PERFOMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

SUBMITTED BY :
MS.SREEJA.P.A 1ST YEAR M.Sc (Nursing) MENTAL HEALTH NURSING, 2011-2013 BATCH, ORIENTAL COLLEGE OF NURSING BANGALORE-560044

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA,BANGALORE, PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.

NAME OF THE CANDIDATE AND ADRESS

MS.SREEJA.P.A SREEBHAVAN, ELAKOLLOOR.P.O, KONNI PATHANAMTHITTA- 689703, KERALA

Oriental college of nursing, Bangalore 560044.

2.

NAME OF THE INSTITUTION

3.

COURSE OF STUDY AND SUBJECT

1ST Year M.Sc Nursing, Mental Health Nursing 15-10-2011 A quasi- experimental study to assess the effectiveness of token economy program on behaviour modification among institutionalized mentally ill patients in selected mental hospitals in Bangalore

4. 5.

DATE OF ADMISSION OF THE COURSE TITLE OF THE TOPIC

6.

BRIEF RESUME OF THE WORK 6.0 INTRODUCTION 6.1 NEED FOR THE STUDY 6.1.1 STATEMENT OF TH STUDY 6.2 REVIEW OF LITERATURE 6.3 OBJECTIVES OF THE STUDY 6.3.1 OPERATIONAL DEFENITIONS 6.3.2 ASSUMPTION 6.3.3 HYPOTHESIS 6.3.4 SAMPLING CRITERIA MATERIALS AND METHODS 7.1 SOURCES OF DATA 7.2 METHOD OF DATA COLLECTION 7.3 Does the study require any investigations of interventions to be conducted on the patients or other human being or animals? 7.4 Has ethical clearance been obtained from your institution?

Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed

7.

Data will be collected from mentally ill patients in selected hospital in Bangalore Evaluative Approach

Yes Yes. Ethical committees report is here with enclosed

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BENGALURU, KARNATAKA PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

NAME OF THE CANDIDATE AND ADDRESS

Miss. SREEJA P A SREE BHAVAN, ELAKOLLOOR P O, KONNI, PATHANAMTHITTA (Dist.), KERALA- 689703

NAME OF THE INSTITUTION

ORIENTAL COLLEGE OF NURSING BANGALORE- 560-010

COURSE OF THE STUDY AND FIRST YEAR M.Sc NURSING SUBJECT MENTAL HEALTH NURSING

DATE OF ADMISSION

15 -10-2011

TITLE OF THE STUDY: A QUASI-EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OF TOKEN ECONOMY PROGRAM ON BEHAVIORAL MODIFICATION AMONG INSTITUTIONALISED MENTALLY ILL PATIENTS IN SELECTED MENTAL HOSPITALS IN BANGALORE.

6. BRIEF RESUME OF THE INTENDED WORK

6.0. INTRODUCTION :
People's behaviour makes sense if you think about it in terms of their goals, needs, and motives.
-- Thomas Mann

Human mind can be defined as a fantabulous device which is natural but rather very complicated. It is an abstruct, abstruse, and an imaginative device which determines the character and thereby the behaviour of a person. As a coin own two faces, humans also have two attitudes in behaviour. They may be positive or negative. Situations and environment plays a vital role in developing either positive or negative behaviour in a person. The positive behaviour of a person can be modified by some reinforcement techniques such as appreciation, giving gifts in the form of tokens etc. Based on this concept researcher have adopted the token economy program.

Anything that is visible and countable can be used as a token. Tokens should preferably be attractive, easy to carry and dispense, and difficult to counterfeit. Commonly used items include poker chips, stickers, point tallies, or play money. When an individual displays desirable behaviour, he or she is immediately given a designated number of tokens. Tokens have no value of their own. They are collected and later exchanged for meaningful objects, privileges or activities. Individuals can also lose tokens (response cost) for displaying undesirable behaviour. Individuals participating in a token economy need to know exactly what they must do in order to

receive tokens. Desirable and undesirable behaviour is explained ahead of time in simple, specific terms.

