Satisfaction research and the uncrowned king: Challenges and future directions

Investigating the Associations between Patient-Reported Quality of Care and Perceived Coercion: A Norwegian Cross-Sectional Study

Patient perspectives on the quality of care received are fundamental to mental health care. This study aimed to investigate the association between patient-reported mental health care quality, perceived coercion, and various demographic, clinical, and ward-related factors. Using a cross-sectional design, data were collected from 169 patients in Norwegian mental health wards using the quality in psychiatric care-inpatient (QPC-IP) instrument and experienced coercion scale (ECS). The analysis revealed a consistent pattern in which patients with higher perceived coercion consistently rated lower quality on all QPC-IP dimensions. The significant findings of the multiple regression models further supported this association. Beyond coercion, the factors influencing quality ratings include self-reported treatment results, participation in treatment planning, and knowledge of complaint procedures. Emphasizing the pivotal role of coercion in enhancing mental health care quality, these findings contribute to a nuanced understanding of patient experiences and underscore the importance of patient participation in mental health care improvement efforts.

Quality in Psychiatric Care in the Community Mental Health Setting from the Perspective of Patients and Staff

The current paradigm of mental health care focuses on care provided in the community, increasingly moving away from hospital care models that involve considerable economic burden. Patient and staff perspectives on the quality of psychiatric care can highlight strengths and areas for improvement to ensure better care provision. The aim of this study was to describe and compare perceptions of quality of care among patients and staff in community mental health services and to determine possible relationships between these perceptions and other study variables. A comparative cross-sectional descriptive study was conducted in a sample of 200 patients and 260 staff from community psychiatric care services in the area of Barcelona (Spain). The results showed high overall levels of quality of care from patient (m = 104.35 ± 13.57) and staff (m =102.06 ± 8.80) perspectives. Patients and staff both gave high scores to Encounter and Support factors, while factors concerning patient Participation and Environment received the lowest scores. Continuous assessment of the quality of psychiatric care in the community setting is essential to ensure the highest quality of care, taking the perspectives of those involved into account.

Models of Risk Selection in Maternal and Newborn Care: Exploring the Organization of Tasks and Responsibilities of Primary Care Midwives and Obstetricians in Risk Selection across The Netherlands

An effective system of risk selection is a global necessity to ensure women and children receive appropriate care at the right time and at the right place. To gain more insight into the existing models of risk selection (MRS), we explored the distribution of different MRS across regions in The Netherlands, and examined the relation between MRS and primary care midwives’ and obstetricians’ satisfaction with different MRS. We conducted a nationwide survey amongst all primary midwifery care practices and obstetrics departments. The questionnaire was completed by 312 (55%) primary midwifery care practices and 53 (72%) obstetrics departments. We identified three MRS, which were distributed differently across regions: (1) primary care midwives assess risk and initiate a consultation or transfer of care without discussing this first with the obstetrician, (2) primary care midwives assess risk and make decisions about consultation or transfer of care collaboratively with obstetricians, and (3) models with other characteristics. Across these MRS, variations exist in several aspects, including the routine involvement of the obstetrician in the care of healthy pregnant women. We found no significant difference between MRS and professionals’ level of satisfaction. An evidence- and value-based approach is recommended in the pursuit of the optimal organization of risk selection. This requires further research into associations between MRS and maternal and perinatal outcomes, professional payment methods, resource allocation, and the experiences of women and care professionals.

A Spanish adaptation of the Quality in Psychiatric Care-Inpatient (QPC-IP) instrument: Psychometric properties and factor structure

Background and aim

Western countries share an interest in evaluating and improving quality of care in the healthcare field. The aim was to develop and examine the psychometric properties and factor structure of the Spanish version of the Quality in Psychiatric Care–Inpatient (QPC-IP) instrument.

Methods

A psychometric study was conducted, translating the QPC-IPS instrument into Spanish, revision of the instrument by a panel of experts, and assessing its psychometric properties. 150 psychiatric inpatients completed the QPC-IP. Test-retest reliability was assessed by re-administering the questionnaire to 75 of these patients.

