Staff views about involving service users in team formulation

OBJECTIVES

The aim of the study was to explore staff views about whether and how service users should be involved in the process of team formulation.

DESIGN

This study used Q methodology to explore health care professionals' views about service user involvement in team formulation meetings.

METHODS

Forty staff members with experience of attending team formulation meetings completed a Q Sort in which they ranked how much they agreed or disagreed with 58 statements about service user inclusion in team formulation. Factor analysis was used to identify viewpoints within the data set.

RESULTS

A three-factor solution accounting for 60% of the variance was considered the best fit for the data. The factors were: 'A safe space for staff', 'Concerns about inclusion and collaboration' and 'Service users might find attendance harmful'. Consensus statements identified areas where all participants agreed.

CONCLUSIONS

This is an important area for exploration, given the growing practice of team formulation and the professional and ethical issues raised by service user involvement. There are a range of ways to promote inclusion within the practice, and staff should always consider the individual needs of service users.

Impact of factor rotation on Q-methodology analysis

The Varimax and manual rotations are commonly used for factor rotation in Q-methodology; however, their effects on the results may not be well known. In this article we investigate the impact of different factor rotation techniques in Q-methodology, specifically how the factors and their distinguishing statements might be affected. We applied three factor rotation techniques including Varimax, Equamax, and Quartimax rotations on two exemplary datasets and compared the results based on the number of Q-sorts loaded on each factor, number of distinguishing statements for each factor, and changes in the number of distinguishing statements. We also estimated the Pearson correlation between the extracted factors based on rotation techniques. This analysis shows that factors can change substantially from one rotation to another. For instance, there was only 3 common distinguishing statements between Factor 1 of no-rotation of Dataset 1 and its matched factor from Varimax rotation. Even for 3 common statements, the factor scores were quite different from no-rotation to Varimax rotation. This analysis shows that the effects of factor rotation on emerging factors are complex. The changes are usually substantial such that the rotated factors might be quite different from the original factors.

South Korean Early Cancer Patients' Perceptions of Difficulties in Fighting Their Disease: A Q Methodological Approach

This study applied the Q methodology to explore breast cancer patients' perceived difficulties in their fight against the disease. We used literature analysis and in-depth interviews and selected 162 statements for the Q population. Then, we chose 40 universal and representative statements for the Q samples from the Q population. The P sample included 13 breast cancer patients in the early stage of the disease who participated in the Q sorting. We interviewed the study participants with high factor weights by type of P sample. The study's results showed three types of breast cancer patients' perceptions of difficulties in the initial fight against the disease. Type 1 showed 'fear of the future', Type 2 showed 'helplessness against what cannot be controlled', and Type 3 showed 'frustration due to difficulties in role performance.' Based on these results, we discuss the characteristics, meanings, and significance of individual types of breast cancer patients' perceptions of the disease, including suggestions for follow-up studies.

A Study on the Subjectivity of Parents Regarding “0th-Period Physical Education Class” of Middle Schools in Korea Using Q-Methodology

The current study examined parents’ subjective perception types and characteristics regarding the 0th-Period Physical Education Class of Middle School in Korea. The Q-methodology was applied, and the final 25 Q-Samples were selected through the composition of the 42 Q-population. Among Korean parents, 20 students who participated in “Physical Education Activities in Class 0” for more than one year were selected as P-Sample. Q-sorting was performed by the P-Sample. Data collected by Q-sorting were analyzed using the PQ method program version 2.35, with centroid factor analysis and varimax rotation. The finding pointed to four types, with a total explanatory variance of 63%. Type 1 (N = 7), and was named “urgent legal and institutional settlement of 0th-period physical education”. Type 2 (N = 4) has the theme of “beach-head for a vibrant school life”. Type 3 (N = 4) was named “enhancement of academic capability”. Type 4 (N = 4) was described as “strengthening physical and mental health”. Moreover, the consensus statements between each type were investigated in Q1 and Q2. These findings highlight the importance of the “0th-period physical education class” so the program could be expanded and institutionalized in Korea.

'Using Q-methodology to Explore What is Valued from Child Sexual Exploitation Services: The Importance of Safety'

Child Sexual Exploitation (CSE) is a complex international issue requiring specialist multi-agency support. There is evidence that survivors of CSE are likely to experience mental health difficulties and have long-term psychological needs in response to trauma. However evidence regarding services and interventions for these difficulties is limited. This study explored viewpoints of key stakeholders, such as young people and frontline staff, about CSE services. Participants were recruited from services that support young people who have experienced CSE. The sample consisted of 18 participants; nine young people and nine professionals. Q-methodology was used to investigate subjective viewpoints regarding this topic. Statements about CSE interventions and services were collected from the existing literature and validated to form a Q-set. Participants sorted the Q-set from most to least important. Q-sorts were subjected to factor analysis using Q-methodology software. Three factors were identified: (1) The importance of safety and attunement, (2) Managing trauma and mental health difficulties and (3) Family, normality, and a relaxed approach. All factors emphasized the importance of safety and trust between young people and professionals. Key areas that may benefit service design were identified. Primarily, young people are likely to benefit from specialist support promoting a trauma-informed and relational approach.

Childhood Personality Assessment Q-Sort (CPAP-Q): A Clinically and Empirically Procedure for Assessing Traits and Emerging Patterns of Personality in Childhood

BACKGROUND

Despite increasing research confirming the existence of childhood personalities, which are recognizable from a developmental perspective, controversies over the possibility to assess personality in childhood have continued. The purpose of this study was to provide initial data on the validation of the Childhood Personality Assessment Q-Sort (CPAP-Q), a clinician report instrument that can be employed to evaluate children's personalities and address the gap in the field of emerging personality in children classification.

METHOD

A sample of 135 clinicians completed the CPAP-Q to assess the personality features of 135 children (ages 4-11) who had been in their care between two and 12 months. The clinicians completed a clinical questionnaire to collect information on them, the children, and their families, as well as the Child Behavior Checklist (CBCL), to evaluate the children's behavioral problems and social competencies.

RESULTS

Q-factor analysis identified seven specific emerging personality patterns: psychological health, borderline/impulsive, borderline/dysregulated, schizoid, inhibited/self-critical, obsessive, and dysphoric/dependent. These patterns revealed good levels of validity and reliability.

CONCLUSIONS

These findings are preliminary, but seem to support the possibility of evaluating emerging personality patterns in childhood and their developmental pathways that may lead to personality disorders in adolescence and adulthood. The CPAP-Q promises to significantly contribute to less explored research areas and encourage systematic studies of children assessment, promoting best practices for individualized diagnoses.

