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Perspectives in Psychiatric Care
ISSN 0031-5990
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire Louise Byrne, MA (Hons), Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD, and Chris Platania-Phung, BA (Hons) Louise Byrne, MA (Hons), PhD Candidate, Lecturer in Recovery & Lived Experience Practitioner, Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Rockhampton, Queensland, Australia; Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD, Engaged Research Chair in Mental Health Nursing, Director, Professor, Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Rockhampton, Queensland, Australia; and Chris Platania-Phung, BA (Hons), Research Fellow, Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Rockhampton, Queensland, Australia.
Search terms: Attitudes, consumer participation, mental health, nursing education Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no conflict of interest. First Received June 26, 2013; Final Revision received January 07, 2014; Accepted for publication January 16, 2014. doi: 10.1111/ppc.12064
PURPOSE: The aims of this article were to evaluate the Mental Health Consumer Participation Questionnaire, and measure nursing students’ attitudes to consumer participation. DESIGN AND METHODS: Undergraduate nursing students (n = 116) completed the Mental Health Consumer Participation Questionnaire at the start of a course on recovery for mental health nursing practice. FINDINGS: The current findings confirm an endorsement of consumer participation in individual care processes, but less agreement with participation in organizational-level processes, such as management of mental health services and education of providers. This article also confirms that the questionnaire can effectively measure attitudes to consumer participation. PRACTICE IMPLICATIONS: The participation of consumers is critical for achieving person-centered services mental health services. It is important that nursing education influence positive attitudes.
Introduction The participation of consumers of mental health services is critical to providing quality services (Happell & Roper, 2007). Consumer participation can take many forms, such as input by the consumer into their own individual care (Goodwin & Happell, 2006, 2007a; Lammers & Happell, 2004a, 2004b), having a voice in how services are run, including representation on committees (Happell & Roper, 2007), and providing education for currently practicing nurses (Simpson, 1999), and students entering the nursing workforce (Byrne, Happell, Welch, & Moxham, 2013; Happell & Roper, 2003; Happell, Pinikahana, & Roper, 2003a). An approach to service delivery based on high levels of consumer participation clearly represents a different model to “traditional” care. For example, power relations between consumers and service providers are significantly different, with no clear assumption that health professionals should automatically be in charge (McAllister & Walsh, 2004). There is consensus in the literature that developing a culture where health professionals are accepting and welcoming of conPerspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
sumer participation is difficult. Qualitative researchers with consumers as participants demonstrate the negative attitudes of health professionals as a cultural barrier (Lammers & Happell, 2003). Attitudes are a major barrier to consumers voicing their own perspective and providing input on the quality of service delivery (Goodwin & Happell, 2007b, 2008; Lammers & Happell, 2003), and one reason that actual change in day-to-day care has been incremental at best. Although consumer participation is a long-term plan to improve mental health services, and research on progress and fostering a consumer participation culture is obviously needed, the divergence between research, evaluation and policy emphasis is large (Browne & Hemsley, 2008; Stewart, Watson, Montague, & Stevenson, 2008). Consumer participation that benefits consumers by improving services requires a major commitment and knowledge-base, as arrangements for consumer participation can easily recede into tokenism, where consumers are selected into roles with the aim of being influential, but the environmental factors required to have an effective voice are not provided (Townsend, Pirkis, Pham, Harris, & Whiteford, 2006), and 45
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
the high demand environments of mental health care generate resistance to changing of the status quo. Moving toward more collaborative styles of care and more effectively meeting consumer needs in a holistic way will require system-wide changes, including a nursing workforce ready for and receptive to consumer participation. Although there is research on staff views (McCann, Baird, Clark, & Lu, 2008) and that of consumer participants on the experience of consumer participation (Callander et al., 2011), there is a shortage of research on students’ views and surveys of attitudes held by all those involved in mental health care. Measures of attitudes on consumer participation are useful for quantifying the level of endorsement of consumer participation and for evaluating if nursing education is adequately moving the next generation of workers toward the principles of consumer participation. The Mental Health Consumer Participation Questionnaire (MHCPQ) is a measure for these purposes. Happell, Moxham, and Platania-Phung (2010) found that the MHCPQ addresses attitudes on consumer involvement in their care, consumer capacity for active participation, and participation in formal organizational processes. Ratings on the MHCPQ also revealed that while nursing students think consumer participation should be implemented with respect to decision-making and involvement in treatment, views on the level of participation in organizational processes were more varied. The context of the current research was an undergraduate nursing program in a regional university in Australia. The interest was in evaluating students’ attitudes and whether they would change from before the course to after the course. This article aimed to report on the students’ attitudes before undergoing a course on mental health, such as the degree to which students are open to the idea of consumer participation, and if so, in what ways. The corresponding aim was to evaluate the MHCPQ as an approach to tracking progress in attitudinal change.