Results

After conducting pilot testing and a cognitive interview with 30 inpatients, it was determined that the QPC-IPS was adequate and could be self-administered. A Cronbach’s alpha of 0.94 was obtained for the full instrument and values of 0.52–0.89 for the various dimensions of the questionnaire. Test re test reliability: The Intraclass Correlation Coefficient for the full questionnaire was 0.69, while for the individual dimensions values between 0.62 and 0.74 were obtained, indicating acceptable temporal stability. Convergent validity was analysed using 10-point numerical satisfaction scale, giving a positive correlation (0.49). Confirmatory factor analysis revealed six factors consistent with the original scale. The Spanish version yielded adequate results in terms of validity and reliability.

Conclusion

Our findings provide evidence of the convergent validity, reliability, temporal stability and construct validity of the Spanish QPC-IP for measuring patient quality in psychiatric care in Spanish hospitals. Hospital administrators can use this tool to assess and identify areas for improvement to enhance quality in psychiatric care.

Inpatients' assessment of outcome at psychiatric institutions: an analysis of predictors following a national cross-sectional survey in Norway

OBJECTIVES

The objective was to assess the importance of different types of predictors for patient-reported outcome, both background factors at the patient level and healthcare predictors related to structure and processes of healthcare.

DESIGN

Cross-sectional patient experience survey.

SETTING

All 280 secondary care institutions in Norway providing inpatient care for adult psychiatric patients.

PARTICIPANTS

1683 inpatients responded to the questionnaire on-site (73.4%).

PRIMARY OUTCOME MEASURES

The outcome scale of the Psychiatric Inpatient Patient Experience Questionnaire-On-Site was the primary dependent variable. The scale consists of five items relating to overall patient satisfaction, benefit of treatment and patient enablement. Regressions were used to assess predictors, for all patients and for five different patient groups reported by the patients including anxiety/depression, drug-related problems and eating disorders.

RESULTS

Multilevel linear regression for all patients showed that background factors related to overall current state, self-perceived mental health before admission and admission type were the most important predictors for patient-assessed outcome. Poor current state was associated with poor assessment of outcome (estimate: 8.64, p<0.001), poor health before admission was associated with better outcome (estimate: -6.89, p<0.001) and patients with urgent admission had poorer scores on the outcome scale (estimate: 4.40, p<0.001). A range of structure and healthcare variables were related to patient-assessed outcome, the most important being clinicians/personnel understanding your situation, treatment adjusted to your situation and adequate information about mental health condition.

CONCLUSIONS

Self-perceived mental health before admission, current overall state and type of admission were the most important background factors for patient-assessed outcome. The most important structure and process variables were related to patient-centred interaction. The background factors should be considered in case-mix adjustments of quality indicators, while the process variables could be used as focus areas in work aiming to improve patients' assessment of outcome.

Satisfaction guaranteed? Forensic consumer satisfaction survey

Despite many people being forensically hospitalized worldwide, there is limited research reporting on their views of the care they receive. To describe consumer satisfaction and areas for improvement, we utilized our forensic psychiatric hospital's consumer survey. Eleven years of surveys, including a total of 541 surveys, were analysed both quantitatively and qualitatively. The majority of the forensic inpatients believed that their views were valued in their care and treatment. Most felt physically and emotionally safe at the hospital and believed that staff knew how to support them in times of distress. The majority felt that their culture and spirituality were respected. However, some areas for improvement were also noted, such as regarding staff attitudes. This consumer survey demonstrated a reasonably high level of satisfaction with forensic inpatient care, over the course of eleven years, despite this population of people being subject to lengthy hospitalisations. Satisfaction surveys of people in forensic inpatient units can be a regular part of forensic care and can help guide improvements in their care.

Examining the concept of patient satisfaction in patients with a diagnosis of schizophrenia: a qualitative study

Aims and Method

Ten people with a diagnosis of schizophrenia were interviewed. The interviews were analysed qualitatively with the aim of examining the concept of patient satisfaction in the context of a recent in-patient admission.

Results

The analysis identified two themes that influenced the expression of patient satisfaction: external factors and internal factors. The theme of external factors contained four categories: fear of violence, communication with staff, lack of autonomy and ward routines. The theme of internal factors comprised participants' conceptions and expectations.