Visualising natural attractions within national parks: Preferences of tourists for photographs with different visual characteristics

To explore what types of photographs are more helpful means to interpret natural attractions within national parks, this study focused on the relationship between the photographs with different visual characteristics and their perceived visual appeal. A photograph-based Q method was adopted. Results confirmed the visual quality of a photograph was the most important characteristic that determined its perceived attractiveness; those photographs with a high visual quality could successfully attract tourists’ attention. The subject also significantly affected the preferences of observers, suggesting an interest-dependent pattern. Using photographs of birds as examples, the participants who were interested in birds were attracted by the photographs of birds rather than those of other subjects. This study provides a better understanding of the effectiveness of photographs for communication. Findings may help researchers, communicators and national park marketers better understand and select appropriate photographs for interpretation within national parks.

Nursing Students' Perceptions of Menstrual Distress during Clinical Practice: A Q-Methodology Study

This study aimed to explore the cluster patterns of female nursing students’ perceptions of the effects of menstrual distress during clinical practice. This study adopted the Q-methodology study design. We recruited female nursing students from a college in northern Taiwan. Forty-seven Q-statements were constructed to explore participants’ experiences of the impact of menstrual distress on clinical learning. In total, 58 participants subjectively ranked Q-statements concerning menstrual distress experiences during clinical practice and were classified. After Q-sorting, the subjective ranking process PQ Method (version 2.35, Schmolck, Emmendingen, Germany) was employed for factor analysis. Four patterns of shared perspectives, accounting for 46.6% of the total variance, were identified: (a) influencing clinical learning and making good use of painkillers; (b) responsible attitudes and diversified relief of discomfort; (c) seeking peer support and effect on mood; (d) negative impact on learning ability and conservative self-care. Clinical practice is a major component of nursing education; menstrual distress affects female nursing students’ clinical learning and performance. The exploration of clustering different nursing students’ perceptions may facilitate customized strategies to enable more appropriate assistance.

Adult mental health practitioner beliefs about psychosis, parenting, and the role of the practitioner: A Q methodological investigation

OBJECTIVES

There is a lack of research into parenting interventions for families which include a parent experiencing psychosis or other serious mental illness (SMI). Preliminary findings highlight the potential benefits of adult mental health practitioners supporting parents experiencing SMI by using self-directed parenting interventions. This study explored beliefs relating to parenting and psychosis held by practitioners working in adult mental health settings, specifically examining their beliefs about the parenting needs of adults experiencing psychosis who have dependent children, as well as their role as adult mental health practitioners.

DESIGN

This study used Q methodology to explore the beliefs of mental health practitioners on psychosis and parenting.

METHODS

Twenty-one adult mental health practitioners ranked 58 items according to how much they agreed with the belief statement presented. Participants also provided additional written information and interviews to contextualize the Q methodology data.

RESULTS

Three factors emerged representing three groups of practitioners with similar beliefs around psychosis and parenting. Factors were labelled: 'Parenting interventions are worthwhile, and I'd deliver them', 'Parenting interventions are worthwhile, but I'm not confident to deliver them', and 'Parenting interventions might be worthwhile, but it's not my responsibility'.

CONCLUSION

Using parenting interventions as part of their clinical work was acceptable to most practitioners; however, some lacked confidence in their ability to work in a family-focused way. Efforts now need to focus on enhancing practitioners' skill, knowledge, and confidence in family-focused approaches to provide increased and improved support to families which include a parent experiencing psychosis or other SMI.

PRACTITIONER POINTS

Parenting interventions need to be made more available and accessible to parents experiencing serious mental illness (SMI), such as psychosis. Adult mental health practitioners are willing to incorporate parenting interventions into their work with parents accessing their services, but some lack confidence to do this. These results highlight the importance of equipping practitioners with the skill, knowledge, and confidence to engage in family-focused approaches. Further research needs to involve parents experiencing SMI as well practitioners working in adult mental health services.

Using the attachment network Q-sort for profiling one's attachment style with different attachment-figures

Attachment instruments vary substantially in practicability of administration, employment of categorical versus dimensional scoring, quality of scales, and applicability to different attachment figures. The Attachment Network Q-sort (ANQ) is a self-report, quasi-qualitative instrument that discriminates relationship-specific attachment styles for multiple attachment figures. The current study assesses the properties of the ANQ in psychotherapy patients and in non-patient respondents, using mother, father and romantic partner as possible attachment figures. Analyzing the ANQ-data with latent class analysis, we found four types or classes of participants: a group with an overall secure profile, a group only insecure for father, a group only insecure for mother, and a group insecure for mother as well as father but not for partner (if available). These profiles proved to have good concurrent, discriminant and construct validity. We conclude that the ANQ is potentially a useful alternative clinical self-report instrument to assess combinations of attachment styles for a range of attachment figures such as parents and a romantic partner.

Listening to parents to understand their priorities for autism research

Involving the autism community in research increases the real-world translation and impact of findings. The current study explored the research priorities of parents of school-aged children on the autism spectrum across the home, school, and community settings. A combination of content analysis of an online questionnaire (n = 134) and Q-sort methodology (n = 9) was used. The most commonly identified research priorities in the online questionnaire were child health and well-being (home setting), socialisation and social support (school), and community awareness and understanding of autism (community). The Q-sort method highlighted different top priorities, with understanding the parent, sibling, child and family impact and stress the highest ranked priority for home, teacher/staff education and support for the school, and recognizing and supporting anxiety for the community. The implications of the findings are discussed in relation to shifting the framework of autism research to align research agendas with parental priorities.

An Innovative Tool Investigating Psychodynamic Therapeutic Skills

The Psychoanalytic Core Competency Q-Sort (PCC Q-Sort) is a newly developed empirical research tool that allows for the description and illustration of the ways psychodynamically-oriented psychotherapists work. It provides a simple, straightforward rating procedure utilizing a well-established q-sort method. The present pilot study describes the psychoanalytic core competency items and discusses the development procedure of the instrument as well as statistical analysis of ratings from psychoanalytic sessions, including inter-rater reliability as well as preliminary findings on possible construct validity. Additionally, a factor analysis was performed. Values were assessed by applying the PCC Q-Sort to 30 audio recordings of psychoanalytic sessions. The results of the present study indicate that the PCC Q-Sort is a reliable process research instrument that allows for a detailed investigation of psychotherapy processes in psychodynamic psychotherapies and change processes.