A token economy is a behavioural therapy technique in which the desired change is achieved by means of tokens administered for the performance of predefined behaviours according to a program. Though token economy programmes were widespread in the 1970s they became largely restricted to wards where long-stay patients from institutions are prepared for transfer into the community and were particularly aimed at changing negative symptoms of schizophrenia - poor motivation, poor attention and social withdrawal.

The token economy is a treatment intervention based on principles of operant conditioning and social learning. Developed in the 1950s and 1960s for long-stay hospital patients, the token economy has fallen out of favour since that time.

"In the token economy, the full range of self-care, social, and work behaviours could be modified by systematic and pre-planned use of antecedents (e.g., prompts) and consequences (e.g., reinforces) of these behaviours. The 'psychopathological' behaviour of the mentally ill was conceptualized as being subject to the same 'laws of learning' that influenced normal behaviour. Tokens could be conveniently dispensed to patients contingent on their exhibiting improvements in their behaviour. The tokens were then subsequently exchanged for a panoply of rewards."

Primary reinforcers are the meaningful objects, privileges, or activities that individuals receive in exchange for their tokens. Examples include food items, toys, extra free time, or

outings. The success of a token economy depends on the appeal of the primary reinforcers. Initially tokens are awarded frequently and in higher amounts, but as individuals learn the desirable behaviour, opportunities to earn tokens decrease.

Ideally, individuals will use the skills learned in a token economy in their everyday surroundings. They will display the undesirable behaviour less frequently or not at all. They will also engage in positive, adaptive behaviours more often. If the token economy was ineffective or time spent in the token economy was limited, individuals may show no changes or actual increases in the undesirable behaviour.

Risks involved in token economies are similar to those in other forms of Behaviour Modification. Staff members implementing the therapy may intentionally or unintentionally neglect the rights of individuals receiving treatment. Token Economies should never deprive individuals of their basic needs, such as sufficient food, comfortable bedding, or reasonable opportunities for leisure. If staff members are inadequately trained or there is a shortage of staff, desirable behaviours may not be rewarded or undesirable behaviours may be inadvertently rewarded, resulting in an increase of undesirable behaviour

6.1. NEED FOR THE STUDY:

A token economy is a form of behaviour modification designed to increase desirable behaviour and decrease undesirable behaviour with the use of tokens. Individuals receive tokens immediately after displaying desirable behaviour. The tokens are collected and later exchanged

for a meaningful object or privilege. The primary goal of a token economy is to increase desirable behaviour and decrease undesirable behaviour. Often token economies are used in institutional settings (such as psychiatric hospitals or correctional facilities) to manage the behaviour of individuals who may be aggressive or unpredictable. However, the larger goal of token economies is to teach appropriate behaviour and social skills that can be used in one's natural environment. Special education (for children with developmental or learning disabilities, hyperactivity, attention deficit, or behavioural disorders), regular education, colleges, various types of group homes , military divisions, nursing homes, addiction treatment programs, occupational settings, family homes (for marital or parenting difficulties), and hospitals may also use token economies. Token economies can be used individually or in groups.

A token economy system is an approach in which students are given a mark for reward redeemable at a later time (Lovitt, 1978). Target behaviours to be used in the token economy (Mueller, Sterling-Turner, & Scattone, 2001). Token economy systems can at times be time consuming and costly (Lovitt, 1978). A separate aspect of a token economy system is response cost. Taking away token or points for disobeying rules is an example of response cost (Lovitt, 1978).

From 1960 to 1970, the token economy has been extended widely across populations and behaviours in treatment, rehabilitation, educational, and community settings. The current review was undertaken as a part of the 2003 update of the schizophrenia treatment recommendation of Patient Outcome Research Team (PORT). A total of uncontrolled studies of the token economy were reviewed. These studies provide evidence of the token economy programs effectiveness in

increasing the desirable or adaptive behaviours of patients with mental illness. The token economy has been shown to reduce violence in various treatment situations, such as for patients in alcohol treatment, chronic psychiatric patients, and those with severe head injuries.