Clinical Implications

This small study suggests the complexity of the concept of patient satisfaction should be respected in assessing experiences of people with a diagnosis of schizophrenia.

Are parents and children satisfied with CAMHS?

BACKGROUND

Client Satisfaction with services is an important predictor of health care seeking, treatment compliance and health status outcome. Given that both parents and young people may have different views of services offered, this study examines both perspectives with respect to Child and Adolescent Mental Health Services (CAMHS) in Ireland.

METHOD

Following ethical approval, the Client Satisfaction Questionnaire-8 (CSQ-8) were sent to all open cases attending three urban CAMHS. Returned questionnaires were received from 426 (280 parents and 146 adolescents) giving a response rate of 49%.

RESULTS

No significant differences were observed between parents and adolescents regarding general satisfaction with CAMHS (Mann-Whitney U-test; Z=-0.255; p=0.799) with a range of good and excellent ratings between 77.1% (for the extent that program met user's needs) and 93.1% (for recommendation of program to a friend). Significant positive associations were found between age of child (Spearman's ρ=0.159; p=0.017), receiving a diagnosis (Mann-Whitney U-test; Z=-2.14; p=0.032), frequent attendance (χ 2=8.74; df=3; p=0.033) and living in close proximity to the service (χ 2=9.24; df=3; p=0.026). There was a strong negative correlation between reduction in impairment and levels of satisfaction (ρ=-0.44, n=275, p<0.000). Waiting time or duration in service were not associated with CSQ and 53% (145) requested clinic opening hours outside of 09:00 a.m. to 17:00 p.m.

CONCLUSION

Regular user feedback, a robust and distinct measure of service quality, will ensure the development of effective, accessible, client-centered and responsive services, which can evolve in partnership with families and young people.

Problems with measuring satisfaction with social care

The measurement of customer satisfaction has become widespread in both healthcare and social care services, and is informative for performance monitoring and service development. Satisfaction with social care services is routinely measured with a single question on overall satisfaction with care, comprising part of the Adult Social Care Survey. The measurement of satisfaction has been problematised, and existing satisfaction measures are known to be under-theorised. In this article, the process of making an evaluation of satisfaction with social care services is first informed by a literature review of the theoretical background, and second examined through qualitative interviews conducted in 2012-2013 with 82 service users and family carers in Hampshire, Portsmouth and Southampton. Participants in this study were from white British and South Asian backgrounds, and the influence of ethnicity in the process of satisfaction evaluation is discussed. The findings show that the majority of participants selected a positive satisfaction rating even though both positive and negative experiences with services were described in their narratives. It is recommended that surveys provide opportunity for service users and family carers to elaborate on their satisfaction ratings. This addition will provide more scope for services to review their strengths and weaknesses.

PIPEQ-OS--an instrument for on-site measurements of the experiences of inpatients at psychiatric institutions

BACKGROUND

The Psychiatric Inpatient Patient Experience Questionnaire (PIPEQ) was developed for post-discharge measurements of experiences, but the low response rates associated with post-discharge surveys restrict their usefulness. A new questionnaire was developed based on the PIPEQ for on-site measurements of patient experiences: the PIPEQ-OS. The aim of this study was to psychometrically test the PIPEQ-OS using data from a nationally representative survey conducted in Norway in 2014.

METHODS

Data were collected using a nationally representative patient-experience survey; 25% of the institutions in each of the 4 health regions in Norway were randomly selected, yielding a total of 26 institutions. The PIPEQ-OS questionnaire was completed by patients on-site on an agreed day in week 37 of 2014. Item missing and ceiling effects were assessed, and factor analysis was used to assess the structure of the items included in the PIPEQ-OS. The scales were tested for internal consistency reliability, test-retest reliability and construct validity.

RESULTS

The initial sample comprised 857 patients. Of these, 60 were excluded for ethical reasons and 57 were excluded because they were absent on the day of the survey. Of the remaining 740 patients, 552 (74.6% of the included population) returned the questionnaire. Low levels of missing or "not applicable" responses were found for 18 of the 21 items (<20%), and 20 of 21 items were below the ceiling-effect criterion. Psychometric testing identified three scales: structure and facilities (six items), patient-centred interaction (six items) and outcomes (five items). All scales met the criterion of 0.7 for Cronbach's alpha (range: 0.79-0.91) and test-retest reliability (range: 0.83-0.84). The construct validity of the scales was supported by 14 of 15 significant associations with variables known to be related to psychiatric inpatient experiences.