Housing options for the future: Older people's preferences and views on villages with care and support

A growing older population worldwide means there is a need to ensure there are sufficient housing options to meet a broad spectrum of need and aspiration. There is little understanding of the relative importance of the "pull factors" that might attract older people to relocate to a new environment. Older people's views of the relative level of attractiveness of potential features of a specialist housing development offering care and support were investigated using Q methodology. Forty-one participants aged 53-89 living in a locality in Northern England rank-ordered 70 statements from April to August 2016. The analysis revealed four viewpoints: adaptation and care seekers, comprising prioritisation of care provision, specialist accommodation and accessibility; care-indifferent luxurians, which encompasses attraction to some "luxury" features and less emphasis on care provision; connected separatists, emphasising a distinct environment with good public transport connections; and independent engagers, comprising attraction towards social opportunities and remaining independent. Broad agreement was found on some topics, such as the generally high prioritisation of safety and security. The research provides a deeper understanding of differences in views towards housing options among older people which developers, planners and funders will need to recognise. While providing high-quality care may be a key objective for some organisations, this may not be the most important concern for some older people contemplating relocation, with many other features considered more attractive.

Coping with diabetes: Provider attributes that influence type 2 diabetes adherence

Diabetes, a chronic disease affecting over 29 million people in the United States, requires the integration of complex medical tasks into a person’s daily life. Patient-centered care and compassion are recognized as essential dimensions of the quality care experience. This research examined provider attributes that influence adherence to type 2 diabetes mellitus (T2DM) regimens and sought to understand the phenomena of provider attributes, treatment adherence, and their relationship to coping ability and treatment outcomes. This quantitative study sampled 474 people with T2DM using a 62-item online survey administered to three different groups. The sample population included people over age 18 diagnosed with T2DM. The first group included 91 persons with T2DM identified through a Facebook group and personal social media connections, the second group included 120 Amazon Mechanical Turk participants with T2DM, and the third group included 263 respondents from a Qualtrics panel who had T2DM. Results indicated that perceived provider compassion (β = .41, ρ < .001) and optimism (β = .48, ρ < .001) positively affected coping ability. Additionally, full mediation effects for self-management were revealed, with coping ability positively mediating the effect of compassion on self-management and the effects of optimism on self-management. Furthermore, full mediation effects were found for treatment satisfaction, with coping ability positively mediating the effect of compassion on treatment satisfaction and the effects of optimism on treatment satisfaction. This research has implications for patients, healthcare professionals, and leaders suggesting that providers who communicate with optimism and compassion positively affect coping ability. As a result, healthcare providers and professionals have an opportunity to enhance self-management adherence by helping their patients cope with the burdens of diabetes. In addition, this study has implications for developing provider communication tools aimed at assessing patients’ coping capacity and increasing compassionate communication.

Do Foster Parents and Care Workers Recognize the Needs of Youth in Family Foster Care with a History of Sexual Abuse?

Children in family foster care have the right to participate in decisions regarding their life, however, adults often advocate on behalf of children. This Q methodological study explored whether shared perspectives among foster parents and care workers resemble shared perspectives of youth regarding the psychosocial needs experienced by youth with a history of sexual abuse. Participants sorted a set of statement cards according to what they thought was most important for youth. By-person factor analyses examined how the Q sorts of foster parents and care workers related to those of youth. The results showed that foster parents mostly recognized the group of youth who value an instrumental relationship with their carers, while care workers mostly recognized the group of youth who value support of both foster and birth parents with regard to their preparation for independent living. The two youth groups characterized by ambivalence and autonomy were barely recognized. Results are discussed in light of the expected roles of foster parents and care workers, and youth's contact with birth parents. Lastly, this study highlights the importance of youth participation, because youth offer unique and varying perspectives about their needs.

Viewpoints of pedestrians with and without cognitive impairment on shared zones and zebra crossings

Background

Shared zones are characterised by an absence of traditional markers that segregate the road and footpath. Negotiation of a shared zone relies on an individual’s ability to perceive, assess and respond to environmental cues. This ability may be impacted by impairments in cognitive processing, which may lead to individuals experiencing increased anxiety when negotiating a shared zone.

Method

Q method was used in order to identify and explore the viewpoints of pedestrians, with and without cognitive impairments as they pertain to shared zones.

Results

Two viewpoints were revealed. Viewpoint one was defined by “confident users” while viewpoint two was defined by users who “know what [they] are doing but drivers might not”.

Discussion

Overall, participants in the study would not avoid shared zones. Pedestrians with intellectual disability were, however, not well represented by either viewpoint, suggesting that shared zones may pose a potential barrier to participation for this group.

Experience of nursing students with standardized patients in simulation-based learning: Q-methodology study

BACKGROUND

Standardized patients (SPs) boost self-confidence, improve problem solving, enhance critical thinking, and advance clinical judgment of nursing students.

OBJECTIVE

The aim of this study was to examine nursing students' experience with SPs in simulation-based learning.

DESIGN

Q-methodology was used.

SETTING

Department of nursing in Seoul, South Korea.

PARTICIPANTS

Fourth-year undergraduate nursing students (n = 47).

METHODS

A total of 47 fourth-year undergraduate nursing students ranked 42 Q statements about experiences with SPs into a normal distribution grid.

RESULTS

The following three viewpoints were obtained: 1) SPs are helpful for patient care (patient-centered view), 2) SPs roles are important for nursing student learning (SPs roles-centered view), and 3) SPs can promote competency of nursing students (student-centered view).

CONCLUSION

These results indicate that SPs may improve nursing students' confidence and nursing competency. Professors should reflect these three viewpoints in simulation-based learning to effectively engage SPs.

Is "end of life" a special case? Connecting Q with survey methods to measure societal support for views on the value of life-extending treatments

Preference elicitation studies reporting societal views on the relative value of end-of-life treatments have produced equivocal results. This paper presents an alternative method, combining Q methodology and survey techniques (Q2S) to determine the distribution of 3 viewpoints on the relative value of end-of-life treatments identified in a previous, published, phase of this work. These were Viewpoint 1, "A population perspective: value for money, no special cases"; Viewpoint 2, "Life is precious: valuing life-extension and patient choice"; and Viewpoint 3, "Valuing wider benefits and opportunity cost: the quality of life and death." A Q2S survey of 4,902 respondents across the United Kingdom measured agreement with these viewpoints; 37% most agreed with Viewpoint 1, 49% with Viewpoint 2, and 9% with Viewpoint 3. Regression analysis showed associations of viewpoints with gender, level of education, religion, voting preferences, and satisfaction with the NHS. The Q2S approach provides a promising means to investigate how in-depth views and opinions are represented in the wider population. As demonstrated in this study, there is often more than 1 viewpoint on a topic and methods that seek to estimate that averages may not provide the best guidance for societal decision-making.

