visited while on previous admission and 7% of
the inmates were not visited while on admission.
 EXPECTATIONS PRIOR TO DISCHARGE
to be accepted back into society
assume your role in the society
assume previuos responsibilities

27%

63% 10%

From figure 7, 63% of the inmates expected that they would assume their previous responsibility
prior to discharge, 27% of the inmates expected to be accepted back into the society prior to
discharge while 10% of the inmates expected to assume their roles in the society prior to
discharge.

EXPERIENCE AFTER DISCHARGE

stigma hatred
lack of support responsibilities taken from you
loss of relationships none
10%
13%
33%
20%

7%
17%

From figure 8, 33% of the inmates had no bad experience after their discharge, 20% experienced
lack of support from the society after discharge, 17% had their responsibility taken from them
after discharge, 13% experienced hatred from the society after discharge, 10% experienced
stigma after their discharge while 7% lost their relationships after discharge.
 DID YOUR FAMILY ACCEPT YOU BACK
yes no

27%

73%

From figure 9, 73% of the inmates said their families accepted them back after discharge whilst
27% did not have their family accepting them back.

DID YOUR SOCIETY ACCEPT YOU BACK

yes no

40%

60%

From figure 10, 60% had the society accepting them back while 40% of the inmates were not
accepted back into the society after discharge.

FOLLOW-UP HOME VISITS

yes no

23%

77%

From figure 11, 77% of the inmates said they did not have any follow up home visits after
discharge whilst 23% of the inmates said they had follow up home visits after discharge.

These findings were made during the study, readmission has a major role in the reduction of the
quality of life and the increase in the years of lost life.
Age, Gender, Marital status, Employment status, Occupation, Educational level, self-history
report of previous admission, type of psychiatric disorder (Diagnosis), and the length of the
current psychiatric disorder were collected from the registered medical files of patients.

I found that diagnosis such as drug addictions, schizophrenia, psychosis, and depression were
statistically significant in the number of readmissions which was characterized by stigma. I could
tell that readmission to the psychiatric ward was mainly predictable by the type of diagnosis, lack
of psychosocial supports as well as poor discharge planning.

Another thing that was realized during the study was, the caliber of people and the facilities they
find themselves in. With the few private psychiatric facilities, one would find clients who
happen to be with good family support there. But it happens to be the vice versa on the other
hand. That is clients with little or no family support happen to find themselves in public
facilities which are very congested. And with such facilities funding alone makes them
functionally inactive, characterized with the undue pressure from the number of clients compared
to the original structural intake.

In conclusion, findings suggest the need to dedicate special attention to mental patients with
multiple previous admissions in an attempt to decrease readmission. This may include the
provision of psychoeducation to both patients and their families with a view to improving the
identification of early symptoms of relapse and help seeking behaviour. There is an urgent need
for improved record keeping procedures by the health institution in this country to facilitate
retrieval of complete medical information about patients for necessary policy formulations.

Cheshire rehabilitation and psychiatric center should continue to support and enhance discharge
planning and practice. Improving bridging strategies and the introduction of motivational
interviewing can further reduce unnecessary readmissions and thereby provide the patient with
the best opportunity to develop skills within the environment in which they will be used in the
communities in which they live. As of this writing, a discharge follow up nurse had begun
contacting all patients post-discharge via telephone and this should have a major impact on
readmissions and influencing patient outcomes positively. They will be asked if they have
initiated contact with their community support systems, if they are currently having difficulties,
and if they have any medication issues. I see this as a great beginning.