CONCLUSIONS

The PIPEQ-OS comprises three scales with satisfactory internal consistency reliability and construct validity. This instrument can be used for on-site assessments of psychiatric inpatient patient experiences, but further research is needed to evaluate its usefulness as basis for external quality indicators.

SEQUenCE: a service user-centred quality of care instrument for mental health services

OBJECTIVE

To develop a quality of care instrument that is grounded in the service user perspective and validate it in a mental health service.

DESIGN

The instrument (SEQUenCE (SErvice user QUality of CarE)) was developed through analysis of focus group data and clinical practice guidelines, and refined through field-testing and psychometric analyses.

SETTING

All participants were attending an independent mental health service in Ireland.

PARTICIPANTS

Participants had a diagnosis of bipolar affective disorder (BPAD) or a psychotic disorder.

INTERVENTIONS

Twenty-nine service users participated in six focus group interviews. Seventy-one service users participated in field-testing: 10 judged the face validity of an initial 61-item instrument; 28 completed a revised 52-item instrument from which 12 items were removed following test-retest and convergent validity analyses; 33 completed the resulting 40-item instrument.

MAIN OUTCOME MEASURES

Test-retest reliability, internal consistency and convergent validity of the instrument.

RESULTS

The final instrument showed acceptable test-retest reliability at 5-7 days (r = 0.65; P < 0.001), good convergent validity with the Verona Service Satisfaction Scale (r = 0.84, P < 0.001) and good internal consistency (Cronbach's alpha = 0.87).

CONCLUSIONS

SEQUenCE is a valid, reliable scale that is grounded in the service user perspective and suitable for routine use. It may serve as a useful tool in individual care planning, service evaluation and research. The instrument was developed and validated with service users with a diagnosis of either BPAD or a psychotic disorder; it does not yet have established external validity for other diagnostic groups.

Barriers to access and minority ethnic carers' satisfaction with social care services in the community: a systematic review of qualitative and quantitative literature

As populations age, the numbers of carers overall and numbers of carers from minority ethnic groups in particular are rising. Evidence suggests that carers from all sections of the community and particularly carers from minority groups often fail to access care services. This may relate to barriers in accessing services and service dissatisfaction. The aim of this systematic review was to identify and summarise minority ethnic carers' perceptions of barriers to accessing community social care services and their satisfaction with these services if accessed. The following databases were searched from their start until July 2013: Social Care Online, Social Policy and Research, Scopus, PsychINFO, HMIC, ASSIA, MEDLINE, Embase, CINAHL Plus and AMED. Thirteen studies met the inclusion criteria. Most investigated either barriers to access or satisfaction levels, although three explored both. Only 4 studies investigated minority ethnic carers' satisfaction with social care, although 12 studies reported perceived barriers to accessing services. Few studies compared minority ethnic carers' perceptions with majority ethnic groups, making it difficult to identify issues specific to minority groups. Most barriers described were potentially relevant to all carers, irrespective of ethnic group. They included attitudinal barriers such as not wanting to involve outsiders or not seeing the need for services and practical barriers such as low awareness of services and service availability. Issues specific to minority ethnic groups included language barriers and concerns about services' cultural or religious appropriateness. Studies investigating satisfaction with services reported a mixture of satisfaction and dissatisfaction. Barriers common to all groups should not be underestimated and a better understanding of the relationship between perceived barriers to accessing services and dissatisfaction with services is needed before the experiences of all carers can be improved.

Hope, happiness and home treatment: a study into patient satisfaction with being treated at home

Aims and method This study investigates patient satisfaction and levels of hope after receiving treatment from a home treatment team. It studies whether distributing questionnaires during the last visit increases the response rate, and explores whether patient satisfaction and levels of hope are associated with particular elements of the care received.