graduate mental health nursing students’ views on consumer participation. The measure involved rating statements on different types of consumer participation (24 overall). Before students are asked to rate their level of agreement or disagreement with each statement, they were provided with definitions. This was presented as follows:
Method
The study was approved by the university ethics committee. Participants were asked for their names in order to match responses to after the course. Prospective participants were informed that only the researchers would have access to names, and that only aggregate responses would be reported.
Participants Undergraduate nursing students from one Australian university were invited to participate in this research. One hundred sixteen undergraduate students participated. Most of the sample were women (n = 108, 93.1%). The age distribution was a follows: 18–29 years (42.2%), 30–39 years (27.6%), 40–49 (20.7%), and 50 and older (9.5%). Eleven participants (9.5%) had taken part in a mental health clinical placement before the current course. Measures The MHCPQ is a self-report questionnaire developed by Happell, Pinikahana, and Roper (2002) to measure post46
A “mental health consumer” or “consumer” is defined as a person who is currently using (or in the past has used) mental health services as either an in-patient or out-patient. You may hear them referred to as patients. A “consumer academic” is defined as a person with lived experience of mental health service use, who is employed in an academic position, and is actively involved in the education of mental health professionals (nurses in this instance). The rating scale was an anchor response format with numbers ranging from 1 to 7 and the end points were “strongly disagree” and “strongly agree,” respectively. Based on a principal components analysis, Happell et al. (2010) found evidence for three underlying attitudinal domains of the Consumer Participation Questionnaire, and reliability in the region of 0.70 and 0.80. The MHCPQ has a second section asking students to state their views on what consumer participation is about and its main elements. This article is focused only on the quantitative data derived from the survey. Procedure The MHCPQ was administered to students completing the mental health nursing component of the nursing program. Data were collected in the second half of 2012. Students were informed that it was a two-stage study, so that they would be invited to participate in a follow-up survey. Ethical Issues
Data Analysis The data approach was confirmatory factor analysis—a rigorous method of assessing scales. Mplus 6.1 (Mplus, Los Angeles, CA, USA) was the analytic platform for the current research. The missing data in this study was minimal—the maximum missing data per item was two cases out of the 116. Missing cases were replaced with values from expected maximum likelihood estimation, in the Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, IL, USA). Perspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
Criteria for evaluating the factor models took into account different approaches to model fit (cf. Byrne, 2012): goodness of fit χ2 statistic with a p value of over .05; less than 0.08 for the root mean square error of approximation (RMSEA); less than 0.05 for the root mean square residual, and over 0.95 for the comparative fit index (CFI) and Tucker Lewis fit index (TLI) of over 0.95, and a standardized root mean square residual (SRMR) of .05 or under. The maximum likelihood estimator was applied. Reliability was assessed through the Cronbach (1951) internal consistency index. Results Students’ Views Table 1 presents the proportion of responses for the 24 items. In order to simplify description of the distributions, ratings
from 1 to 3 were classified as“toward disagree,”a rating of 4 was classified as “neither toward disagree nor agree” and ratings from 5 to 7 as “toward agree.” The pattern of responses shows that participants were mainly in agreement about consumer involvement in their own care, while there were varied opinions on the outcomes of consumer participation and organizational types of participation (e.g., decision-making on staff). Structure of Items: Confirmatory Factor Analysis Following the findings of Happell et al. (2010), a threefactor model was applied: consumer as staff, consumer involvement, and consumer capacity. Consumer as staff refers to attitudes to the notion of the consumer as a staff member or as someone active in staff processes (such as interview panels) and in the education of staff (e.g., consumer academic); consumer involvement includes involve-
Table 1. Distribution of Responses Statement: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
