Skip to main content
NCBI home page
Wiley Open Access Collection logoLink to Wiley Open Access Collection
. 2024 Jul 29;32(1):102–111. doi: 10.1111/jpm.13090

Factors that influence hospitalization stress in patients with chronic schizophrenia: A cross‐sectional study in psychiatric hospitals

Sumin Chai 1, Goun Kim 2,✉
PMCID: PMC11704990  PMID: 39075883

Accessible Summary

What Is Known on the Subject?

  • Patients with chronic schizophrenia become vulnerable to stress when admitted to psychiatric wards, lacking the abilities to independently cope with stress. Therefore, it is crucial to focus on the stress associated with hospitalization.

  • Stress increases when interpersonal functioning is impaired due to schizophrenia symptoms. Social support acts as a protective factor against stress, boosting coping skills and problem‐solving abilities.

What the Paper Adds to Existing Knowledge

  • Interpersonal relationships, marital status, having cohabited before hospitalization and hospitalization type were associated with hospitalization stress in patients with chronic schizophrenia.

  • Patients with chronic schizophrenia continue aging (mean 55.73 ± 11.14) within closed psychiatric hospitals due to their long‐term hospitalizations (mean 14.24 ± 11.37).

What Are the Implications for Practice?

  • Mental health nurses need to use a standardized nursing assessment including interpersonal relationships, family support system and hospitalization type that may affect hospitalization stress in patients with chronic schizophrenia.

  • Mental health nurses should develop tailored interventions to reduce hospitalization stress for long‐stay patients with chronic schizophrenia that consider aging, illness duration, and length of hospital stay, as well as psychiatric symptoms.

  • Mental health nurses need to make efforts to help the families of patients with schizophrenia solidify an important support system by participating in treatment plans and intervention programs, checking on the patients' condition, and spending time with them.

Abstract

Introduction

Patients with chronic schizophrenia in psychiatric hospitals often experience increased stress due to living in closed spaces and frequently lack the coping skills necessary for independent stress management.

Aim

To explore interpersonal relationships, social support and hospitalization stress, and identify the factors associated with hospitalization stress in patients with chronic schizophrenia in psychiatric hospitals.

Method

This cross‐sectional study included 135 patients who had been diagnosed with schizophrenia for over 2 years, recruited from two psychiatric hospitals in City B, South Korea through convenience sampling. We conducted descriptive statistics and quantile regression.

Results

Interpersonal relationships, marital status, cohabiting before hospitalization, and voluntary admission were significant factors influencing the hospitalization stress at the 90th percentile.

Discussion

Standardized nursing assessment, active family support, and tailored stress management programs including interpersonal relationships are needed to reduce hospitalization stress in patients with chronic schizophrenia.

Implications for Practice

To identify the 90th percentile group for hospitalization stress among patients with chronic schizophrenia, it is essential to consider interpersonal relationships, marital status, pre‐hospitalization cohabitation, type of hospitalization, as well as aging and prolonged hospitalization. Mental health nurses should develop and implement family therapy‐based interpersonal relationship programs to reduce hospitalization stress in patients with chronic schizophrenia and actively involve families in the process.

Keywords: interpersonal relationship, schizophrenia, social support, stress

1. INTRODUCTION

Schizophrenia is a severe and prevalent chronic mental disorder that impacts approximately 1% of the global population, regardless of region or gender (Jongsma et al., 2018; Min, 2023). The lifetime and 1‐year prevalence of schizophrenia in 2016 in South Korea have been reported as 0.5% and 0.2%, respectively (National Center for Mental Health, 2021). The number of schizophrenia treatment recipients per 100,000 people in South Korea has increased from 504.0 in 2018 to 505.6 in 2021, indicating a rising trend (National Center for Mental Health, 2018, 2021). Additionally, 44.6% of all psychiatric hospital inpatients are diagnosed with schizophrenia and remain hospitalized (National Center for Mental Health, 2018).

Patients with chronic schizophrenia find it difficult to adapt to the common living rules and restrictions on free activities in closed psychiatric wards, and they may lose hope owing to negative thoughts about their situation (Kim et al., 2017). Hospitalization in closed psychiatric wards exposes patients to a restrictive treatment environment, increases fear about their illness and causes stress due to separation from their families (Park & Park, 2018; Park & Sung, 2014). In particular, negative hospitalization experiences can lead to negative perceptions of treatment (Mielau et al., 2018), feelings of human rights violations (Danzer & Wilkus‐Stone, 2015) and experiences of coercion and humiliation (Brophy et al., 2016), which can affect their hospitalization stress. Considering the insufficient ability of patients with chronic schizophrenia to independently cope with overwhelming stress, their hospitalization stress warrants attention (Min, 2023).

Patients with chronic schizophrenia can receive help to flexibly cope with stress through interpersonal relationships (Jung et al., 2018). However, schizophrenia often recurs and shows a long‐term course even with appropriate treatment, leading to a decline in physical and social functioning. The impairment in interpersonal relationship skills, such as empathy and communication, hinders treatment and rehabilitation at home, and in society (Corbera et al., 2013; Green et al., 2015). Patients with this condition live in restrictive environments due to repeated hospitalizations and isolation from the community, making it challenging to form relationships outside of their family or healthcare providers (Corbera et al., 2013). Additionally, unlike positive symptoms that respond well to medication, negative symptoms such as inappropriate emotional expression and emotional blunting lead patients with chronic schizophrenia to avoid expressing emotions and causing social isolation (Min, 2023). Therefore, it is crucial to assess the interpersonal relationship abilities of patients with chronic schizophrenia admitted to closed psychiatric wards and determine their relationship with hospitalization stress.