Results Patients who answered the questionnaire tended to be satisfied. When forms were distributed during the last visit, the response rate increased to at least 64%. People with negative views were more likely to return the form by post. Patient satisfaction and levels of hope were associated with most elements of received care, and the resolution of problems was predictive of both satisfaction and increased hope in logistic regression.

Clinical implications The distribution of service evaluation questionnaires during the last visit increased the response rate considerably. This study suggests that in order to improve services, it is important to focus on whether patients think their problems have been resolved.

Gender and the relative importance of mental health satisfaction domains

Consumer-reported satisfaction data is a tool used for measuring and targeting areas for quality improvement in mental healthcare. In this study, we investigated the relationship between gender and the relative importance of mental health service satisfaction domains to overall satisfaction, in addition to gender differences in satisfaction across domains. People receiving mental health services (1765 males and 1950 females) completed questionnaires regarding their overall service satisfaction and satisfaction along six domains: Access to Services, Quality and Appropriateness, Participation in Treatment Planning, Outcome of Services, Social Connectedness, and Functioning. While all were important to overall satisfaction across genders, women reported slightly higher overall satisfaction. Linear regression analyses were used to determine the relative importance of these subscales to overall satisfaction for each gender. While the correlations between each subscale and overall satisfaction were significant for both, gender was found to moderate the relationship between some subscales and overall satisfaction. Although predictive of overall service satisfaction across the sample, we found Functioning, Outcome of Services, Social Connectedness, and Access to Services were relatively more important to overall satisfaction for men than women. Consistent feedback of results and improved access to services may be particularly effective for engaging both men and women in treatment.

Quality of care in psychosis and bipolar disorder from the service user perspective

According to the recovery model of mental health care, service development should incorporate the expert knowledge of service users. To date, there has been limited research into conceptualizations of mental health care quality among services users diagnosed with bipolar disorder or psychosis. To investigate service user perspectives on quality of care, we conducted six focus groups (N = 29) with inpatients and outpatients of an independent Irish mental health service. We undertook an inductive thematic analysis of the data. Participants identified proactive staff, meaningful and warm staff-patient interactions, and safety and sociability in the inpatient environment as components of good quality mental health care. Participants also discussed how the implementation of best practice guidelines does not necessarily improve quality of care from the service user perspective. This and similar qualitative research should be used to inform service development and the creation of evaluation instruments compatible with the recovery model.

Communicating about breast cancer: rural women's experience of interacting with their surgeon

OBJECTIVE

This study examined rural women's satisfaction with the interaction and communication with their surgeon during diagnosis and treatment planning for early breast cancer. Differences in satisfaction were investigated between treatment groups (mastectomy and breast conservation surgery) and demographic variables (age, marital status, education level, employment status and place of residence). Practice was compared with clinical practice guidelines.

DESIGN

The study was designed as a cross-sectional survey.

SETTING

The study was set in Eastern regional Victoria, Australia.

PARTICIPANTS

Seventy women diagnosed with early breast cancer participated in the study.

MAIN OUTCOME MEASURES

The main outcome measures used by the study were satisfaction in three areas of practice: (i) telling a woman she has breast cancer; (ii) providing information and involving the woman in the decision-making; and (iii) preparing the woman for specific management.

RESULTS

No differences in satisfaction were found between treatment groups and demographic variables. Overall, women in this study were highly satisfied (>93%) with the interaction and communication with their surgeon. Women reported that the surgeon created a supportive environment for discussion, that they were provided with adequate information and referrals, and that they were actively involved in the decision-making. Practice could have been improved for women who were alone at diagnosis as women without a partner made a quicker decision about treatment.

CONCLUSION

Rural women in Victoria Australia were largely satisfied with the interaction and communication with their surgeon during diagnosis and treatment planning for early breast cancer. Current practice was predominately in line with clinical practice guidelines.

