econmy token
TRANSCRIPT
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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
NURSINGBANGALORE-560044
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA,BANGALORE,
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION1. NAME OF THE CANDIDATE AND
ADRESS
MS.SREEJA.P.A
SREEBHAVAN, ELAKOLLOOR.P.O, KONNIPATHANAMTHITTA- 689703, KERALA
2. NAME OF THE INSTITUTION Oriental college of nursing,Bangalore560044.
3. COURSE OF STUDY AND SUBJECT 1ST Year M.Sc Nursing,
Mental Health Nursing
4. DATE OF ADMISSION OF THE COURSE 15-10-2011
5. TITLE OF THE TOPIC 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. BRIEF RESUME OF THE WORK6.0 INTRODUCTION
6.1 NEED FOR THE STUDY6.1.1 STATEMENT OF TH STUDY6.2 REVIEW OF LITERATURE6.3 OBJECTIVES OF THE STUDY6.3.1 OPERATIONAL DEFENITIONS
6.3.2 ASSUMPTION6.3.3 HYPOTHESIS6.3.4 SAMPLING CRITERIA
Enclosed
EnclosedEnclosedEnclosedEnclosedEnclosed
EnclosedEnclosedEnclosed
7. MATERIALS AND METHODS
7.1 SOURCES OF DATA
7.2 METHOD OF DATA COLLECTION7.3 Does the study require any investigationsof interventions to be conducted on the patients
or other human being or animals?7.4 Has ethical clearance been obtained fromyour institution?
Data will be collected from mentally ill patients inselected hospital in BangaloreEvaluative Approach
YesYes. Ethical committees report is here with enclosed
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BENGALURU, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 NAME OF THE CANDIDATE
AND ADDRESS
Miss. SREEJA P A
SREE BHAVAN,
ELAKOLLOOR P O,KONNI, PATHANAMTHITTA (Dist.),
KERALA- 689703
2 NAME OF THE INSTITUTION ORIENTAL COLLEGE OF NURSING
BANGALORE- 560-010
3 COURSE OF THE STUDY AND
SUBJECT
FIRST YEAR M.Sc NURSING
MENTAL HEALTH NURSING
4 DATE OF ADMISSION 15 -10-2011
5 TITLE OF THE STUDY:
A QUASI-EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OFTOKEN ECONOMY PROGRAM ON BEHAVIORAL MODIFICATION AMONG
INSTITUTIONALISED MENTALLY ILL PATIENTS IN SELECTED MENTALHOSPITALS IN BANGALORE.
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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
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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 patientscontingent ontheir exhibiting improvements
in their behaviour. The tokens were then subsequently exchanged for apanoplyof 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
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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 modificationdesigned 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
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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, addictiontreatment 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
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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
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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 study3.
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 patients4.
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
group5
.
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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 learning6
.
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 students7.
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
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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 trials8.
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 treatments9
.
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 date10
.
A 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 meta-
analytic 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 well-
validated 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
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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 illpatients.
To assess the post-intervention level ofbehaviour 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 ofbehaviour
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
behaviourmodification 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 behaviouras determined by
significant difference between pre and post test level ofbehaviour.
3 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.
4 Behaviour modification: - An observable change in the behaviour of a patient
which the society accepted as a desirable behaviour.
5 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. Mentally ill patients may have some behavioural difficulties.
2. Mentally ill patients may need some behaviour modification.
3. 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. The mentally ill patients who are willing to participate in the study.
2. Mentally ill patients who are available during the study period.
3. 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 fordata 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 : 6 weeks
Research variables
Dependent Variables : Behavior modification of the mentally ill
patients.
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 Community Psychiatry.1975 Oct;26(10):651-8.
10. 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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9SIGNATURE OF THE CANDIDATE
10 REMARKS OF THE GUIDE
11NAME AND DESIGNATION OF:
11.1GUIDE
11.2SIGNATURE
11.3CO-GUIDE
11.4SIGNATURE
11.5HEAD OF THE DEPARTMENT
11.6SIGNATURE
12.1 REMARKS OF THE PRINCIPAL
12.2SIGNATURE