Social support helps patients with chronic schizophrenia improve problem‐solving skills, overcome frustration and adversity, and engage in proactive health behaviours (Lee et al., 2018; Lee & Kim, 2019). Furthermore, social support is crucial because it helps reduce and manage stress through various forms, such as emotional support and advice (Acoba, 2024; Choo et al., 2017). Patients with chronic schizophrenia need psychological and social support to improve symptoms and functions due to difficulties in interpersonal relationships (Corbera et al., 2013; Jeon & Jeong, 2015; Robustelli et al., 2017). However, due to prolonged illness and hospitalization, these patients often maintain low levels of social support because of reduced support from family and the community (Cheng et al., 2022; Choo et al., 2017). Patients with chronic schizophrenia admitted to a closed psychiatric wards are likely to experience social exclusion and find it challenging to form social relationships. Therefore, it is necessary to assess the degree of social support for these patients and confirm its relationship with hospitalization stress.

Previous studies have demonstrated that increased stress in patients with chronic schizophrenia is linked to higher levels of depression, anxiety (Karademas et al., 2009; Park & Sung, 2014) and suicidal ideation (Han et al., 2013). Elevated stress in these patients adversely affects their coping strategies (Park & Sung, 2016), treatment adherence (Jaeger et al., 2013), and neurocognitive function (Krkovic et al., 2017). In addition, marital status and family conflicts (Jung, 2000), as well as age (Lee & Ha, 2018), gender (Kim & Im, 2017), and the number and duration of hospitalizations (Kim et al., 2019) have been found to be associated with hospitalization stress in patients with chronic schizophrenia. However, studies on interpersonal relationships and social support are lacking.

1.1. Aim

The aim of this study was to: (1) measure interpersonal relationships, social support and hospitalization stress in patients with chronic schizophrenia in psychiatric hospitals and (2) identify the factors related to hospitalization stress among them.

2. METHODS

2.1. Design

This study was performed using a cross‐sectional design. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement was used for reporting this study (Von Elm et al., 2007).

2.2. Setting and participants

The study setting was closed psychiatric wards in two long‐term psychiatric hospitals in City B, South Korea. Participants were patients diagnosed with schizophrenia by a psychiatrist according to the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (American Psychiatric Association, 2013). We used convenience sampling, also called the non‐probability sampling method, taking into account geographic proximity, availability at a specific times or willingness to participate in the study (Simkus, 2022).

All participants met the following inclusion criteria: (1) diagnosed with schizophrenia for over 2 years, (2) adults aged 19 years and above, (3) no history of organic mental disorders, substance or alcohol dependence, intellectual disabilities, or dual diagnoses other than schizophrenia, (4) able to understand the study purpose and answer the survey questions and (5) able to participate voluntarily. The exclusion criteria were (1) severe psychiatric symptoms such as hallucinations or delusions, (2) self‐harm or harm to others as determined by medical staff and (3) significant communication difficulties or challenges in reading and comprehending the survey questionnaire.

The sample size was determined using the G‐Power 3.1.9.7 program (Faul et al., 2009). Based on a medium effect size of .15, a significance level of .05, and a statistical power of 80%, and 14 independent variables in linear multiple regression, the required sample size was 135 (Cohen, 1992). Assuming a dropout rate of approximately 20%, we recruited 169 patients with chronic schizophrenia who were admitted to closed psychiatric wards. A total of 169 questionnaires were distributed and 145 were collected. After excluding 10 incomplete responses, 135 questionnaires were used for the final analysis.

2.3. Data collection and procedure

Data were collected from June 16 to July 10, 2023. Approval was obtained from two psychiatric hospitals to distribute questionnaires to the patients. Participants were fully informed about the research and voluntarily decided to participate. Detailed information about the research purpose, procedures, duration, and precautions was provided to ensure anonymity and confidentiality. The researcher ensured participants' privacy by conducting surveys in a private setting within the hospital.

2.4. Ethical considerations

This study received ethical approval from the Institutional Review Board (IRB No. 2023‐04‐013‐002) of the Inje University. Participants were given sufficient time to understand the research, enabling them to voluntarily decide to participate, and were explicitly informed that they could withdraw from the study at any time without facing any disadvantages. To address potential inquiries or the need for assistance, the researcher's contact information was provided in the questionnaire and consent forms. For participants diagnosed with chronic schizophrenia, who are considered a vulnerable population, written consent was obtained from their families or legal guardians. If written consent was difficult to obtain, online consent was used. Data were stored on a password‐protected computer and securely stored in an encrypted digital format to prevent unauthorized access. Data will be stored for 3 years after publication, after which they will be permanently deleted. Participants received a monetary gift for their cooperation.

2.5. Instruments

The use of all instruments was approved by the authors.

2.5.1. Interpersonal relationships

Interpersonal relationships were measured using the Relationship Change Scale (RCS) developed by Schlein et al. (1971), translated into Korean by Moon (1980) and revised for patients with schizophrenia by Chun (1995). RCS comprises seven subscales: intimacy (three items), communication (four items), understanding (four items), trust (three items), satisfaction (four items), openness (five items) and sensitivity (two items). It consists of 25 items rated on a five‐point scale from 1 (Not at all) to 5 (Very much). Higher scores indicate higher levels of interpersonal functioning. Cronbach's alpha was .86 in the original study (Schlein et al., 1971), and .91 in this study.

2.5.2. Social support

Social support was measured using the Multi‐Dimensional Scale of Perceived Social Support (MSPSS) developed by Zimet et al. (1988) and translated into Korean by Shin and Lee (1999). MSPSS comprises three subscales: family (four items), significant others (four items) and friends (four items). It consists of 12 items rated on a five‐point scale from 1 (Not at all) to 5 (Very much). Higher scores indicate higher levels of social support. Cronbach's alpha was .85 in the original study (Zimet et al., 1988), and .89 in this study.