Baccalaureate nursing students' perspectives of peer tutoring in simulation laboratory, a Q methodology study

OBJECTIVES

The study aim was to identify the perceived perspectives of baccalaureate nursing students toward the peer tutoring in the simulation laboratory. Insight into the nursing students' experiences and baseline data related to their perception of peer tutoring will assist to improve nursing education.

DESIGN

Q methodology was applied to explore the students' perspectives of peer tutoring in the simulation laboratory.

PARTICIPANTS

A convenience P-sample of 40 baccalaureate nursing students was used.

METHOD

Fifty-eight selected Q statements from each participant were classified into the shape of a normal distribution using an 11-point bipolar scale form with a range from -5 to +5. PQ Method software analyzed the collected data.

RESULTS

Three discrete factors emerged: Factor I ("Facilitate or empower" knowledge acquisition), Factor II ("Safety Net" Support environment), and Factor III ("Mentoring" learn how to learn).

CONCLUSIONS

The findings of this study support and indicate that peer tutoring is an effective supplementary strategy to promote baccalaureate students' knowledge acquisition, establishing a supportive safety net and facilitating their abilities to learn in the simulation laboratory.

Clinical psychologists' attitudes towards the biology and 'new genetics' of intellectual and developmental disabilities: a pilot study using Q-methodology

BACKGROUND

The current study investigated how ideas and models from the 'New Genetics' and associated fields of developmental neuroscience and behavioural phenotypes are perceived by clinical psychologists working with people with intellectual and developmental disabilities (IDD). As well as examining the take-up and influence of such ideas, it also examines barriers, both personal and institutional, to the widespread adoption of such concepts and research findings in services for people with IDD.

METHODS

A Q-methodology study was undertaken with 31 qualified and 16 trainee clinical psychologists in the North West of England using a specifically developed 81-item Q set.

RESULTS

Three factors were identified and labelled Integration of social and medical models, Social model of disability is more helpful and Genetic advances in conflict with recognising the value of people with IDD.

CONCLUSION

There was a lack of consensus in clinical psychologists working with people with IDD, with amount and type of professional experience affecting the factor loadings, which may need to be considered in developing clinical applications of genetic IDD research.

Opportunities and Obstacles for Good Work in Nursing

Good work in nursing is work that is scientifically effective as well as morally and socially responsible. The purpose of this study was to examine variables that sustain good work among entering nurses (with one to five years of experience) and experienced professional nurses despite the obstacles they encounter. In addition to role models and mentors, entering and experienced nurses identified team work, cohesiveness and shared values as levers for good work. These nurses used prioritization, team building and contemplative practices to overcome obstacles. Entering professional nurses tended to avoid conflict in the work setting. Experienced nurses reported forming teams of decision makers who share similar values to resolve conflict. These findings have implications for nurse education and nursing practice. Reflection on the importance of values and virtue in sustaining good work is important. Entering professional nurses should be encouraged to seek positive role models and reflect on the lessons that can be learned from experienced exemplary nurses.

Constructions of Sexual Relationships

Q methodology was applied to investigate the views of young people from Catalunia, England and Slovakia regarding sexual relationships and their health implications. The Q sorts of 188 16-18-year-olds from these three diverse European regions were reduced by Q factor analysis to six clear accounts. These accounts are presented in relation to three emergent themes: (a) traditionalism/liberalism; (b) locus of responsibility; and (c) the relationship between sex and love, and these discursive themes are discussed in relation to health-salient criteria such as awareness of sex-related risk and corresponding implications for conduct.

Exploring Student and Faculty Perceptions of Clinical Simulation: A Q-Sort Study

BACKGROUND

Simulation learning has become a widely accepted and valuable methodology within nursing education. This study assessed whether student and faculty perceptions regarding simulation learning have changed since curricular integration of simulation activities within an undergraduate nursing program.

METHOD

Q-methodology was used to identify unique and similar perspectives of 12 faculty and 21 students. Participants completed a brief demographic questionnaire and sorted statements related to beliefs about simulation-based learning.

RESULTS

Faculty perceptions were captured within one viewpoint-positive enthusiasts. Three student viewpoints were identified: challenge seekers, realistic embracers, and support seekers. Both students and faculty believed that simulation improved critical thinking.

CONCLUSION

The findings suggest that faculty should be aware of the range of student perceptions and tailor their teaching approaches accordingly to maximize student learning.

Kidney transplant patients' attitudes towards self-management support: A Q-methodological study

OBJECTIVE

Kidney transplant recipients face many self-management challenges. We aimed to identify profiles of attitudes towards self-management support (SMS) shortly after kidney transplantation.

METHODS

Profiles were generated using Q-methodology: In face-to-face interviews participants rank-ordered opinion statements on aspects of SMS according to agreement. Socio-demographic and medical characteristics were assessed using a questionnaire. By-person factor analysis was used to analyze the rankings and qualitative data was used to support choice of profiles. The resulting factors represent clusters of patients with similar attitudes towards SMS.

RESULTS

Forty-three patients (mean age=56; 77% male) participated. Four profiles were identified: (A) transplant-focused and obedient; (B) holistic and collaborative; (C) life-focused and self-determined; and (D) was bipolar. The positive pole (D+) minimalizing and disengaged and the negative pole (D-) coping-focused and needy represent opposing viewpoints within the same profile. Socio-demographic and medical characteristics were not related to profile membership.

DISCUSSION

Each profile represents a specific attitude on post-transplant life, responsibility for health and decision-making, SMS needs, and preferences for SMS.

PRACTICAL IMPLICATIONS

Patients vary in their attitude, needs and preferences for SMS indicating the necessity of providing personalized support after kidney transplantation. Health professionals should explore patients' SMS needs and adapt support accordingly.