Risk factors for psychiatric re-hospitalization: an exploration

Predecessor research suggests that anything from 37% to 53% of hospitalized service users are readmitted within 12 months of discharge. This cycle of frequent admissions represents a serious challenge to clinicians and service users alike. Critically, much of the research in this field has relied exclusively on professional attributions for readmission with little acknowledgement of service user or patient viewpoints. This paper reports on a phenomenological study which used multiple data collection approaches to explore service user and clinician attributions for frequent hospitalization to an identified psychiatric unit over a 24-month index period. Methods included a retrospective review of multi-professional case notes, clinician and service user semi-structured interviews, and focus groups. Service users cited 'situational circumstances', rather than medically accepted relapse indicators such as 'non-adherence with prescribed medication' as the main reasons for readmission. Notable disagreement existed between clinician and service user data sources. Hospitalization is a complex, individually determined experience. Clinicians and service users have differing perspectives on the causal risk factors and this presents complications for those developing relapse prevention strategies. However, a shared appreciation of the multiple realities paves the way for the development of a conceptual risk-factor identification model which may serve as a guide to practitioners in relapse prevention.

Nonoffending caregiver and youth experiences with child sexual abuse investigations

Qualitative responses by caregivers (n = 203) and youth (aged 8 and older; n = 65) about their experiences with sexual abuse investigations were analyzed in conjunction with quantitative ratings of satisfaction. Respondents described mostly high levels of satisfaction, although dissatisfaction was reported with some key aspects of investigations. The features cited as worse than expected by caregivers were the investigators' commitment to prosecuting the alleged offender and the absence of clear and regular communication about the status of the case. The features mentioned most often by caregivers as better than expected were the emotional support and interviewing skills of investigators. Youth focused both praise and criticism on investigators' interviewing skills. There were relatively few complaints by either caregivers or youth about the duration of the investigation, medical exams, lack of services, or failures of interagency communication, areas of considerable reform in the past several decades. Implications for investigator training and reform initiatives are discussed.

Satisfaction of early breast cancer patients with discussions during initial oncology consultations with a medical oncologist

OBJECTIVE

The purpose of this report is to extend the current understanding of patient satisfaction by examining expectations of a sample of breast cancer patients and concordance with their medical oncologists about the content of consultations and the importance of consultation items.

METHODS

Three hundred and ninety-five female early stage breast cancer patients of 56 oncologists participated. Patients and oncologists completed a matched questionnaire measuring (a) met expectations, (b) concordance over content and item importance, and (c) satisfaction.

RESULTS

Overall patient satisfaction was extremely high (x=91/100%) although expectations were not met at the stated level desired. Patients and physicians disagreed over what was conveyed and received. Higher overall satisfaction was predicted by levels of met expectations (unstandardized beta=0.69, p=0.008, SE=0.26) and concordance over (a) content (unstandardized beta=1.09, p=0.002, SE=0.34) and (b) importance (unstandardized beta=-0.78, p=0.006, SE 0.28).

CONCLUSION

Although patient expectations were not well met and physician-patient discord was high about the content of consultations and the importance of consultation items, patients reported high levels of satisfaction. Expectation fulfillment and levels of concordance predicted satisfaction.

User satisfaction with child and adolescent mental health services: impact of the service unit level

BACKGROUND

Child and adolescent mental health service units (CAMHS) play an important role in the supply of services to children and adolescents with mental illness. The purpose of this study was to examine the service unit effect on parent satisfaction with outpatient treatment.

METHOD

The study was undertaken in 49 of 72 Norwegian outpatient CAMHS in 2004. A total of 2253 of the parents who were asked to participate (87%) responded. Parent satisfaction was measured using two summated scales: clinician interaction/information and treatment outcome. Multilevel analyses were used to assess the contribution of the service units to satisfaction and to investigate patient level predictors of parent satisfaction.

RESULTS

About 96-98% of the parent satisfaction variance could be attributed to factors within CAMHS, leaving only 2-4% of the variance attributable to the CAMHS level. Parents of patients aged 0-6 years were more satisfied than older patients' parents. Longer treatment episodes were positively associated with satisfaction. Parents whose children had been referred with externalizing symptoms were less satisfied with treatment outcome than those referred for internalizing symptoms. Waiting time was negatively associated with treatment outcome satisfaction. Adjustments for patient characteristics did not substantially change the relative effect of CAMHS on satisfaction ratings.