2.5.3. Hospitalization stress

Hospitalization stress was measured using the Measurement of Stress of Hospitalization in Schizophrenic Patients (Park & Sung, 2014). This tool comprises six subscales: unjust human rights infringement (seven items), infringement of basic needs (three items), alienation from other family members (six items), futureless life (six items), inconvenience of shared living (three items) and infringement of personal preference (three items). In this study, with the author's approval, the phrase ‘compulsory hospitalization’ was modified to ‘involuntary hospitalization’, owing to the abolition of compulsory hospitalization in 2017 (Ministry of Government Legislation, 2023). It consists of 28 items rated on a four‐point scale from 0 (Not feeling at all) to 3 (Feeling severely). Higher scores indicate higher levels of hospitalization stress. Cronbach's alpha was .93 in the original study (Park & Sung, 2014), and .89 in this study.

2.5.4. General and hospitalization‐related characteristics

General characteristic items included age, gender, education, marital status, cohabiting before hospitalization, primary guardian and living expenses management. Hospitalization‐related characteristic items included medical guarantee, first onset, duration of illness, total number of hospitalizations, total length of hospitalization and hospitalization type.

2.6. Data analysis

For the data analyses, we used IBM SPSS (version 27.0; Armonk, NY, USA) and STATA 18.0 (StataCorp, LLC, TX, USA). The statistical significance level for all analyses was set at p < .05. Descriptive statistics were used to summarize the participants' general and hospitalization‐related characteristics. Differences in hospitalization stress based on the general and hospitalization‐related characteristics of the participants were analysed using t‐tests, ANOVA and Scheffe's test. The means and standard deviations were analysed for the participants' interpersonal relationships, social support and level of hospitalization stress.

Factors affecting hospitalization stress were analysed using Quantile Regression (QR). The quantiles, which were 10%, 25%, 50%, 75% and 90%, were based on the distribution of hospitalization stress values. Variables with significant effects were identified in each quantile. QR analysis is a method of estimating the functional relationship between explanatory and dependent variables by calculating the conditional quantile of the dependent variable. Compared to the least‐squares method of multiple linear regression analysis, quantile regression analysis estimates the relationship in all distributions, not just the average value of the dependent variable. This method can overcome the limitations of existing analyses and is also commonly used in health and medical research (Buchinsky, 1998; Kang & Sim, 2018; Koenker, 2005).

3. RESULTS

3.1. General and admission‐related characteristics

Participants had a mean age of 55.73 years (SD = 11.14; range = 26–78 years). Gender distribution revealed 81 males (60.0%) and 54 females (40.0%). Regarding the type of cohabitation before admission, 94 individuals (69.6%) lived with their family, four (3.0%) lived with facility peers and two (1.5%) lived with relatives. The average age at the first onset of the participants was 33.44 years (SD = 12.99; range = 9–68 years). The duration of illness was calculated by subtracting the age at the first onset from the current age, resulting in an average of 22.36 years (SD = 13.68; range = 2–59 years). The average number of admissions to psychiatric hospitals was 4.27 times (SD = 3.33; range = 1–22 times), with a mean duration of psychiatric hospitalizations of 14.24 years (SD = 11.37; range = 1–56 years). Regarding types of psychiatric hospital admissions, 65 individuals (48.1%) were admitted under the obligation of a guardian, and 26 individuals (19.3%) had administrative admissions, totaling 91 individuals (67.4%) for involuntary admissions. Voluntary and consensual admissions accounted for 44 individuals (32.6%).

There was a significant difference in hospitalization stress based on marital status (F = 4.34, p = .015), with married individuals (1.94 ± 0.35) experiencing higher stress than those who were separated, divorced, or widowed (1.41 ± 0.54) (Table 1).

TABLE 1.

Differences in hospitalization stress in patients with chronic schizophrenia (N = 135).

Character Categories n (%) Mean ± SD t/F (p)
Age (years) <40 37 (27.4) 1.50 ± 0.57 0.29 (.748)
40–<60 62 (45.9) 1.56 ± 0.53
≥60 36 (26.7) 1.60 ± 0.45
Gender Male 81 (60.0) 1.54 ± 0.52 −0.36 (.718)
Female 54 (40.0) 1.58 ± 0.52
Education Elementary school 10 (7.4) 1.58 ± 0.51 0.28 (.840)
Middle school 25 (18.5) 1.63 ± 0.56
High school 71 (52.6) 1.52 ± 0.54
College degree 29 (21.5) 1.55 ± 0.44
Marital status Unmarrieda 87 (64.4) 1.57 ± 0.51

4.34 (.015)

(b > c)
Marriedb 10 (7.4) 1.94 ± 0.35
Separated, widowed or divorced c 38 (28.2) 1.41 ± 0.54
Cohabiting before hospitalization Exist 100 (74.1) 1.45 ± 0.66 −1.17 (.249)
None 35 (25.9) 1.59 ± 0.46
Guardian Parents 46 (34.1) 1.55 ± 0.59 1.33 (.257)
Siblings 53 (39.3) 1.61 ± .060
Children 17 (12.6) 1.57 ± 0.46
Spouse 4 (3.0) 1.47 ± 0.70
Others 15 (11.0) 1.42 ± 0.64
Living expenses management Oneself 51 (37.8) 1.57 ± 0.52 1.06 (.388)
Immediate family 34 (25.2) 1.45 ± 0.53
Siblings 42 (31.1) 1.66 ± 0.48
Spouse 3 (2.2) 1.48 ± 0.85
Others 5 (3.7) 1.24 ± 0.51
Medical guarantee National health insurance 30 (22.2) 1.56 ± 0.49 0.42 (.677)
Medical protection 105 (77.8) 1.52 ± 0.62
First onset <20 19 (14.1) 1.53 ± 0.46 0.12 (.888)
20–<40 72 (53.3) 1.57 ± 0.53
≥40 44 (32.6) 1.53 ± 0.53
Duration of illness 2–<5 18 (13.3) 1.67 ± 0.55 2.36 (.075)
5–<10 11 (8.2) 1.23 ± 0.64
10–<25 49 (36.3) 1.50 ± 0.52
≥25 57 (42.2) 1.63 ± 0.46
Total number of hospitalizations 1 24 (17.8%) 1.68 ± 0.38 2.30 (.105)
2–<5 63 (46.6%) 1.45 ± 0.59
≥5 48 (35.6%) 1.62 ± 0.46
Total length of hospitalization <1 9 (6.7%) 1.61 ± 0.59 1.44 (.224)
1–<5 23 (17.0) 1.64 ± 0.54
5–<10 21 (15.6) 1.53 ± 0.48
10–<25 55 (40.7) 1.44 ± 0.48
≥25 27 (20.0) 1.70 ± 0.57
Hospitalization type Voluntary 44 (32.6) 1.54 ± 0.47 −0.23 (.819)
Involuntary 91 (67.4) 1.56 ± 0.54
Open in a new tab

Abbreviation: SD, standard deviation.