Discourses of sexual relationships in a sample of German and British young people: a Q methodological study

Young people live in an environment that sexualises them, particularly women, along traditional gender roles. This, in parallel with a silence about positive sexuality in policy development, means that sexual double standards prevail in young people's lives. The aim of this study was to explore the discourses young women and men from two European countries, Germany and England, draw on when making sense of sexual relationships and how these are steeped in the local cultural climate and messages. The study used Q methodology and included 65 German and English young people between 16 and 19 years of age. Six accounts emerged: sex as responsible, intimate and shared experience; sex as joint fun; ideal versus reality; sex has to be responsible, consensual and shared; caring relationships offer the perfect context for fulfilling sex; and equality between partners. The importance of cultural context in the availability of specific dominant and alternative discourses is discussed with a focus on how this influences young people's sense-making with regard to sexuality and sexual relationships. Future directions for research are highlighted.

Exploring student preferences with a Q-sort: the development of an individualized renal physiology curriculum

Medical education reform is underway, but the optimal course for change has yet to be seen. While planning for the redesign of a renal physiology course at the Duke School of Medicine, the authors used a Q-sort survey to assess students' attitudes and learning preferences to inform curricular change. The authors invited first-year medical students at the Duke School of Medicine to take a Q-sort survey on the first day of renal physiology. Students prioritized statements related to their understanding of renal physiology, learning preferences, preferred course characteristics, perceived clinical relevance of renal physiology, and interest in nephrology as a career. By-person factor analysis was performed using the centroid method. Three dominant factors were strongly defined by learning preferences: "readers" prefer using notes, a textbook, and avoid lectures; "social-auditory learners" prefer attending lectures, interactivity, and working with peers; and "visual learners" prefer studying images, diagrams, and viewing materials online. A smaller, fourth factor represented a small group of students with a strong predisposition against renal physiology and nephrology. In conclusion, the Q-sort survey identified and then described in detail the dominant viewpoints of our students. Learning style preferences better classified first-year students rather than any of the other domains. A more individualized curriculum would simultaneously cater to the different types of learners in the classroom.

Identifying dentists' attitudes towards prevention guidance using Q-sort methodology

OBJECTIVE

To gain insight into the attitudes and motivating factors of dentists working in the English National Health Service (NHS) towards prevention guidance.

DESIGN

Q-methodology: an established hybrid quantitative/qualitative technique used in the social sciences to categorise subjects based on their views by considering factors as part of their overall decision-making profile.

SETTING

General Dental Practices offering care under an NHS contract.

SUBJECTS AND METHODS

NHS dentists (n = 26) placed 36 statements about prevention guidance derived from an earlier study into a distribution grid that ranked the statements from "most agree" to "most disagree". Principal components factor analysis was applied to determine the principal patterns in the rankings of statements.

RESULTS

Analysis indicated a total of six distinct profiles within the responses, of which three profiles had at least six dentists loading onto them. The first profile was strongly characterised by dentists who appear motivated to provide prevention but financial and time constraints prevent them from doing so. The second was characterised by dentists using prevention guidance but restricting its use to only certain patients. The third was characterised by dentists who appeared "health-focused". They placed importance on working to prevention guidance, but were keen to have greater patient and professional support in achieving this.

CONCLUSION

In this group of dentists Q-methodology identified three main profiles to the delivery of prevention guidance.

Attitudes toward clinical practice in undergraduate nursing students: A Q methodology study

BACKGROUND

Clinical practice (CP) provides an opportunity to directly apply nursing theories learned in class to practice, with the aim of improving nursing knowledge and skills. Nursing students' perspectives about CP can be diverse.

OBJECTIVE

To identify nursing students' attitudes toward CP.

DESIGN

Q-methodology, an integration of quantitative and qualitative methods, was used.

PARTICIPANTS

A convenience P-sample consisting of 43 second-year undergraduate nursing students.

METHODS

Forty-three selected Q-statements from each of the 43 participants (P-sample) were classified into the shape of a normal distribution using a 9-point bipolar scale. The collected data were analyzed using the pc-QUANL program.

RESULTS

Two discrete factors emerged. Factor I comprised a querulous attitude with a critical perspective. Factor II comprised an enthusiastic attitude with a future-oriented perspective.

CONCLUSION

The subjective viewpoints of the two identified factors can be applied in planning effective CP for nursing students.

The development of an instrument to measure global dimensions of maternal care in rhesus macaques (Macaca mulatta)

One of the strongest predictors of healthy child development is the quality of maternal care. Although many measures of observation and self-report exist in humans to assess global aspects of maternal care, such qualitative measures are lacking in nonhuman primates. In this study, we developed an instrument to measure global aspects of maternal care in rhesus monkeys, with the goal of complementing the individual behavioral data collected using a well-established rhesus macaque ethogram during the first months postpartum. The 22 items of the instrument were adapted from human maternal sensitivity assessments and a maternal Q-sort instrument already published for macaques. The 22 items formed four dimensions with high levels of internal reliability that represented major constructs of maternal care: (1) Sensitivity/Responsivity, (2) Protectiveness, (3) Permissiveness, and (4) Irritability. These dimensions yielded high construct validity when correlated with mother-infant frequency and duration behavior that was collected from focal observations across the first 3 postnatal months. In addition, comparisons of two groups of mothers (Maltreating vs. Competent mothers) showed significant differences across the dimensions suggesting that this instrument has strong concurrent validity, even after controlling for focal observation variables that have been previously shown to significantly differentiate these groups. Our findings suggest that this Instrument of Macaque Maternal Care has the potential to capture global aspects of the mother-infant relationship that complement individual behaviors collected through focal observations.

Using Bourdieu's theory of practice to understand ICT use amongst nurse educators

BACKGROUND

Implementing changes in practice in either clinical or educational settings remains challenging. In the context of Information and Communication Technologies (ICT) adoption, the literature focuses either on organisational factors influencing its implementation, or on individual factors influencing its adoption into practice. Separately both fail to examine the issue holistically. Bourdieu's theory of practice provides a method for reconciling the two.

OBJECTIVE

To provide a practical example of how Bourdieu's theory of practice can be employed to better understand nurse educators' responses to ICT.

DESIGN

Exploratory descriptive design, using a Bourdieusian case-study to guide a documentary analysis.

METHODS

In 2009 a two-part study was conducted within a Department of Nursing (DON) in higher education (HE) in England. First Bourdieu's theory of practice was used to develop a case-study; then nurse educators were recruited for a Q-methodology (Q) study. This paper focuses exclusively on the case study and the use of the theory of practice to interpret the findings from the Q-study.

RESULTS

Nursing's transition into academia, promotions criteria in HE and the value placed on research over teaching have influenced educators' responses to technology.

CONCLUSION

The use of Bourdieu's framework provides a rich and contextual backdrop for understanding how organisational factors interact to influence individuals' responses to technology adoption.

