|Year : 2022 | Volume
| Issue : 1 | Page : 21-25
Impact and facilitators of a psychiatric rehabilitation daycare work program: A qualitative study
Amrita Roy, Thanapal Sivakumar, Deepak Jayarajan
Department of Psychiatry, Psychiatric Rehabilitation Services, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
|Date of Submission||01-Dec-2021|
|Date of Acceptance||08-Jan-2022|
|Date of Web Publication||30-Mar-2022|
Dr. Thanapal Sivakumar
Department of Psychiatry, Psychiatric Rehabilitation Services, National Institute of Mental Health and Neuro Sciences, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Work confers many benefits to persons with psychiatric disabilities. The daycare work programs can be helpful for patients in multiple ways. Many stakeholders plan and implement a daycare work program, including patients, caregivers, trainers, staff members, and professionals. The literature on daycare work programs is limited. The present study aimed to understand the impact and facilitators of a selected daycare work program (Green Skills Program [GSP]) from the lens of stakeholders. Methods: Criterion sampling was used to recruit the stakeholders who have been part of GSP. Twenty-seven stakeholders were interviewed using a researcher-prepared semi-structured interview schedule. Atlas. ti version 9 was used for coding. Thematic analysis was done to identify themes. Results: Stakeholders considered GSP easy, enjoyable, and accommodative to patients with different functioning levels. GSP participation was deemed as gainful engagement and vital to day-structuring. The patients worked in groups, which promoted peer learning and teamwork. Various behavioral, social, and work-related improvements were noted among the patients by the stakeholders. Incentives and social reinforcements were significant motivators. Stakeholders were content with the trainer's way of teaching the patients and felt that she possessed many essential attributes that motivated them and improved their work outcomes. Conclusions: While conceiving daycare work programs, ease of doing activities, accommodation of patients with varying levels of functionality, trainer's aptitude, and use of reinforcements should be considered.
Keywords: Daycare work program, phenomenological research, psychiatric disabilities, psychiatric rehabilitation, qualitative study, Stakeholder's experiences
|How to cite this article:|
Roy A, Sivakumar T, Jayarajan D. Impact and facilitators of a psychiatric rehabilitation daycare work program: A qualitative study. Indian J Soc Psychiatry 2022;38:21-5
|How to cite this URL:|
Roy A, Sivakumar T, Jayarajan D. Impact and facilitators of a psychiatric rehabilitation daycare work program: A qualitative study. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Jun 30];38:21-5. Available from: https://www.indjsp.org/text.asp?2022/38/1/21/341335
| Introduction|| |
Psychiatric rehabilitation services are critical to helping patients with psychiatric disabilities recover. These services are usually provided in daycare (institutional or community-based) or residential settings (transitional, half-way, and long-stay homes). Patients availing psychiatric rehabilitation are involved in various activities, including social, informational, religious, recreational, activities of daily living, and work programs.,, The daycare centers' work programs include running canteen or café, manufacturing things to sell, carpentry, painting, tailoring, weaving, art and craft, notebooks manufacturing, bookbinding, offset printing, carton making, medicine cover making, and horticulture.,, Work is beneficial for persons with psychiatric disabilities. Work hosts a scope of clinical and socioeconomic benefits and promotes recovery.,,,
Psychiatric rehabilitation services, NIMHANS, collaborated with a Nongovernmental Organization (NGO)– Craftizen, to initiate a daycare work program named “Green Skills Program (GSP)” in 2017. GSP involved preparing “eco-friendly Holi colors.” Over time, various products such as “eco-friendly Diwali kits,” “eco-pens,” and “paper-dust products” were added. The products were sold, and the profits were distributed among the GSP participants during a public event conducted yearly.
A key feature of designing and executing policies and programs for psychiatric rehabilitation is involving various stakeholders. Many stakeholders plan and implement a daycare work program, including patients, caregivers, trainers, staff members, and professionals. NGO personnel, trainer, and supervisors played vital roles in the planning and implementation of GSP. Nursing, administrative and support staff provided operational and administrative support.