3.2. Interpersonal relationships, social support and hospitalization stress

Participants' interpersonal relationships, perceived social support, and hospitalization stress scores are shown in Table 2. Interpersonal relationships received an average score of 3.72 ± 0.65 on a scale of 1 to 5 points. Social support obtained an average score of 3.19 ± 0.88 on a scale of 1 to 5 points. Hospitalization stress received an average score of 1.55 ± 0.52 on a scale of 0 to 3 points (Table 2).

TABLE 2.

Interpersonal relationships, perceived social support, and hospitalization stress in patients with chronic schizophrenia (N = 135).

Variables Subcategories Mean ± SD Range
Interpersonal relationships Total 3.72 ± 0.65 1–5
Intimacy 3.89 ± 0.74 1–5
Communication 3.85 ± 0.86 1–5
Understanding 3.77 ± 0.84 1–5
Trust 3.67 ± 0.93 1–5
Satisfaction 3.63 ± 0.79 1–5
Openness 3.62 ± 0.72 1–
Sensitivity 3.57 ± 1.01 1–5
Perceived social support Total 3.19 ± 0.88 1–5
Family 3.34 ± 1.06 1–5
Significant others 3.17 ± 1.08 1–5
Friends 3.05 ± 1.13 1–5
Hospitalization stress Total 1.55 ± 0.52 0–3
Unjust human rights infringement 1.73 ± 0.75 0–3
Infringement of basic needs 1.61 ± 0.79 0–3
Alienation from other family members 1.58 ± 0.67 0–3
Futureless life 1.50 ± 0.85 0–3
Inconvenience of shared living 1.40 ± 0.77 0–3
Infringement of personal preference 1.31 ± 0.85 0–3
Open in a new tab

Abbreviation: SD, standard deviation.

3.3. Quantile regression analysis of hospitalization stress

Quantile regression analysis was conducted to predict hospitalization stress. At the 90th percentile, interpersonal relationships (β = 0.34, p = .018), separated, widowed and divorced (β = −0.37, p = .032), cohabiting before hospitalization (β = −0.25, p = .048), and voluntary admission (β = −0.28, p = .045) were significant indicators (Table 3).

TABLE 3.

Quantile regression results for factors influencing hospitalization stress in patients with chronic schizophrenia (N = 135).

Variables Category Quantile regression
β (p)
10% 25% 50% 75% 90%
Interpersonal relationships −.11 (.660) .00 (.990) .07 (.599) .19 (.136) .34 (.018)
Perceived social support .09 (.482) .09 (.414) .00 (.965) −.01 (.953) −.06 (.477)
Gender (ref. female) Male −.13 (.516) −.12 (.518) −.16 (.188) −.19 (.125) −.20 (.120)
Marital status (ref. married) Unmarried −.47 (.113) −.45 (.045) −.34 (.070) −.20 (.281) .00 (.983)
Separated, widowed, divorced −.59 (.064) −.70 (.002) −.50 (.011) −.37 (.049) −.37 (.032)
Cohabiting before hospitalization (ref. none) Exist .77 (.005) .28 (.212) .00 (.981) −.22 (.040) −.25 (.048)
Duration of illness (years) .00 (.891) .00 (.700) .01 (.320) .00 (.561) −.01 (.401)
Total number of hospitalizations .00 (.892) −.03 (.199) −.01 (.309) −.02 (.231) −.01 (.440)
Total duration of hospitalization (years) .01 (.552) .00 (.933) .00 (.874) .01 (.166) .01 (.379)
Hospitalization type (ref. involuntary) Voluntary .07 (.725) −.08 (.623) −.13 (.265) −.16 (.183) −.28 (.045)
Open in a new tab

4. DISCUSSION

This study attempted to understand interpersonal relationships, social support and levels of hospitalization stress among patients with chronic schizophrenia, aiming to provide foundational data for reducing hospitalization stress. Herein, we discuss various factors focusing on the key results that influence hospitalization stress in patients with chronic schizophrenia.

The mean hospitalization stress score was 1.55 ± 0.52 on a three‐point scale. This result is similar to previous scores of patients with schizophrenia (1.56 ± 0.56) (Kim & Im, 2017). However, considering the various changes in mental health policy resulting from the abolition of compulsory hospitalization from the law in 2017 (Ministry of Government Legislation, 2023), the absence of differences in the hospitalization stress scores in patients with schizophrenia before and after the enforcement of the law suggests that the amended legislation may not have significantly affected patients with chronic schizophrenia. Particularly, the score of ‘unjust human rights infringement’ among the subscales of hospitalization stress was 1.73 ± 0.75, indicating also the highest score in previous studies (Kim et al., 2019; Kim & Im, 2017). In addition, the participants in this study had an average age of 55.73 ± 11.14 years, with 60.7% having been hospitalized for over 10 years, confirming the ongoing trends of aging and prolonged hospitalization. This implies that individuals with chronic schizophrenia experience considerable stress owing to a lack of autonomy and dignity restrictions resulting from long‐stays in psychiatric hospitals with locked wards (Chung et al., 2009; Jin & Yoo, 2013).