Mental health consumer involvement and participation should be fully supported by all mental health services Consumers should be actively involved in identifying the goals for their treatment Consumer input should be central in the planning of mental health services Consumers should always be involved in the evaluation and diagnosis of their presenting problems Consumers should be involved in the process for the hiring of all new staff of mental services Consumers should have the opportunity for genuine input into the planning of their own treatment Consumers should be encouraged to contribute to the writing of their own notes and records Consumers are already given sufficient opportunity to participate in the care they receive The medications used in mental health are very complex and consumers should only have limited input into deciding the most appropriate medications to be used Consumers should be involved in the planning and delivery of all staff education and professional development sessions A consumer academic should be a member of staff in all mental nursing courses An experienced mental health nursing academic can present a good understanding of the consumer perspective I need to be taught by a mental health consumer academic to more fully understand how a consumer might experience the mental health system People with mental illness can’t handle too much responsibility All mental health service committees should have at least one consumer member Mental health services work as well as they can and we shouldn’t use valuable resources trying to change them Consumers should be the ones to decide what a quality mental health service is Consumers use mental health services because they need help and therefore they shouldn’t be burdened with how these services are being provided Mental health services would not change significantly if consumers were employed by the services Medications should be explained in detail to consumers in ways that they can understand so they are fully informed and can make choices Mental health services would be likely to improve if consumers were involved in the planning and delivery of those services Increased consumer involvement in mental health services would probably increase the stress levels for service providers Consumers do not understand the language and complexities of mental health services, which makes it difficult for them to have meaningful input Consumers do not have enough self-confidence to become involved in the planning and delivery of mental health services
Perspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
Disagree (%)
Midpoint (%)
Agree (%)
0.0 5.2 0.0 10.3 70.7 0.9 56.0 45.7 43.1
5.2 4.0 8.6 16.4 20.7 11.2 19.8 35.3 31.0
94.0 99.1 89.7 72.4 7.8 87.1 23.3 17.2 25.0
57.8
20.7
20.7
16.4 12.9
37.9 19.8
44.8 65.5
13.8
28.4
56.0
64.7 7.8 72.4
24.1 25.9 17.2
10.3 65.5 8.6
19.8 37.1
33.6 37.9
45.7 24.1
50.9 2.6
37.9 6.0
24.1 90.5
9.5
27.6
62.1
44.0
37.9
16.4
50.0
29.3
19.8
58.6
31.0
9.5
47
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
.52
Consumer Capacity
Involvement would probably increase the stress levels for service providers
.71 Do not understand the language/complexities of MHS, difficult to have input .77 Do not have enough self-confidence to become involved planning/delivery MHS
.07 .77
Should be involved in process for hiring of new staff of MHS
.68
Consumer as Staff
.12
Should be encouraged contribute to writing of own notes/records .70 Should be involved in planning/delivery staff education and PD sessions
.02 .74 .87
Consumer Involvement
.77
Consumer participation should be fully supported by all MHS Should be actively involved in identifying the goals for their treatment Input should be central to planning MHS
.51 .73
Should always be involved in the evaluation and diagnosis of their presenting problems Should have the opportunity for genuine input into planning their own treatment
Figure 1. Standardized Factor Loadings and Inter-Factor Correlations for the Consumer Participation Questionnaire MHS, mental health services; PD, professional development.
ment in own treatment and services, views on consumers as an active and valuable part of own treatment, and mental health care planning and management; and consumer capacity is whether consumers can contribute to better mental health care on the basis of their skills and confidence, including mental health service management and planning, involvement in own treatment. Confirmatory factor analysis indicated that there were several low loading items especially for consumer capacity. Single-step refinements to the factors by removing “lowperforming” items were conducted. The final model showed reasonable fit: χ2 (41) = 42.92, p = .39, RMSEA = 0.02 (90% CI: 0.00, 0.07), CFI = 0.99, TLI = 0.99, SRMR = 0.06. Figure 1 presents the standardized factor loadings for the three-factor model. Factor coefficients ranged from 0.51 to 0.87. There was good discriminant validity among the three factors; the largest inter-factor correlation was 0.12 between consumer involvement and consumer capacity.