Perceived effects of innovations in postgraduate medical education: a Q study focusing on workplace-based assessment

PURPOSE

Anticipating users' perceptions of the effects an innovation will have in daily practice prior to implementation may lead to a more optimal innovation process. In this study, the authors aimed to identify the kinds of perceptions that exist concerning the effects of workplace-based assessment (WBA), an innovation that is widely used in medical education, among its users.

METHOD

In 2012, the authors used Q methodology to ascertain the principal user perceptions of effects of WBA in practice. Participating obstetrics-gynecology residents and attending physicians (including residency program directors) at six hospitals in the Netherlands performed individual Q sorts to rank 36 statements concerning WBA and WBA tools according to their level of agreement. The authors conducted by-person factor analysis to uncover patterns in the rankings of the statements. They used the statistical results and participant comments about their sorts to interpret and describe distinct perceptions.

RESULTS

The analysis of 65 Q sorts (completed by 22 residents and 43 attendings) identified five distinct user perceptions regarding the effects of WBA in practice, which the authors labeled enthusiasm, compliance, effort, neutrality, and skepticism. These perceptions were characterized by differences in views on three main issues: the intended goals of the innovation, its applicability (ease of applying it to practice), and its actual impact.

CONCLUSIONS

User perceptions of the effects of innovations in medical education can be typified and should be anticipated. This study's insights into five principal user perceptions can support the design and implementation of innovations in medical education.

The Situational Eight DIAMONDS: a taxonomy of major dimensions of situation characteristics

Taxonomies of person characteristics are well developed, whereas taxonomies of psychologically important situation characteristics are underdeveloped. A working model of situation perception implies the existence of taxonomizable dimensions of psychologically meaningful, important, and consequential situation characteristics tied to situation cues, goal affordances, and behavior. Such dimensions are developed and demonstrated in a multi-method set of 6 studies. First, the "Situational Eight DIAMONDS" dimensions Duty, Intellect, Adversity, Mating, pOsitivity, Negativity, Deception, and Sociality (Study 1) are established from the Riverside Situational Q-Sort (Sherman, Nave, & Funder, 2010, 2012, 2013; Wagerman & Funder, 2009). Second, their rater agreement (Study 2) and associations with situation cues and goal/trait affordances (Studies 3 and 4) are examined. Finally, the usefulness of these dimensions is demonstrated by examining their predictive power of behavior (Study 5), particularly vis-à-vis measures of personality and situations (Study 6). Together, we provide extensive and compelling evidence that the DIAMONDS taxonomy is useful for organizing major dimensions of situation characteristics. We discuss the DIAMONDS taxonomy in the context of previous taxonomic approaches and sketch future research directions.

Attitudes toward simulation-based learning in nursing students: an application of Q methodology

SBL is a highly advanced educational method that promotes technical/non-technical skills, increases team competency, and increases health care team interaction in a safe health care environment with no potential for harm to the patient. Even though students may experience the same simulation, their reactions are not necessarily uniform. This study aims at identifying the diversely perceived attitudes of undergraduate nursing students toward simulation-based learning. This study design was utilized using a Q methodology, which analyzes the subjectivity of each type of attitude. Data were collected from 22 undergraduate nursing students who had an experience of simulation-based learning before going to the clinical setting. The 45 selected Q-statements from each of 22 participants were classified into the shape of a normal distribution using a 9-point scale. The collected data was analyzed using the pc-QUANL program. The results revealed two discrete groups of students toward simulation-based learning: 'adventurous immersion' and 'constructive criticism'. The findings revealed that teaching and learning strategies based on the two factors of attitudes could beneficially contribute to the customization of simulation-based learning. In nursing education and clinical practice, teaching and learning strategies based on types I and II can be used to refine an alternative learning approach that supports and complements clinical practice. Recommendations have been provided based on the findings.

Therapeutic interaction with an older personality disordered patient

This study reflects an assessment of the relationship between change in defensive functioning and change in the therapeutic interaction during an eight-year treatment episode of an older personality disordered woman. The patient, Ms. Q, possessed schizoid, avoidant, and depressive personality disorders as well as major depression as assessed by the Millon Clinical Multiaxial Inventory-III (MCMI-III). At the end of the treatment episode, Ms. Q still possessed an avoidant personality disorder and significant depressive personality traits but no longer possessed clinically significant schizoid traits or major depression. Ms. Q made significant positive change in her adaptive defensive functioning as assessed by the Defense Mechanism Rating Scale (DMRS). Through time-series analysis it was discovered that positive change in adaptive defenses was predicted by increases in a specific type of therapeutic interaction as assessed by the Psychotherapy Q Sort (PQS). In this therapeutic interaction the therapist in a didactic and advice-giving manner highlighted the patient's role in a problem in a clear and coherent way that could be perceived as tactless. Time-series analysis revealed a reciprocal relationship in which positive changes in adaptive defenses predicted further increases in that particular quality of therapeutic interaction.

Attitudes toward Video-Assisted Debriefing after simulation in undergraduate nursing students: an application of Q methodology

BACKGROUND

Video-Assisted Debriefing (VAD) provides an affirmative self-reflection through reviewing what went right, what went wrong, what had to be done, and what should be done in the future.

OBJECTIVE

To identify attitudes toward Video-Assisted Debriefing after a simulation in undergraduate nursing students.

DESIGN

Q-methodology, which has been identified as a method for the analysis of subjective viewpoints and to have the strengths of both qualitative and quantitative methods, was used.

SETTING

College of Nursing in Seoul.

PARTICIPANTS

A convenience P-sample consisting of 44 third-year undergraduate nursing students.

METHODS

Thirty-nine selected Q-statements from each of 44 participants (P-sample) were classified into the shape of a normal distribution using a 9-point bipolar scale from -4 for strongly disagree to +4 for strongly agree. The collected data were analyzed using the pc-QUANL program.

RESULTS

Three discrete factors emerged: Factor I (VAD helps self-reflection; strategic view), Factor II (VAD makes us tired and humiliated; reluctant view), and Factor III (VAD boosts self-confidence; forward view).

CONCLUSION

The findings could be used as a cornerstone for application of customized debriefing method to undergraduate nursing students. Debriefing techniques considering student's individual learning style.