Interpersonal relationships were associated with hospitalization stress in patients with chronic schizophrenia at the 90th percentile. Despite the communication difficulties and limited emotional exchange abilities among patients with chronic schizophrenia (Hyun, 2017), interpersonal relationships are associated with stress (Kim et al., 2011). This suggests that their efforts to maintain positive relationships with fellow patients and healthcare providers during long‐stays in psychiatric hospitals with locked wards influence hospitalization stress. Therefore, it is necessary to provide interventions such as cognitive behavioural therapy (Hyun, 2017; Kim & Cho, 2018; Kim & Na, 2017; Lee et al., 2018) and stress management skill training (Kim et al., 2011) to assist these patients in utilizing their interpersonal skills to reduce hospitalization stress. Additionally, considering psychosocial changes such as aging and prolonged hospitalization, further research is needed to understand how chronically hospitalized patients with schizophrenia perceive, feel and adapt to changes in their interpersonal relationships.

Marital status showed a negative association with hospitalization stress in patients with chronic schizophrenia. In this study, married individuals (mean 4.75 years) had relatively shorter hospitalization periods than the other participants (mean 14.24 ± 11.37 years) which is consistent with the findings of previous study (Cheng et al., 2022). However, the hospitalization stress for married individuals (1.94 ± 0.35) was higher than for individuals who were separated, divorced, or widowed (1.41 ± 0.54). Married individuals with schizophrenia tend to experience higher levels of hospitalization stress due to high apprehension about the confined environment of the psychiatric ward (Park & Sung, 2014) and feelings of guilt toward their spouses and children (Park & Park, 2018). However, marriage can potentially help alleviate symptoms, and improve lifestyles, enhance overall well‐being, and the recovery process for people with schizophrenia (Sarhan et al., 2023). Therefore, it is essential to implement marital enhancement programs that include sexual and communication education to help patients with chronic schizophrenia maintain harmonious relationships in their married lives.

Having cohabited before hospitalization had a negative association with hospitalization stress in patients with chronic schizophrenia at the 90th and 75th percentiles. In this study, approximately 69.6% of participants had lived with their families before hospitalization. Considering that the participants were patients with chronic schizophrenia undergoing long‐term hospitalization, it can be inferred that they may have experienced distress due to the absence of family visits and stress related to family issues (Chung et al., 2009; Park & Sung, 2014). Sharing difficulties with family members through mutual understanding and engaging in activities such as visits and outings to overcome the feeling of abandonment in the hospital, as well as experiencing the love of family (Park & Sung, 2016), are expected to provide relief from tension and a sense of stability (Cheng et al., 2022). This has the potential to mitigate hospitalization stress (Park & Park, 2018; Park & Sung, 2014). Based on this understanding, mental health professionals, including psychiatric nurses, must recognize the stress related to family factors in patients with chronic schizophrenia who have been living in isolation for an extended period. They should offer personalized intervention programs that involve family participation.

Involuntary hospitalization was associated with hospitalization stress in patients with chronic schizophrenia at the 90th percentile. In this study, 67.4% of the participants were involuntary hospitalized. Involuntary hospitalization can lead to coercion, humiliation (Bergk et al., 2010), and human rights violations (Brophy et al., 2016), thereby influencing hospitalization stress. Negative hospitalization experiences can result in a negative perception of the treatment process (Mielau et al., 2018). It is necessary for psychiatric nurses to enhance their sensitivity to human rights issues when caring for patients with chronic schizophrenia. Additionally, it is crucial to recognize that uncontrolled symptoms necessitate protective and managed treatment processes (Katsakou & Priebe, 2007; Stylianidis et al., 2017) while actively involving patients in the decision‐making process to provide opportunities for them to develop their identity (Katsakou & Priebe, 2007).

Social support was not associated with hospitalization stress in patients with chronic schizophrenia in this study. The mean social support score was of 3.19 ± 0.88 on a five‐point scale, which is comparable to previous scores reported for patients with schizophrenia using community mental health services (3.20 ± 0.72) (Seo et al., 2014). However, considering that individuals living with their families may receive various mental health services such as individual case management and rehabilitation programs in the community, it is difficult to categorize the social support score in this study as high. Long‐stays in psychiatric hospitals with locked wards and an aging patient population might have led to a decrease in social support (Cheng et al., 2022; Jeon & Jeong, 2015). Considering that the meaningful connections for patients with chronic schizophrenia in psychiatric hospitals with closed wards are limited to family, peers with the same condition, psychiatric nurses, and mental health professionals (Lee et al., 2018), the role of psychiatric nurses is particularly crucial. Therefore, psychiatric nurses and mental health professionals should facilitate mutual understanding and maintain close relationships between patients, families, and friends.

4.1. Limitations

This study has several limitations. First, the generalizability of the results is limited because the study used convenience sampling of inpatients with chronic schizophrenia from two psychiatric hospitals in City B, South Korea. Additionally, the small number of participants who remained married (10 individuals, 7.4%) may not adequately represent the low marriage retention rates among patients with chronic schizophrenia. Therefore, future research should include comprehensive studies that consider various family structures, age groups, illness duration and length of hospitalization. Second, this study found that social support among participants was not a significant factor influencing inpatient stress. The social support measurement tool used in this study focused on subjective feelings such as ‘someone in my life who cares about my feelings and moods’. Therefore, future research should compare the subjective support experienced by patients with chronic schizophrenia with external support systems, including family relationships and social support structures, to investigate the impact of social support on inpatient stress. Finally, the sub‐factors of inpatient stress related to ‘unjust human rights infringement’, such as ‘feeling secluded or restrained’, ‘being involuntarily hospitalized’ and ‘being unable to be discharged despite continuous review of documents’, may vary depending on individual inpatient experiences, such as hospitalization type and duration. Therefore, future studies should analyse the differences in inpatient stress based on these experiences.