CONCLUSION

The results indicate that information from user satisfaction surveys has clear limitations as an indicator of CAMHS quality. From a quality improvement perspective, the factors affecting the variance within CAMHS are of dominating importance compared to factors affecting between CAMHS variance.

The impact of mental illness on patient satisfaction with the therapeutic relationship: a multilevel analysis

BACKGROUND

The relationship between patients and their clinicians is an essential factor in psychiatric treatment. The purpose of this study was to analyze the influence of psychopathology on patient satisfaction with the therapeutic relationship.

METHODS

Data from 969 patients from 40 different treatment teams collected from eight Norwegian community mental health centres were analyzed. Patient satisfaction with the therapeutic relationship was assessed with a six-item scale: sufficient time for contact/dialogue, clinicians' ability to listen and understand, follow-up of planned interventions, respect for patients' views/opinions, cooperation among clinicians, and patients' influence on treatment. Mental illness was assessed using the Health of the Nation Outcome Scales (HoNOS) and Global Assessment of Functioning (GAF) scale. Diagnoses were established using the International Statistical Classification of Diseases and Related Health Problems -- 10th revision (ICD-10). Treatment outcomes were clinically assessed retrospectively by rating changes from start of treatment on seven items. Multilevel regression analysis was used for a simultaneous analysis of the contribution of patient and team variables.

RESULTS

Satisfaction was associated with treatment outcome, better health as assessed using HoNOS, being female, of older age and having less psychiatric team severity indicated by the teams' mean GAF score. Patients with a schizophrenia spectrum disorder were more satisfied when treated as in- and day patients, compared with outpatient treatment. Patients in other diagnostic categories were less satisfied with day treatment.

CONCLUSIONS

Patients' perceptions of the therapeutic relationship may be influenced by psychopathology. Teams comprising many patients with severe mental illness may constrain the therapeutic relationship. Hence, resources and organizational measures should be carefully considered in such care units.

Promoting coping: salutogenesis among people with mental health problems

This article aims to illustrate how Antonovsky's salutogenic theory and its central concept of sense of coherence can be operationalized into salutogenic therapy principles and an intervention program for promoting a sense of coherence, coping, and mental health among people with mental health problems. The intervention is based on the following five basic components or therapy principles: (1) the health continuum model; (2) the story of the person; (3) health-promoting (salutary) factors; (4) the understanding of tension and strain as potentially health promoting, and (5) active adaptation. The program is a talk therapy group intervention and consists of 16 group meetings and homework. The intervention may serve as a guide to mental health nursing practice when coping is the main target.

Engagement with health and social care services: perceptions of homeless young people with mental health problems

The present qualitative study describes and discusses the perspectives and experiences of young homeless people with mental health problems in relation to their interactions with health and social care services. Working in partnership with Streetlink, a supported accommodation assistance programme in Adelaide, Australia, the authors interviewed 10 homeless young people, aged from 16 to 24 years of age, who had experienced mental health problems. In-depth interviews elicited accounts of the best and worst of the participants' experiences of health and social care services. Access to services was not identified as being a significant problem in comparison with the participants' concerns regarding the quality of the services encountered. The central findings stress the importance of a respectful and supportive climate in relation to the qualities of service provision that the young people identified as valuable for their continuing treatment or consultation.

A conversation: challenging the relevance and wisdom of separate mental health legislation

This paper explores the dilemmas encountered by mental health nurses when working with mental health legislation. The concerns and considerations of an expert mental health nurse, complemented by the opinion of an expert in health-care and legal issues are presented. It is argued that there is currently a distorted perception with regard to the function and sentiment of mental health legislation, and this paper aims to restore balance in interpreting and working with such law. Viewing mental health legislation primarily as a mechanism for involuntary hospitalization effectively removes any power or recourse given to mental health consumers by the law. Principles of mental health care and legislation are examined as well as the relationship the law has with dangerousness to self or others and mental ill health. A dialogue is established between the two authors to assist the exploration of these legal and clinical issues. The continued relevance of specific mental health legislation is brought into question. It is proposed that the existence of such legislation constitutes discrimination and contributes to stigma associated with mental illness. An alternative legislation for all circumstances where an individual is deemed incompetent is proposed as the most significant step towards mainstreaming of mental health care and an end to discrimination.