The researcher observed that although there are studies on the effects of a token economy program, there are seem to indicate with a need for an extended study. The recent research lacks the needed intervention time for reliable results. The effects of this research will extend the intervention phase to attain more reliable results. Hence the researcher selected to research on A quasi- experimental study to assess the effectiveness of token economy program on behaviour modification among institutionalized mentally ill patients in selected mental hospitals in Bangalore

6.1.1. STATEMENT OF THE PROBLEM

A quasi- experimental study to assess the effectiveness of token economy program on behaviour modification among institutionalized mentally ill patients in selected mental hospitals in Bangalore

6.2 REVIEW OF LITERATURE:

The review of literature is defined as a broad, comprehensive, in depth, systematic and critical review of scholarly publications, unpublished scholarly print materials, audio visual

materials and personal communications. It aids in the identification of relevant theoretical or conceptual frame work for a research problem, identification of suitable designs and data collection methods for the study 3.

A study conducted in India assessed the effectiveness of token economy in bringing up adaptive behaviour of schizophrenic patient admitted in Vidyasagar hospital, Amritsar. The observation method used to assess 50 schizophrenic patients randomly selected for this study. The researcher followed the patients for three months and assessed behaviour including maintenance of personal hygiene, grooming etc. The result indicates a wide range improvement in patients adaptive behaviour, and they suggest the implementation of token economy in improving the adaptive behaviour of psychiatric ill patients 4.

A study conducted in Iran investigated effect of social and token economy reinforcements on academic achievement of 9th grade boy students with intellectual disabilities in an experimental science class in Tehran Province. The method used for this study was experimental by pre-test, post- test with a control group. The boy students with intellectual disabilities from three junior high schools participated in this study. The sample consisted of thirty, 9th grade boy students with intellectual disabilities in the selected schools. The results showed that there was a significant increase in academic achievement of students with intellectual disabilities when using token economy than using social reinforcements compared with the control group. Also, when using social reinforcements, the academic achievement of students was more than the control group 5 .

A study conducted in US to investigate the effects of a token economy system in comparison to social praise on the manifest behaviors of learning disabled students at an elementary school in West Virginia. Ten learning disabled students from an elementary school tested using the Conners Teacher Rating Scale-Revised to obtain the manifest behaviors of the Control and Experimental Groups. The results of this study found that there was no significant difference between a token economy system in comparison to social praise on the manifest behaviors of elementary learning disabled students. This may have been caused by the similarities of the learning disabled students. Furthermore, these findings do not support the related literature which stated there was a positive relationship between a token economy system and manifest behaviors of learning 6 .

A study on mentally retarded African American students was conducted on four boys and three girls. The students received cents contingent upon a correct response. Cents were then used to buy backup reinforcers such as sweets or access to a video or listening to music. The token economy was established in order to increase appropriate responses, and decrease verbal outbursts. The results of the study indicated a positive outcome with the use of a token economy as well as self-monitoring techniques to be useful with mild mentally retarded students 7.

A study was conducted in Ireland to review the effects of token economies for people with schizophrenia, or other serious or chronic mental illnesses, compared with standard care. Randomized studies comparing a token economy regime to standard care for those with schizophrenia or any other similar chronic or serious mental illness were used for the study. Studies were reliably selected, quality rated and data extracted. For dichotomous data relative 10

risk with 95% confidence intervals was estimated. Where possible, the number needed to treat statistic was also calculated. Results indicate that the token economy approach may have effects on negative symptoms but it is unclear if these results are reproducible, clinically meaningful and are maintained beyond the treatment program. Token economy remains worthy of careful evaluation in well designed conducted and reported randomized trials 8.

A review was undertaken as part of the 2003 update of the schizophrenia treatment recommendations of the Patient Outcomes Research Team (PORT). A total of 13 controlled studies of the token economy were reviewed. As a group, the studies provide evidence of the token economy's effectiveness in increasing the adaptive behaviors of patients with schizophrenia. Most of the studies are limited, however, by methodological shortcomings and by the historical context in which they were performed. More research is needed to determine the specific benefits of the token economy when administered in combination with contemporary psychosocial and psychopharmacological treatments 9.