4.2. Conclusions

This study revealed that chronically hospitalized patients with schizophrenia had an average age exceeding 55, had an illness duration of over 20 years, and experienced sustained prolonged hospitalization for over a decade. Considering the evolving psychosocial characteristics, including long‐stay hospitalization and aging, a new perspective is needed to identify high‐risk groups for stress among patients with chronic schizophrenia. Additionally, a comprehensive understanding of the individual characteristics of patients' hospitalization experiences, family support, and degree of interpersonal relationships is imperative to develop personalized and integrated stress intervention programs.

5. RELEVANCE STATEMENT

This study elucidates the association between interpersonal relationships and hospitalization stress in patients with chronic schizophrenia. In Korea, patients with schizophrenia account for the largest proportion of psychiatric patients. The annual prevalence of schizophrenia is about 0.2% and has seen a steady increase. Patients with chronic schizophrenia in this study had a mean disease duration of approximately 22 years, with an average hospitalization period of 14 years. However, there is a lack of hospitalization stress management programs tailored for long‐stay patients with chronic schizophrenia who undergo extended hospital stays. Therefore, there is a critical need for systematic health assessments for these patients and the implementation of stress management programs that include training in interpersonal skills. In addition, it is necessary to promote family support and develop treatment plans and programs that involve families, enabling them to better understand and alleviate the patient's stress.

AUTHOR CONTRIBUTIONS

All listed authors meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors and agree with the manuscript. GUK and SMC were responsible for both the concept and design of this study; SMC performed data acquisition; GUK and SMC were responsible for data analysis and interpretation; SMC wrote the manuscript under the supervision of GUK. All the authors contributed to and approved the final version of the manuscript.

FUNDING INFORMATION

None.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

All procedures involving human participants performed in this study were in accordance with the ethical standards of the institutional and/or national research committee (Inje University, Institutional Review Board No. 2023‐04‐013‐002) and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all the participants.

Chai, S. , & Kim, G. (2025). Factors that influence hospitalization stress in patients with chronic schizophrenia: A cross‐sectional study in psychiatric hospitals. Journal of Psychiatric and Mental Health Nursing, 32, 102–111. 10.1111/jpm.13090