Differences in Students’ Views Items for each score were summed and averaged. The average ratings showed that students were consistent with the pattern for the full set of items for the questionnaire— students were most endorsing of consumer involvement (M = 5.99, standard deviation [SD] = 0.83), followed by consumer capacity (M = 4.64, SD = 1.07), and more toward disagreement with consumer involvement as staff (M = 2.85, SD = 1.39). Spearman rank correlations suggest that age was not associated with views on consumer as staff (rs = −0.03, p > .05), nor consumer capacity (rs = −0.02, p > .05), but was associated with consumer involvement (rs = 0.21, p < .05), with older students tending to agree more with involvement. As less than 1 in 10 students reported doing a mental health placement in the past, and less than 1 in 10 students were male, few inferences could be made into how these aspects of nurse background differentiate views on consumer participation.
Reliability Cronbach’s internal reliability alpha was in the moderate to good range for the respective scales: 0.70 for consumer capacity, 0.76 for consumer as staff, and 0.82 for consumer involvement. 48
Discussion The discussion begins, first, with attitudes on consumer participation, and second, with the findings on the quality of the MHCPQ and student differences in attitudes. Perspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
Students’ Attitudes on Consumer Participation
Differences in Attitudes on Consumer Participation
Although the current measure is different from others on consumer participation, and studies have looked at views of service providers (Kent & Read, 1998) more than students, the current findings reflect the limited broader literature (Happell, Pinikahana, & Roper, 2003b; Happell et al., 2002). The common finding was favorable views on consumer participation in terms of choice and autonomy in individual treatment and care, and not as favorable attitudes toward other forms of consumer participation, such as involvement as staff in the organization of mental health services, and involvement in the education of nurses. For instance, no participant (0%) disagreed with the notion that “consumers should be actively involved in identifying the goals for their treatment,” and in contrast, 58% disagreed that “Consumers should be involved in the planning and delivery of all staff education and professional development sessions.” Although the level of student observation or experience of actual mental health services was unclear, this cohort did indicate that they thought services can be conducted better. For instance, only 17.2% agreed that “consumers are already given sufficient opportunity to participate in the care they receive.” Nevertheless, students’ views on the level of consumer participation that should take place were a more contestable issue for them. While students endorsed representation of consumers in general, such as having at least one on committees (65.5% agree to this arrangement), and there was a high proportion of students who believed that consumers would have sufficient self-confidence to take part in mental health services—reservations were more frequent on consumer participation of a higher degree, such as decisionmaking in mental health care services (e.g., hiring of staff). This is consistent with the wider literature reporting that people (to be) involved in mental health sector are reluctant about the notion of formal organizational input of consumers (Happell et al., 2010; Kent & Read, 1998), and reflects the lack of consumer participation that actually takes place at an organization of mental health care (Storm, Hausken, & Knudsen, 2011).
This study found that older students tended to favor consumer participation more than younger students. While Happell et al. (2010) who used the MHCPQ, did find some links with student age, in that study, age was connected with more positive attitudes toward consumer capacity for participation, rather than consumer involvement. These divergent findings may be due to differences in operationalization of the scales between the two studies, where the current one was based on fewer items. Nevertheless, comparing the studies suggests that age may need to be considered in education (e.g., tailored instruction for students of different age groups), and the reasons for age differences addressed in depth through qualitative studies. The evaluation of the MHCPQ is an important step in improving the evaluation of the impact of nursing education, such as learning about consumer participation. Given the current finding that the MHCPQ has good reliability, further steps will be comparing views before the course with views after the course, including whether age-related differences endured. The next stages of research will include determining whether attitudes toward consumer participation are associated with other attitudes, such as toward mental health nursing and recovery. What will be especially important to identify is whether there are any changes in students’ views about the higher-level forms of consumer participation, such as involvement in decision-making on staff.