The literature on daycare work programs is limited, especially about the perceptions and experiences of stakeholders involved in daycare work programs. The present study aimed to understand a selected daycare work program (i.e., GSP) from the lens of stakeholders. Only the findings of impact and facilitators are presented and discussed in this paper.
| Methods|| |
A qualitative approach using phenomenological research was considered to explore the perceptions and experiences of stakeholders involved in GSP. The stakeholders included patients, caregivers, trainers, staff, Mental Health Professionals (MHP), and NGO personnel.
Criterion sampling was used to recruit the stakeholders who have been part of GSP. Twenty-seven stakeholders were recruited consisting of six patients (three diagnosed with mental illness and three with intellectual developmental disabilities), seven caregivers, six staff members (two nursing staff, three administration staff, and one support staff), three NGO personnel, one trainer, and four MHP (one Psychiatrists, one Clinical Psychologist, and two faculty of Psychiatric Social Work).
Tools for data collection
The researcher prepared a datasheet to collect the sociodemographic details of the stakeholders participating in the interview.
Semi-structured interview schedule
The researcher prepared a semi-structured interview schedule to interview the stakeholders involved in GSP. Three variants were prepared-for patients, caregivers, and professionals/staff. The content validation was done by seven experts from the field of Psychiatry, Psychology, and Psychiatric Social Work. The tool was translated to Kannada by certified translators.
The standardized open-ended interview approach was adopted for interviewing the stakeholders. The consent forms were sent through E-mail or post. Interviews were conducted at a mutually agreed convenient time. Most of the interviews were conducted telephonically (due to COVID-19). Face-to-face interviews were done only for members available on campus, following COVID-appropriate norms. The researcher conducted the interviews in English. For Kannada-speaking patients, a translator's assistance was taken to conduct and transcribe the interviews. All the interviews were audio-recorded and transcribed. Data collection was done from October 2020 to December 2020.
Atlas More Details.ti (Version 9) (developed by ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used for qualitative data analysis. Data were coded, code groups were created using Atlas. ti by AR and reviewed by TS and DJ. Thematic analysis was used to identify themes and sub-themes from the codes and code groups by AR. The themes and sub-themes were reviewed independently by TS and DJ. Differences were discussed and resolved. A narrative style is used to present the study findings.
This study is a part of Ph. D. thesis and is approved by the Institute Ethics Committee, NIMHANS.
| Results|| |
The sociodemographic details of all the stakeholders are given in [Table 1].
Theme I: What helped green skills program
Stakeholders highlighted that GSP could accommodate patients with varying functionality levels. GSP offered simpler tasks such as depetaling and segregating flower petals to moderately difficult tasks such as painting mud lamps, cutting and rolling newspapers to make eco-pens, weighing, and packaging. Complex activities such as grinding (using a machine to grind the dried petals) and molding the dough for making paper dust products were also carried out. The key ingredient-”flowers” were considered natural, safe, and visually appealing. The flowers were considered suitable for sensory stimulation and having a calming and relaxing effect on the patients. One of the caregivers commented about the flowers: “As there are different colors, when they see this, their mind is relaxed. It feels good for them. Therefore, they also do it with interest.” Stakeholders perceived GSP easy and enjoyable and noted that patients were happy doing the activities. One MHP stated: “What I have noticed is that people who have significant cognitive difficulties where they were not comfortable in successfully completing the task elsewhere, they found this process little easy, engaging and were happy that they were completing a task which was given to them.” Few patients also said that they felt relaxed and calm while involved in GSP. One patient said: “Even in any pain or tiredness, I will forget by doing the work, and I feel peaceful and calm.”