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

REFERENCES

  1. Acoba, E. F. (2024). Social support and mental health: The mediating role of perceived stress. Frontiers in Psychology, 15, 1330720. 10.3389/fpsyg.2024.1330720 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. American Psychiatric Association . (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. 10.1176/appi.books.9780890425596 [DOI] [Google Scholar]
  3. Bergk, J. , Flammer, E. , & Steinert, T. (2010). Coercion experience scale (CES)‐validation of a questionnaire on coercive measures. BMC Psychiatry, 10(1), 1–10. 10.1186/1471-244x-10-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Brophy, L. M. , Roper, C. E. , Hamilton, B. E. , Tellez, J. J. , & McSherry, B. M. (2016). Consumers and their supporters' perspectives on poor practice and the use of seclusion and restraint in mental health settings: Results from Australian focus groups. International Journal of Mental Health Systems, 10(1), 1–10. 10.1186/s13033-016-0038-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Buchinsky, M. (1998). Recent advances in quantile regression models: A practical guideline for empirical research. Journal of Human Resources, 33(1), 88–126. 10.2307/146316 [DOI] [Google Scholar]
  6. Cheng, P. , Wang, L. , Xu, L. , Zhou, Y. , Zhang, L. , & Li, W. (2022). Factors related to the length of stay for patients with schizophrenia: A retrospective study. Frontiers in Psychiatry, 12, 818254. 10.3389/fpsyt.2021.818254 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Choo, C. C. , Chew, P. K. H. , Ho, C. S. , & Ho, R. C. (2017). Prediction of quality of life in Asian patients with schizophrenia: A cross‐sectional pilot study. Frontiers in Psychiatry, 8, 198. 10.3389/fpsyt.2017.00198 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Chun, S. K. (1995). A study on the effectiveness of social skills training program for rehabilitation of the schizophrenic patients (doctoral dissertation). Soongsil University. [Google Scholar]
  9. Chung, I. W. , Hyun, M. H. , Kim, J. Y. , Bae, J. N. , Jang, H. S. , & Na, D. S. (2009). Survey on clients and facilities of mental health institutions. National Human Rights Commission of Korea. [Google Scholar]
  10. Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155–159. 10.1037/0033-2909.112.1.155 [DOI] [PubMed] [Google Scholar]
  11. Corbera, S. , Wexler, B. E. , Ikezawa, S. , & Bell, M. D. (2013). Factor structure of social cognition in schizophrenia: Is empathy preserved? Schizophrenia Research and Treatment, 2013, 409205. 10.1155/2013/409205 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Danzer, G. , & Wilkus‐Stone, A. (2015). The give and take of freedom: The role of involuntary hospitalization and treatment in recovery from mental illness. Bulletin of the Menninger Clinic, 79(3), 255–280. 10.1521/bumc.2015.79.3.255 [DOI] [PubMed] [Google Scholar]
  13. Faul, F. , Erdfelder, E. , Buchner, A. , & Lang, A. G. (2009). Statistical power analyses using G* power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41(4), 1149–1160. 10.3758/BRM.41.4.1149 [DOI] [PubMed] [Google Scholar]
  14. Green, M. F. , Horan, W. P. , & Lee, J. H. (2015). Social cognition in schizophrenia. Nature Reviews. Neuroscience, 16(10), 620–631. 10.1038/nrn4005 [DOI] [PubMed] [Google Scholar]
  15. Han, I. Y. , Lee, E. J. , & Kim, S. Y. (2013). A comparative study of suicide attempters and non‐attempters registered in mental health center. The Korean Academy of Mental Health Social Work, 41(4), 201–226. [Google Scholar]
  16. Hyun, M. Y. (2017). The effects of cognitive behavioral group therapy improving social cognition on the self‐efficacy, relationship function and social skills for chronic schizophrenia. Journal of Korean Academy of Psychiatric and Mental Health Nursing, 26(2), 186–195. 10.12934/jkpmhn.2017.26.2.186 [DOI] [Google Scholar]
  17. Jaeger, S. , Pfiffner, C. , Weiser, P. , Längle, G. , Croissant, D. , Schepp, W. , & Steinert, T. (2013). Long‐term effects of involuntary hospitalization in medication adherence, treatment engagement and perception of coercion. Social Psychiatry and Psychiatric Epidemiology, 48(11), 1787–1796. 10.1007/s00127-013-0687-x [DOI] [PubMed] [Google Scholar]
  18. Jeon, K. S. , & Jeong, H. C. (2015). Effects of social support for chronic mental inpatients on self‐care capacity. Indian Journal of Science and Technology, 8(S1), 302–306. 10.17485/ijst/2015/v8iS1/59281 [DOI] [Google Scholar]
  19. Jin, J. H. , & Yoo, J. H. (2013). Psychiatric patients' experiences of being restrained: A phenomenological study. Journal of Korean Academy of Psychiatric and Mental Health Nursing, 22(4), 349–358. 10.12934/jkpmhn.2013.22.4.349 [DOI] [Google Scholar]
  20. Jongsma, H. E. , Gayer‐Anderson, C. , Lasalvia, A. , Quattrone, D. , Mulè, A. , Szöke, A. , & European Network of National Schizophrenia Networks Studying Gene‐Environment Interactions Work Package 2 (EU‐GEI WP2) Group . (2018). Treated incidence of psychotic disorders in the multinational EU‐GEI study. JAMA Psychiatry, 75(1), 36–46. 10.1001/jamapsychiatry.2017.3554 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Jung, J. E. (2000). The hospital experience of psychiatric patient: A phenomenological approach. Journal of Korean Academy of Psychiatric and Mental Health Nursing, 9(2), 156–169. [Google Scholar]
  22. Jung, J. W. , Jang, M. Y. , & Shin, S. H. (2018). The mediating effect of internalized stigma on the relationship between hospitalization stress and quality of life among patients with mental illness in a closed ward. Journal of East‐West Nursing Research, 24(1), 70–80. 10.14370/jewnr.2018.24.1.70 [DOI] [Google Scholar]
  23. Kang, S. J. , & Sim, K. H. (2018). The effects of risk perception and self‐efficacy on diabetes self‐care activities and hemoglobin A1c: A quantile regression approach. Journal of the Korean Data and Information Science Society, 29(1), 111–123. 10.7465/jkdi.2018.29.1.111 [DOI] [Google Scholar]
  24. Karademas, E. C. , Tsagaraki, A. , & Lambrou, N. (2009). Illness acceptance, hospitalization stress and subjective health in a sample of chronic patients admitted to hospital. Journal of Health Psychology, 14(8), 1243–1250. 10.1177/1359105309345169 [DOI] [PubMed] [Google Scholar]
  25. Katsakou, C. , & Priebe, S. (2007). Patient's experiences of involuntary hospital admission and treatment: A review of qualitative studies. Epidemiologia e Psichiatria Sociale, 16(2), 172–178. 10.1017/s1121189x00004802 [DOI] [PubMed] [Google Scholar]
  26. Kim, B. J. , & Im, S. B. (2017). Schizophrenic patients' perception and nurses' estimation of the stress during hospitalization in psychiatric ward. Korean Journal of Stress Research, 25(3), 201–208. 10.17547/kjsr.2017.25.3.201 [DOI] [Google Scholar]
  27. Kim, B. M. , & Cho, O. K. (2018). The effect of the cognitive‐behavioral program on the schizophrenia's psychosocial function. The Journal of Welfare and Counselling Education, 17(2), 311–330. 10.20497/jwce.2018.7.2.311 [DOI] [Google Scholar]