Playing with curricular milestones in the educational sandbox: Q-sort results from an internal medicine educational collaborative

PURPOSE

In competency-based medical education, the focus of assessment is on learner demonstration of predefined outcomes or competencies. One strategy being used in internal medicine (IM) is applying curricular milestones to assessment and reporting milestones to competence determination. The authors report a practical method for identifying sets of curricular milestones for assessment of a landmark, or a point where a resident can be entrusted with increased responsibility.

METHOD

Thirteen IM residency programs joined in an educational collaborative to apply curricular milestones to training. The authors developed a game using Q-sort methodology to identify high-priority milestones for the landmark "Ready for indirect supervision in essential ambulatory care" (EsAMB). During May to December 2010, the programs'ambulatory faculty participated in the Q-sort game to prioritize 22 milestones for EsAMB. The authors analyzed the data to identify the top 8 milestones.

RESULTS

In total, 149 faculty units (1-4 faculty each) participated. There was strong agreement on the top eight milestones; six had more than 92% agreement across programs, and five had 75% agreement across all faculty units. During the Q-sort game, faculty engaged in dynamic discussion about milestones and expressed interest in applying the game to other milestones and educational settings.

CONCLUSIONS

The Q-sort game enabled diverse programs to prioritize curricular milestones with interprogram and interparticipant consistency. A Q-sort exercise is an engaging and playful way to address milestones in medical education and may provide a practical first step toward using milestones in the real-world educational setting.

Technical and operational users' opinions of a handheld device to detect directed energy

INTRODUCTION

Lasers, a form of directed energy (DE), are a threat to pilots and Air Force personnel. In light of this threat, a handheld medical device called the "Tricorder" is under development to improve situational awareness of DE. Current operational procedures do not include methods for recording or handling new information regarding DE. The purpose of this study was to understand Air Force personnel opinions and beliefs about desired features and operational use to enhance user acceptance of the Tricorder.

METHOD

Q-methodology was implemented to study opinions and beliefs related to DE. Two groups were approached, medical personnel in the Illinois Air National Guard and four active duty members of an Air Force Rescue Squadron. Both groups completed the same Q-sort of both operational and equipment concerns.

RESULTS

Six opinion sets regarding operational concerns described 61% of the total variation in perceptions among participants. The factors were: concern over health effects, implications to individuals, combat/tactical concerns, force health protection, and theater/tactical concerns. Five opinion sets described 68% of the variation in the equipment functions perceived as most important. The participants indicated that ideally the device should measure exposure, enhance laser detection/response, support night vision and ease of use, detect threats, and enhance combat medicine.

CONCLUSION

This survey revealed the complexity of equipment and the operational implications of detecting DE. Q-methodology is a unique strategy to both evaluate technology and explore users' concerns.

First year nursing students' viewpoints about compromised clinical safety

OBJECTIVE

Undergraduate nursing students must uphold patient safety as a professional and moral obligation across all clinical learning experiences. This expectation commences at entry into the nursing program. As part of a larger study exploring undergraduate baccalaureate nursing students' understanding of clinical safety, this paper specifically focuses on first year students' viewpoints about unsafe clinical learning situations.

METHODS

Q-methodology was used. Sixty-eight first year nursing students participated in the ranking of 43 statements indicative of unsafe clinical situations and practices. Data was entered into a Q-program for factor analysis.

RESULTS

The results revealed a typology of four discrete viewpoints of unsafe clinical situations for first year students. These viewpoints included an overwhelming sense of inner discomfort, practicing contrary to conventions, lacking in professional integrity and disharmonizing relations. Overall, a consensus viewpoint described exonerating the clinical educator as not being solely responsible for clinical safety.

DISCUSSION

This information may assist students and educators to cooperatively and purposefully construct a clinical learning milieu conducive to safety.

Models of intellectual disability: towards a perspective of (poss)ability

BACKGROUND

The social and medical models of disability configure the relationship between disability and impairment differently. Neither of these models has provided a comprehensive theoretical or practical basis for talking about intellectual disability (ID). Models that emphasise the interactive nature of disability appear to be more promising. This study explores the ways in which models of disability are reflected in disability discourse in an empirical discourse analysis conducted in the Eastern Cape Province of South Africa.

METHODS

Q methodology was used in this study as a discourse analysis tool. Adults with ID, parents of children with ID and professionals who work with people with ID completed a sorting task where they stated the degree to which they agreed or disagreed with statements that are made about people with ID. This exercise resulted in a pattern of responses for each participant, termed a Q sort and these were used as data in a factor analysis using dedicated Q method software. A second order factor analysis was then performed on the resulting factors.

RESULTS

Four discourses were identified: the Social Model/Human Rights Discourse, the Medical Model/Professional Religious Discourse, the Community Model/Community Religious Discourse and the Interactive Discourse. Except for the last one, each of these discourses adopts a model of disability with a static view of impairment as fixed. The Interactive Discourse appears to be related to dynamic, environmental conceptions of disability where competence is built through social interaction.

CONCLUSIONS

A theory of (poss)ability is proposed and some of its concerns are suggested. This perspective views impairment as an interaction between individuals and their environment and postulates that competence is a function of context, rather than a property of the individual.

Differential expression of social dominance as a function of age and maltreatment experience

Recent perspectives on social dominance in normative populations have suggested a developmental progression from using primarily coercive strategies to incorporation of more socially competent strategies to attain material and social resources. Parental influences on the resource control strategies children use have been proposed but not investigated empirically. The present study examined age- and gender-related differences in dominance strategies in 470 children from high-risk neighborhoods who were between 6 and 13 years of age, approximately half of whom had experienced maltreatment. A Q-sort measure of social dominance was developed and received preliminary support. Consistent with predictions from resource control theory, age-related differences in dominance-related behavior were demonstrated in both nonmaltreated and maltreated children. Maltreated children were more likely than nonmaltreated children to be identified as dominant bullies at any age. Dominance and bullying were not more likely to be associated for children who had experienced physical and sexual abuse relative to those who were neglected or emotionally maltreated. Results are discussed in terms of the influence of maltreatment on the social development of children, and intervention approaches for limiting these deleterious effects are recommended.

What influences patients' decisions on artificial hydration at the end of life? A Q-methodology study

CONTEXT

Artificial hydration (AH) is used to palliate patients with reduced fluid intake at the end of life but is a controversial practice. Patients' involvement in decision making varies, and little is known about patients' understanding of the benefits and burdens of AH.

OBJECTIVES

To identify the factors that patients consider most important when making decisions regarding AH at the end of life.

METHODS

Interview study using Q-sort methodology conducted with 20 patients with advanced diseases recruited from inpatient and outpatient palliative care services.