Theme II: Working environment at green skills program
Many caregivers highlighted that the staff members and MHP were pleasant, friendly, resourceful, had a nonjudgemental attitude, and displayed teamwork. One caregiver said: “When we go there, nobody judges us. There are kids with different types of disabilities, but all staff gives proper attention.” Stakeholders emphasized that using reinforcement techniques such as appreciation, encouragement, and positive feedback improved patients' work-related outcomes, made patients happy, and enhanced their self-esteem. Caregivers expressed happiness over patients' work involvement and learning new skills. Many stakeholders felt that working in groups facilitated peer learning and promoted teamwork. One caregiver described group work as a source of peer motivation: “If other is doing one basket of flowers, she will also feel doing it, irrespective of whether she is doing late.… if one child paints nicely, other will think-”I will paint more nicely,” these positive things come in them. I have seen.” Some caregivers were actively involved in various GSP activities, worked collaboratively with the patients, and guided and motivated them. Caregivers also shared their burden of care with other caregivers and learned from other caregivers' experiences. One caregiver stated: “I got help from the other caregivers and knowing more about whatever activities going on in the section to help these kids, that also they were informing because they were already there for a long time before, they would explain me-how we have to go about, how can I take the help of the instructors, how I can make my daughter progress in activities and learning.”
Theme III: Trainer
Stakeholders found the trainer very friendly, caring, and polite, committed, and patient. Both patients and caregivers expressed contentment with the trainer's way of teaching. She assigned work as per the patient's interest and capabilities and paid individual attention. One caregiver said: “I have observed this for every child; madam will go near and teach everybody individually. I liked that very much.” She allowed the patients to ease into work involvement, handheld and encouraged them, and facilitated leadership and teamwork. Stakeholders felt that these attributes motivated the patients and improved their work outcomes. One caregiver said-“… instructor praises them-”very good, you have done so much” and all. They (patients) will feel that “I have to do more and more.” Like that kind of feeling they will have.”
Theme IV: How green skills program helped patients
Stakeholders felt that the patients were having a structured day, were exposed to diverse work activities, and showcased their capabilities. The caregivers emphasized that patients were engaged in productive work rather than remaining idle at home. Many positive behavioral changes, including getting up early and grooming, were noted among the patients. They were actively involved in GSP and would seek additional work after task completion. With continued participation, improvements were noticed in dexterity, working speed, and quality of work output. One MHP said: “…over two to 3 weeks of work, the speed, I think the task completion speed, as well as the skill of task completion, also had improved over a period of time.” Gradually, they were also able to sustain attention and work for a longer duration, work independently or with minimal supervision, and display a sense of commitment and responsibility towards the assigned tasks. Being able to perform a task was associated with building self-confidence and self-esteem among the patients.
Participation in GSP was also seen as an opportunity for socialization as patients could meet and interact with other people and make friends. Having friends was reported as a critical reason for coming to GSP. One participant said: “I feel bored sitting at home. Here so many people are there. I talk with everyone here. So, I want to come here.” The patients enjoyed interacting with friends and were happy working together. A nursing staff identified GSP participation as a chance to learn and improve social skills: “They (patients) are engaged, they will be co-operating and interacting. How to interact with the friends, how to interact with the teacher, those things they have learnt. They all are learning.”
Theme V: Incentives
The incentives were considered rewarding and motivating by the caregivers: “… she (patient) used to tell the instructor-”I want to get the incentive” and slowly she started showing interest in her work and doing the work, you know, with lot of interest and finishing her work faster.” The caregivers also viewed the incentives as a source of self-esteem and self-respect for the patients. A caregiver also designated incentives as a reason for her ward developing a sense of achievement: “So, if I do more, it is like a job only for me. So, I will earn more money, I will also have more money, like that she (patient) used to feel proud of whatever she has said. It shows that she has achieved a sense of achievement.” The incentives were used to contribute towards expenses or saved or were used by the patient to purchase items such as clothing, books, medicines, daily use items, travel and movie tickets, and gift items for parents.
| Discussion|| |
Daycare work programs often serve as the first step toward work participation and offer an opportunity to develop basic work skills and habits. Having a range of simple to complex activities helped GSP to accommodate patients with varying functionality levels. GSP was perceived as easy, enjoyable, and relaxing. This can be the consequence of a few other inter-linked findings of this study: (a) Work was assigned as per patients' aptitude and interest; (b) patients were given individual attention; (c) having friends and working in groups boosted team spirit; (d) therapeutic effect of flowers – good for sensory stimulation; (e) a friendly, polite, and patient trainer; (f) nonjudgmental attitude of staff and MHP.