  28. Kim, E. J. , Gwon, E. S. , Lee, H. S. , Lee, S. Y. , Park, I. H. , Jung, D. N. , & Jeong, Y. H. (2011). Effects of a stress‐management program on stress coping methods, interpersonal relations, and quality of life in patients with chronic mental illness. Journal of Korean Academy of Psychiatric and Mental Health Nursing, 20(4), 423–433. 10.12934/jkpmhn.2011.20.4.423 [DOI] [Google Scholar]
  29. Kim, E. J. , Park, J. H. , & Sung, K. M. (2017). The effectiveness of forest walking program on stress and recovery of schizophrenic patients in a closed ward. Journal of East‐West Nursing Research, 23(1), 86–95. 10.14370/jewnr.2017.23.1.86 [DOI] [Google Scholar]
  30. Kim, J. E. , Chung, M. S. , Kwon, M. S. , Kang, S. , Ko, J. , Kang, H. A. , & Nam, Y. (2019). Effects of the integrated stress management program on stress and depression in psychiatric inpatients. Journal of Korean Academy of Psychiatric and Mental Health Nursing, 28(3), 226–235. 10.12934/jkpmhn.2019.28.3.226 [DOI] [Google Scholar]
  31. Kim, J. H. , & Na, H. J. (2017). Effects of a positive psychotherapy program on positive affect, interpersonal relations, resilience, and mental health recovery in community‐dwelling people with schizophrenia. Journal of Korean Academy of Nursing, 47(5), 638–650. 10.4040/jkan.2017.47.5.638 [DOI] [PubMed] [Google Scholar]
  32. Koenker, R. (2005). Quantile regression. Cambridge University Press. 10.1017/CBO9780511754098 [DOI] [Google Scholar]
  33. Krkovic, K. , Moritz, S. , & Lincoln, T. M. (2017). Neurocognitive deficits or stress overload: Why do individuals with schizophrenia show poor performance in neurocognitive tests? Schizophrenia Research, 183, 151–156. 10.1016/j.schres.2016.11.002 [DOI] [PubMed] [Google Scholar]
  34. Lee, A. N. , Kim, S. W. , & Kang, Y. S. (2018). The effect of mental illness stigma on attitude towards psychiatric medication: The mediating effects of social support and self‐esteem. Korea Association for Rehabilitation Psychology, 25(3), 461–478. [Google Scholar]
  35. Lee, J. W. , & Ha, J. H. (2018). The effects of an acceptance‐commitment therapy based stress management program on hospitalization stress, self‐efficacy and psychological well‐being of inpatients with schizophrenia. Journal of Korean Academy of Nursing, 48(4), 443–453. 10.4040/jkan.2018.48.4.443 [DOI] [PubMed] [Google Scholar]
  36. Lee, J. Y. , & Kim, J. Y. (2019). The effect of symptom, psychological flexibility and social support on the quality of life of inpatients with schizophrenia. The Convergent Research Society among Humanities, Sociology, Science, and Technology, 9(6), 541–552. 10.12934/jkpmhn.2018.27.3.284 [DOI] [Google Scholar]
  37. Mielau, J. , Altunbay, J. , Lehmann, A. , Bermpohl, F. , Heinz, A. , & Montag, C. (2018). The influence of coercive measures on patients' stances towards psychiatric institutions. International Journal of Psychiatry in Clinical Practice, 22(2), 115–122. 10.1080/13651501.2017.1383437 [DOI] [PubMed] [Google Scholar]
  38. Min, S. G. (2023). Modern psychiatry (7th ed.). Il Cho Kak. [Google Scholar]
  39. Ministry of Government Legislation . (2023). Act on the improvement of mental health and the support for welfare services for mental patients. Retrieved from https://www.law.go.kr/LSW/lsInfoP.do?lsiSeq=183629&chrClsCd=010203&urlMode=engLsInfoR&viewCls=engLsInfoR#0000.
  40. Moon, S. M. (1980). A study on the effect of human relations training of university students. Journal of Gyeongsang National University, 19(2), 195–203. [Google Scholar]
  41. National Center for Mental Health . (2018). National mental health statistics 2018. Ministry of Health and Welfare. Retrieved from https://www.ncmh.go.kr/ncmh/board/boardView.do?no=8726&fno=106&gubun_no=6&menu_cd=04_03_00_02&bn=newsView&search_item=&search_content=&pageIndex=1. [Google Scholar]
  42. National Center for Mental Health . (2021). National mental health statistics 2021. Ministry of Health and Welfare. Retrieved from https://www.ncmh.go.kr/ncmh/board/boardView.do?no=9289&fno=37&menu_cd=01_01&bn=newsView&search_item=&search_content=&pageIndex=. [Google Scholar]
  43. Park, S. A. , & Park, K. W. (2018). Integrated study on hospitalization stress experience of schizophrenic patient. Journal of the Korea Convergence Society, 9(4), 397–408. 10.15207/JKCS.2018.9.4.397 [DOI] [Google Scholar]
  44. Park, S. A. , & Sung, K. M. (2014). Development of a measurement of stress for hospitalized schizophrenic patient. Journal of Korean Academy of Nursing, 44(3), 339–349. 10.4040/jkan.2014.44.3.339 [DOI] [PubMed] [Google Scholar]
  45. Park, S. A. , & Sung, K. M. (2016). Effects on stress, problem solving ability and quality of life of as a stress management program for hospitalized schizophrenic patients: Based on the stress, appraisal‐coping model of Lazarus and Folkman. Journal of Korean Academy of Nursing, 46(4), 583–597. 10.4040/jkan.2016.46.4.583 [DOI] [PubMed] [Google Scholar]
  46. Robustelli, B. L. , Newberry, R. E. , Whisman, M. A. , & Mittal, V. A. (2017). Social relationships in young adults at ultra high risk for psychosis. Psychiatry Research, 247, 345–351. 10.1016/j.psychres.2016.12.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Sarhan, A. L. , Obaid, W. , Sabouba, M. , & Mahamid, F. (2023). Marriage experience among patients with schizophrenia: A qualitative narrative study. Journal of Psychosocial Rehabilitation and Mental Health, 10(1), 119–127. 10.1007/s40737-022-00307-2 [DOI] [Google Scholar]
  48. Schlein, A. , Guerney, B. G. , & Stover, L. (1971). Relationship enhancement. Josey‐Bass. [Google Scholar]
  49. Seo, D. D. , Choi, K. S. , Park, W. R. , Lee, M. R. , Kim, D. Y. , & Yu, J. C. (2014). The effects of mental fitness, social support and psychological distress on suicidal idea of people with schizophrenia using community mental health services. Journal of Korean Neuropsychiatric Association, 53(6), 364–369. 10.4306/jknpa.2014.53.6.364 [DOI] [Google Scholar]
  50. Shin, J. S. , & Lee, Y. B. (1999). The effects of social supports on psychosocial well‐being of the unemployed. Korean Journal of Social Welfare, 37, 241–269. [Google Scholar]
  51. Simkus, J. (2022). Convenience sampling: Definition, method and examples. Simply Psychology. [Google Scholar]
  52. Stylianidis, S. , Peppou, L. E. , Drakonakis, N. , Douzenis, A. , Panagou, A. , Tsikou, K. , Pantazi, A. , Rizavas, Y. , & Saraceno, B. (2017). Mental health care in Athens: Are compulsory admissions in Greece a one‐way road? International Journal of Law and Psychiatry, 52, 28–34. 10.1016/j.ijlp.2017.04.001 [DOI] [PubMed] [Google Scholar]
  53. Von Elm, E. , Altman, D. G. , Egger, M. , Pocock, S. J. , Gøtzsche, P. C. , & Vandenbroucke, J. P. (2007). The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Annals of Internal Medicine, 147(8), 573–577. [DOI] [PubMed] [Google Scholar]
  54. Zimet, G. D. , Dahlem, N. W. , Zimet, S. G. , & Farley, G. K. (1988). The multidimensional scale of perceived social support. Journal of Personality Assessment, 52(1), 30–41. 10.1207/s15327752jpa5201_2 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Articles from Journal of Psychiatric and Mental Health Nursing are provided here courtesy of Wiley

RESOURCES