A study was conducted reviewed outcome studies of token economy programs for psychiatric inpatients. Only studies that employed some control procedures in their evaluation were included. Token economies were most effective in modifying in hospital work, personal care, and some psychotic behaviour. Studies that assessed token programs to prepare patients for community living and reduce recidivism generally affirmed the effectiveness

of token procedures, but the studies were poorly designed, and they lacked systematic follow-up data. Almost all studies failed to examine possible interactions between chemotherapy and

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the token economies. The author suggests the need for studies using token economies with psychiatric patients other than chronic schizophrenics, who have been studied almost exclusively to date 10.

two-part

systematic

review

was

undertaken

to

assess

the

effectiveness

of token economies in increasing rates of appropriate classroom behaviour for students demonstrating behavioural difficulties. The first part of the review utilized the recently published What Works Clearinghouse (WWC) standards for evaluating single-subject research to determine the extent to which eligible studies demonstrated sufficient evidence to classify the token economy as an evidence-based practice. The second part of the review employed metaanalytic techniques across four different types of effect sizes to evaluate the quantitative strength of the findings. Methodological strengths and weaknesses across the studies were systematically investigated. Results indicated that the extant research on token economies does not provide sufficient evidence to be deemed best-practice based on the WWC criteria.11

A study was conducted in the US reveals that the token economy is among the most wellvalidated and effective behavioral treatments for schizophrenia and other serious psychiatric disorders, its use in clinical and research settings has declined from a peak in the early 1970s. Reasons for this decrease in use include staff resistance, reduced length of inpatient admissions, greater emphasis on community based treatments, economic constraints, and legal and ethical challenges. Nevertheless, a small but enthusiastic group of proponents still conducts token economy research and treatment. Important topics pertaining to the token economy remain to be addressed, including specifying its remediative components, developing strategies to promote 12

generalization and maintenance of treatment gains, and creating better methods to identify patients who would most benefit from participating in these programs.12

6.3

THE OBJECTIVE OF THE STUDY

To assess the pre-intervention level of behaviour modification of mentally ill patients.

To design and develop a token economy program for mentally ill patients. To assess the post-intervention level of behaviour modification of mentally ill patients.

To determine the effectiveness of token economy on behaviour modification of mentally ill patients

To find out the association between the pre test and post test level of behaviour modification of mentally ill patients.

To determine the association between the selected demographic variables such as age, sex, education, period of stay in the hospital, use of other behavior techniques, etc. and behaviour modification of mentally ill patients.

6.3.1. OPERATIONAL DEFINITIONS:

1.

Assess: - It refers to the process used to estimate the behaviour modification of mentally ill patients with the help of an observation check list.

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2.

Effectiveness: - refers to the improvement in patient behaviour as determined by significant difference between pre and post test level of behaviour.

Token economy program: - A token economy is a behavioural therapy technique in which the desired change is achieved by means of tokens administered for the positive performance of predefined behaviours according to a program.

Behaviour modification: - An observable change in the behaviour of a patient which the society accepted as a desirable behaviour.

Mentally ill patients: - individual with a common debilitating mental weakness, and is associated with the psychiatric signs and symptoms which will be diagnosed by the professional qualified person

6. 3.2 ASSUMPTIONS:
1. 2. 3. Mentally ill patients may have some behavioural difficulties. Mentally ill patients may need some behaviour modification. Token economy is an ideal behaviour modification technique

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6 .3.3 HYPOTHESIS

H1. There will be significant improvement between pre and post test level of behaviour modification of mentally ill patients.

H2. There will be significant association between pre test levels of behaviour modification of mentally ill patients with their selected demographic variables

6. 3.4 SAMPLING CRITERIA:

INCLUSION CRITERIA:

1. 2. 3.

The mentally ill patients who are willing to participate in the study. Mentally ill patients who are available during the study period. In-patients who are admitted for a period of six week.

EXCLUSION CRITERIA:

1. Mentally ill patients who have already benefited by token economy. 2. Chronically ill patients with poor prognosis

6. 3.5 LIMITATION
The study is limited to Mentally ill patients who are admitted in a selected mental hospital in Bangalore. 6 week period of data collection

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7. MATERIALS AND METHODS:

Data will be collected from mentally ill patients who admitted in a selected mental hospital in Bangalore.