GSP was viewed as an enabler to patients' day-structuring and gainful engagement. This might not be unique to GSP but common to patients attending daycare services. Studies have noted that daycare attendees perceived higher activity levels, had routines and were productive., The likelihood of enthusiastic work participation is augmented when the work programs and working environment is congruent to the patient's abilities and expectations. Patients feel happy and satisfied when they like the task and have friends to socialize with. When patients are in a positive frame of mind, the chances of negative interactions with caregivers are minimized, and the family's emotional climate is improved. This further helps to reduce the “caregiver burden,” which caregivers of persons with psychiatric disabilities frequently experience.,
Involvement in GSP was also seen as an opportunity for socialization. Working in groups paved the way for peer learning and peer motivation. The patients learned new skills from other patients and caregivers and helped each other, gradually developing a “sense of team” and a “sense of belonging.” Participation in daycare activities has been viewed as a way of belonging, providing a social network, being included, and being normal.,
The stakeholders expressed contentment with the trainer's way of teaching, handling, and supervising the patients. They acknowledged that the trainer possessed many essential attributes that motivated the patients and improved their work outcomes. Although the trainer did not have any previous experience related to the field, she developed a rapport and managed the patients well. For work programs in psychiatric rehabilitation settings, the trainer's attributes are more important than the educational qualification. Work programs also benefit from the involvement of caregivers. Some caregivers were also involved in GSP as participants. They learned the GSP activities, taught and guided other patients, and supported the trainer. Caregivers also shared and learned from each other's experiences about handling and supporting their wards better.
Social reinforcement techniques and incentives were used to motivate patient participation in GSP. Argentzell et al. have pointed out that getting praise from others was seen as attaining social approval and confirmation, which was considered necessary by patients attending daycare work programs. The use of incentives has been documented for reinforcing patients' participation in work programs at Indian psychiatric rehabilitation centers.
The study's strengths were simultaneous data collection, transcription and analysis, and the use of analyst triangulation to review the findings of stakeholder interviews. Engaging multiple stakeholders enhanced the understanding of utility and acceptance of the selected work program. A significant limitation was stakeholders' awareness of the researcher being an MHP associated with the GSP, which might have led to socially desirable answers. Patients were not expressive enough during the interview and gave limited information. A lot of the information was provided by the caregivers.
| Conclusions|| |
Daycare work programs are advantageous for patients in multiple ways. The selected daycare work program was judged beneficial by the stakeholders for day-structuring, gainful engagement, facilitating behavioral and work-related improvements, improving social skills, and enabling socialization. Social reinforcers and incentives were appraised as motivating and rewarding. Both participation and reinforcements boosted their “self-esteem” and “self-confidence” and contributed to patients' happiness. Not all improvements can be quantified or causally associated with the program alone; additionally, individual improvements happen over variable periods determined by individual and contextual factors. Future studies need to quantify the therapeutic elements of the daycare work program.
The study findings will help improve the existing services and plan work programs accordingly in other psychiatric rehabilitation settings. Daycare work programs can be designed to entail a range of simple to complex activities to cater to patients with varying functionality levels. Getting a trainer having the core qualities and bringing caregivers on board are essential prerequisites. A nonjudgemental working environment and the use of reinforcements can maximize work outcomes. In the context of COVID-19, the feasibility of translating a daycare work program into self-employment or home-based employment opportunities need to be explored.
We thank all the stakeholders and Craftizen foundation for their contribution to run the daycare work program and agreeing to be part of this research.
Financial support and sponsorship
This study was financially supported by Indian Council of Medical Research.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Anthony W, Cohen M, Farkas M, Gagne C. Psychiatric Rehabilitation. 2nd
ed. Boston: Center for Psychiatric Rehabilitation, Boston University; 2002.