Psychometric Properties of the MHCPQ Although exploratory techniques have been applied to the MHCPQ in an educational context (Happell et al., 2010), to our knowledge, this is the first study of a confirmatory factor evaluation of this measure. Although there were several items of the MHCPQ that were not accounted for by the specified factors, there was good support for three domains of consumer participation. In addition, reasonable to good internal consistency was found for the final items for each scale. Perspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
Limitations This study had a small sample size (n = 116), which limits the capacity to provide robust parameter estimates in confirmatory factor analysis. Although the sample size was small, it should be noted that small sample sizes are not uncommon in this area of research (e.g., McCann, Clark, Baird, & Lu, 2008). Another limitation is that in refining the MHCPQ, a large number of items were removed to optimize measurement of attitudes. The implication is that it is unlikely that the construct representation can be generalized to other cohorts. Given this, items that were not included in the final confirmatory factor model should not be discounted in future research; more psychometric evaluation of the full questionnaire is needed. Conclusion Establishing genuine consumer participation, as aimed for in mental health policy, will require tracking of views of those preparing for nursing, including changes in attitudes that coincide with cultural change. Measures of views and attitudes of students are critical to this function. This article demonstrates that the Consumer Participation 49
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
Questionnaire is highly informative on students’ views, and also demonstrates adequate measurement properties, albeit after much refinement of scales. The views of students from a regional university in Australia were found to be remarkably similar to those of student and staff bodies in Australia and other countries, in that there was endorsement of the ideals of consumer participation, but less readiness for the levels of consumer participation enshrined in policy. The uniformity of views found thus far in the field suggests that a generic approach to changes toward consumer participation may be warranted.
Acknowledgments The authors sincerely thank the participants in this research for taking the time to complete these surveys. Also, thanks to the staff who assisted with the printing, distribution, and collection of surveys, and those involved with data entry, too many to mention, but all are greatly appreciated.
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Goodwin, V., & Happell, B. (2008). Psychiatric nurses’ attitudes toward consumer and carer participation in care: Part 2—Barriers to participation. Policy, Politics, & Nursing Practice, 9(4), 249–256. Happell, B., & Roper, C. (2003). The role of a mental health consumer in the education of postgraduate psychiatric nursing students: The students’ evaluation. Journal of Psychiatric and Mental Health Nursing, 10(3), 343–350. Happell, B., & Roper, C. (2007). Consumer participation in mental health research: Articulating a model to guide practice. Australasian Psychiatry, 15(3), 237–241. doi:10.1080/10398560701320113 Happell, B., Pinikahana, J., & Roper, C. (2002). Attitudes of postgraduate nursing students towards consumer participation in mental health services and the role of the consumer academic. International Journal of Mental Health Nursing, 11(4), 240–250. Happell, B., Pinikahana, J., & Roper, C. (2003a). Changing attitudes: The role of a consumer academic in the education of postgraduate psychiatric nursing students. Archives of Psychiatric Nursing, 17(2), 67–76. doi:10.1053/apnu.2003 .00008 Happell, B., Pinikahana, J., & Roper, C. (2003b). Changing attitudes: The role of a consumer academic in the education of postgraduate psychiatric nursing students. Archives of Psychiatric Nursing, 17(2), 67–76. doi:10.1053/apnu .2003.00008 Happell, B., Moxham, L., & Platania-Phung, C. (2010). A psychometric analysis of the Mental Health Consumer Participation Questionnaire. International Journal of Mental Health Nursing, 19(6), 377–384. doi:10.1111/j.1447-0349 .2010.00692.x Kent, H., & Read, J. (1998). Measuring consumer participation in mental health services: Are attitudes related to professional orientation? International Journal of Social Psychiatry, 44(4), 295–310. Lammers, J., & Happell, B. (2003). Consumer participation in mental health services: Looking from a consumer perspective. Journal of Psychiatric and Mental Health Nursing, 10(4), 385–392. Lammers, J., & Happell, B. (2004a). Mental health reforms and their impact on consumer and carer participation: A perspective from Victoria, Australia. Issues in Mental Health Nursing, 25(3), 261–276. Lammers, J., & Happell, B. (2004b). Research involving mental health consumers and carers: A reference group approach. International Journal of Mental Health Nursing, 13(4), 262–266. McAllister, M., & Walsh, K. (2004). Different voices: Reviewing and revising the politics of working with consumers in mental health. International Journal of Mental Health Nursing, 13(1), 22–32. McCann, T. V., Baird, J., Clark, E., & Lu, S. (2008). Mental health professionals’ attitudes towards consumer participation in inpatient units. Journal of Psychiatric and Mental Health Nursing, 15(1), 10–16. doi:10.1111/j.1365-2850.2007.01199.x