RESULTS

Several domains appear to influence a decision about AH: the patient's understanding of AH, their philosophical position on end-of-life care, the process of discussion, and who makes the final decision. Patients generally based their decision on whether AH would improve quality of life, although prolonging life was important for some. Hydration was not considered a burden, and many would want a trial of AH in the event that they could no longer drink. Patients wanted to be guided by medical opinion, although some wanted to make the decision on their own. All patients welcomed the opportunity to discuss AH.

CONCLUSION

Patients view AH as an important issue and are keen to be involved in decision making. Health care professionals may withhold AH at the end of life because they perceive it as a burden on patients and on their interactions with family, although this view is not shared by patients. Some patients lack understanding regarding the likely benefits of AH. Research examining the impact of clinical information regarding AH on patients' decision making is now needed.

Maternal sensitivity: within-person variability and the utility of multiple assessments

In this study, we examined within-person variability in maternal sensitivity among a culturally diverse sample of high-risk mother-infant dyads (N = 25). We also examined incremental increases in effect sizes between maternal sensitivity and two related variables, attachment state of mind and child removal from the home, as a function of increasing observations of maternal sensitivity. The dyads were videotaped during 10 1-hour-long home visits and maternal sensitivity was coded using the abbreviated (25-item) version of the Maternal Behavior Q-Sort (MBQS). Attachment state of mind was assessed using the Adult Attachment Interview (AAI). Within-person variability in maternal sensitivity was greater for nonautonomous mothers compared to autonomous mothers. Mothers who were relatively low in maternal sensitivity were more likely to be nonautonomous and also more likely to have their child removed from their home by child protective services. Results from data sampling trials showed incremental increases in these effect sizes as the number of observations of maternal sensitivity increased. Fewer observations of maternal sensitivity resulted in systematic underestimates of effect sizes between maternal sensitivity and related variables. We discuss the implications for maltreatment researchers and interventionists.

Educational needs: what female patients want from their cardiovascular health care providers

This descriptive convenience study used a card sort technique to determine the self-identified cardiovascular health care needs of 81 female patients as compared to those identified as most important by their health care providers.

[Use of Q-sort assessment methods for diagnostic purposes and in treatment evaluation?]

OBJECTIVES

Does quantifying psychotherapy research do justice to its subject matter?

METHODS

Q-sort techniques are presented for the assessment of personality pathology, mental and interpersonal problems, as well as for quantifying the psychotherapeutic process.

RESULTS

In studies on psychotherapy planning we identified mechanisms characteristic of nonresponders which could be efficiently captured with q-sort methods. From these clinically relevant intervention techniques can be derived. In psychoanalytic process research we operationalized relevant microelements in the patient-therapist interaction.

CONCLUSIONS

Q-sort methods are efficient and helpful for studying research questions that are clinically relevant but often difficult to grasp as well as for dismantling studies.

Attitudes among stakeholders towards compulsory mental health care in Norway

OBJECTIVES

The Norwegian Mental Health Care Act allows use of coercion under certain conditions. Even though the current practice has been criticized, little empirical data exist about the attitudes towards compulsory mental health care.

METHOD

This study used Q-methodology to identify prototypical attitudes and to test possible differences of attitudes between groups of stakeholders towards the use of coercion in mental health care. Sixty-two respondents who represented six groups with different roles in mental health care participated: former patients, relatives of psychiatric patients, members of supervisory commissions, psychiatrists, other physicians, and lawyers. The participants were asked to assess the degree to which they agreed on 30 statements concerning use of coercion for the mentally ill.

RESULTS

Three factors that in a meaningful way express different attitudes towards the question were found. The most widely shared attitude stated that a trusting relationship between patient and therapist is more important than the right to have an attorney. This attitude gives partial support to the present Mental Health Care Act. However, the second most common attitude argues that involuntary hospitalization, if necessary, should be decided in a court and not by the hospital doctor.

CONCLUSIONS

Differences in attitude could partly be explained by the respondents' role in mental health care. Both psychiatrists and "somatic" physicians expressed more agreement with the present legislation than the other stakeholders. The findings may have implications for the legal protection of mental health care patients.

Organization of co-occurring Axis II features in borderline personality disorder

OBJECTIVES

Considerable heterogeneity exists in the comorbid Axis II features that frequently accompany borderline personality disorder (BPD). These features have potential to be meaningfully organized, relate to specific BPD presentation, and have implications for treatment process and outcome. The present study explored patterns of Axis II comorbidity in order to identify subtypes of BPD.

DESIGN

A well-defined sample of 90 patients diagnosed with BPD was recruited as part of an RCT study. Participants were administered the International Personality Disorder Examination (Loranger, 1999) to diagnose BPD and assess comorbid Axis II features. Other measures were also administered to assess aspects of current work and relationship functioning, symptomatology, and self-concept.

METHODS AND RESULTS

Q-factoring was used to develop subtypes based on commonly occurring Axis II profiles, identifying three: Cluster A (elevated paranoid and schizotypal features), Cluster B (elevated narcissistic and histrionic features), and Cluster C (elevated avoidant and obsessive-compulsive features). An additional factor analysis revealed two dimensions underlying the comorbid features identifiable as: extraversion versus introversion and antagonism versus constraint. Validity of these two maps of comorbidity was explored in terms of the BPD criteria themselves, as well as on work and relationship functioning, identity diffusion, views of self and others, positive and negative affect, behavioural dyscontrol, and symptomatic distress.

CONCLUSIONS

Clinically meaningful subtypes can be identified for BPD based on co-occurring Axis II features. Further research is needed to replicate and further establish base-rates of these subtypes as well as their differential implications for treatment.

Exploration of personality factors and their predictive impact on therapy utilization: the externalizing mode of functioning

The aim of this study was to identify personality factors predicting psychotherapy utilization on the basis of personality pathology, affect regulation and interpersonal functioning. The authors assessed affectivity (using the Affect Experience and Affect Regulation Q-Sort), interpersonal context (using the Quality of Object Relations Scale), and character pathology (using the Shedler-Westen Assessment Procedure-200). Combination of instruments showed one stable factor predictive for nonengagement in psychotherapy, revealing an externalizing personality dimension, dominated by externalizing defenses, acting out, deficient superego functions, and impairment in reflective functioning and in relating to others. Stability of the predictive power of this personality factor for therapy engagement could be shown, and replication in two other samples confirmed the findings. The results highlight the importance of measuring affect-regulatory mechanisms, and clinical implications for intervention techniques are discussed.