Agarwal AK, Rai S, Upreti MC, Srivastava AK, Sheeba. Day care as an innovative approach in psychiatry: Analysis of Lucknow experience. Indian J Psychiatry 2015;57:162-4.
] [Full text]
Sahu KK, Niveditha S, Dharitri R, Kalyanasundaram S. A decade and half of day care service for persons with psychiatric disabilities: The RFS (I) experience. Int J Psychosoc Rehabil 2013;18:37-47.
Tjörnstrand C, Bejerholm U, Eklund M. Participation in day centres for people with psychiatric disabilities: Characteristics of occupations. Scand J Occup Ther 2011;18:243-53.
Roy A, Jayarajan D, Sivakumar T. Income generation programs for persons with mental health challenges: Practices from 13 Indian mental health rehabilitation centers. Indian J Psychol Med 2020;42:1-7.
Suresh Kumar PN. Impact of vocational rehabilitation on social functioning, cognitive functioning, and psychopathology in patients with chronic schizophrenia. Indian J Psychiatry 2008;50:257-61.
] [Full text]
Liberman R. Recovery from disability: Manual of Psychiatric Rehabilitation. Washington: American Psychiatric Publishing; 2008.
Provencher HL, Gregg R, Mead S, Mueser KT. The role of work in the recovery of persons with psychiatric disabilities. Psychiatr Rehabil J 2002;26:132-44.
Dunn EC, Wewiorski NJ, Rogers ES. The meaning and importance of employment to people in recovery from serious mental illness: Results of a qualitative study. Psychiatr Rehabil J 2008;32:59-62.
Marwaha S, Johnson S. Views and experiences of employment among people with psychosis: A qualitative descriptive study. Int J Soc Psychiatry 2005;51:302-16.
Samuel R, Abirame S, Jacob KS. A qualitative study exploring the lived experience of unemployment among people with severe mental illness. Indian J Psychol Med 2020;42:435-44.
Roy A, Sivakumar T, Jayarajan D, Maithreyi NB, Balasubramanian M, Kalyanasundaram S, et al
. Eco-friendly holi colors: Hospital based 'income generation activity' for persons with mental health challenges at a quaternary mental health care facility in India. J Psychosoc Rehabil Mental Health 2019;6:217-25.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77-101.
Corbiere M, Lecomte T. Vocational services offered to people with severe mental illness. J Mental Health 2009;18:38-50.
Argentzell E, Leufstadius C, Eklund M. Factors influencing subjective perceptions of everyday occupations: Comparing day centre attendees with non-attendees. Scand J Occup Ther 2012;19:68-77.
Leufstadius C, Erlandsson LK, Björkman T, Eklund M. Meaningfulness in daily occupations among individuals with persistent mental illness. J Occup Sci 2008;15:27-35.
Ayalew M, Workicho A, Tesfaye E, Hailesilasie H, Abera M. Burden among caregivers of people with mental illness at Jimma University Medical Center, Southwest Ethiopia: A cross-sectional study. Ann Gen Psychiatry 2019;18:10.
Salazar-Torres LJ, Castro-Alzate ES, Dávila-Vásquez PX. Caregiver burden in families of people with mental illness linked to the day hospital program of a tertiary institution in the city of Cali (Colombia). Rev Colomb Psiquiatr (Engl Ed) 2019;48:88-95.
Blank AA, Harries P, Reynolds F. 'Without occupation you don't exist': Occupational engagement and mental illness. J Occup Sci 2015;22:197-209.
Tjörnstrand C, Bejerholm U, Eklund M. Participation in day centres for people with psychiatric disabilities – A focus on occupational engagement. Br J Occup Ther 2013;76:144-50.
Roy A, Jayarajan D, Sivakumar T. Incentives for Involvement in Income Generation Programs: Pragmatic Mechanisms Used by Indian Mental Health Rehabilitation Centers. Indian Journal of Psychological Medicine. 2021. https://doi.org/10.1177/0253717621997181
This paper has won the JK Trivedi Award at the XXVIII National Conference of Indian Association for Social Psychiatry, Imphal, 26-28 November 2021.