7.2 METHOD OF DATA COLLECTION

For the present study the data will be collected by using a structured observation check list. The tool for the present study will be developed by the investigator based on the objectives, review of literature and the suggestion of the experts regarding token economy and behaviour modification.
Research Approach

: Evaluative approach

Research Design

: Quasi experimental design

Research Setting

: Selected mental hospital in Bangalore

Population

: All mentally ill patients in selected hospital

Sample size

: 40

Sampling technique

: Simple Random Technique

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 Method of data collection

Phase 1: conducting pre-test to assess the behaviour modification of mentally ill patients with the help of an observation check list.

Phase 2: administering token economy program on behavior modification to the selected mentally ill patients.

Phase 3: Conducting post-test to assess the behaviour modification of mentally ill patients with the help of an observation check list

Tool for data collection

: Observation check list

Method of data analysis

The data will be analyzed by using descriptive and inferential statistics

DESCRIPTIVE STATSTICS: Descriptive statistics such as mean, median, percentage distribution, frequency, paired t-test, correlation and standard deviation will be used for assessing demographic data. INFERENTIAL STATISTICS:

Chi- square test will be used to determine the association between the selected demographic variables and the pre test score.

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 Duration of study Research variables Dependent Variables patients.

6 weeks

: Behavior modification of the mentally ill

Independent Variables : Is the token economy.

Demographic Variables

: Age, Sex, Education, Occupation, Type of Family, Period of stay in hospital, Use of other behavior therapies, Previous Knowledge about token economy program

Projected Outcomes

: This study will enable mentally ill patients to improve their behavior as a desirable one which is accepted by the society

7.3.

Does the study require any investigation or any intervention on patient or human/animals?

Yes. Token economy program

7.4.

Has the ethical clearance been obtained from your institution?

Yes. Administrative permission and ethical clearance to the study will be obtained from the research committee of Oriental college of Nursing, Bangalore, prior to conducting the study.

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8. LISTS OF REFERENCES:

1. Brunner and Suddharth, Text book of Medical Surgical Nursing, 10th edition, Elsevier Publications 2007.p525-9 2. Joyce m Black, medical surgical nursing 8th edition, Elsevier India 2006 p820-7 3. Walid and leech NL. Writing narrative literature reviews. 5(3)2005p101-114 4. Amith Chopra. : Effects of token economy in Schizophrenic patient in the Journ Psychol June 2010..(52)24: 124-128. 5. Seyed-Mahmood Mirzamani, Mohammad Ashoori, Narges Adib Sereshki. Iranian Journal of Psychiatry > Vol 6, No 1 (2011) > Mirzamani 6. Kimberly Waggy The effectsof a token economysystem in comparison to social praise. The American journal June 2002- (1-28). 7. Akande A.; The role of reinforcement in self-monitoring; Education; 1997; 118, 275- 82. 8. . Faith B. Dickerson,Wendy N. Tenhula,Lisa D. Green-Paden; The token economy for schizophrenia: review of the literature and recommendations for future research; Schizophrenia Research,Volume 75, Issue 2 , Pages 405-416, 15 June 2005 9. Milby JB; A review of token economy treatment programs for psychiatric inpatients;Hosp 10. Community Psychiatry. 1975 Oct;26(10):651-8.

Maggin DM, Chafouleas SM, Goddard KM, Johnson AH; A systematic evaluation token economies as a classroom management tool for students with challenging behavior; J Sch Psychol. 2011 Oct;49(5):529-54. Epub 2011 Jun 28.

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11. Shirley M. Glynn; Token Economy Approaches for Psychiatric Patients Progress and Pitfalls Over 25 Years; psychiatric service; 1995 dec; 46(12): 1258-63. 12. McMonagle T, Sultana A; Token economy for schizophrenia; Cochrane Database Syst Rev. 2000;(3):CD001473.

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SIGNATURE OF THE CANDIDATE

10

REMARKS OF THE GUIDE

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NAME AND DESIGNATION OF:

11.1

GUIDE

11.2

SIGNATURE

11.3

CO-GUIDE

11.4

SIGNATURE

11.5

HEAD OF THE DEPARTMENT

11.6

SIGNATURE

12.1

REMARKS OF THE PRINCIPAL

12.2

SIGNATURE

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