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Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
McCann, T. V., Clark, E., Baird, J., & Lu, S. (2008). Mental health clinicians’ attitudes about consumer and consumer consultant participation in Australia: A cross-sectional survey design. Nursing and Health Science, 10(2), 78–84. doi:10.1111/ j.1442-2018.2008.00388.x Simpson, A. (1999). Creating alliances: The views of users and carers on the education and training needs of community mental health nurses. Journal of Psychiatric and Mental Health Nursing, 6(5), 347–356. Stewart, S., Watson, S., Montague, R., & Stevenson, C. (2008). Set up to fail? Consumer participation in the mental health service
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system. Australasian Psychiatry, 16(5), 348–353. doi:10.1080/ 10398560802047367 Storm, M., Hausken, K., & Knudsen, K. (2011). Inpatient service providers’ perspectives on service user involvement in Norwegian community mental health centres. International Journal of Social Psychiatry, 57(6), 551–563. doi:10.1177/ 0020764010371270 Townsend, C. E., Pirkis, J. E., Pham, A. T., Harris, M. G., & Whiteford, H. A. (2006). Stakeholder concerns about Australia’s mental health care system. Australian Health Review, 30(2), 158–163.
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Perspectives in Psychiatric Care
ISSN 0031-5990
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire Louise Byrne, MA (Hons), Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD, and Chris Platania-Phung, BA (Hons) Louise Byrne, MA (Hons), PhD Candidate, Lecturer in Recovery & Lived Experience Practitioner, Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Rockhampton, Queensland, Australia; Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD, Engaged Research Chair in Mental Health Nursing, Director, Professor, Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Rockhampton, Queensland, Australia; and Chris Platania-Phung, BA (Hons), Research Fellow, Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Rockhampton, Queensland, Australia.
Search terms: Attitudes, consumer participation, mental health, nursing education Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no conflict of interest. First Received June 26, 2013; Final Revision received January 07, 2014; Accepted for publication January 16, 2014. doi: 10.1111/ppc.12064
PURPOSE: The aims of this article were to evaluate the Mental Health Consumer Participation Questionnaire, and measure nursing students’ attitudes to consumer participation. DESIGN AND METHODS: Undergraduate nursing students (n = 116) completed the Mental Health Consumer Participation Questionnaire at the start of a course on recovery for mental health nursing practice. FINDINGS: The current findings confirm an endorsement of consumer participation in individual care processes, but less agreement with participation in organizational-level processes, such as management of mental health services and education of providers. This article also confirms that the questionnaire can effectively measure attitudes to consumer participation. PRACTICE IMPLICATIONS: The participation of consumers is critical for achieving person-centered services mental health services. It is important that nursing education influence positive attitudes.
Introduction The participation of consumers of mental health services is critical to providing quality services (Happell & Roper, 2007). Consumer participation can take many forms, such as input by the consumer into their own individual care (Goodwin & Happell, 2006, 2007a; Lammers & Happell, 2004a, 2004b), having a voice in how services are run, including representation on committees (Happell & Roper, 2007), and providing education for currently practicing nurses (Simpson, 1999), and students entering the nursing workforce (Byrne, Happell, Welch, & Moxham, 2013; Happell & Roper, 2003; Happell, Pinikahana, & Roper, 2003a). An approach to service delivery based on high levels of consumer participation clearly represents a different model to “traditional” care. For example, power relations between consumers and service providers are significantly different, with no clear assumption that health professionals should automatically be in charge (McAllister & Walsh, 2004). There is consensus in the literature that developing a culture where health professionals are accepting and welcoming of conPerspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
sumer participation is difficult. Qualitative researchers with consumers as participants demonstrate the negative attitudes of health professionals as a cultural barrier (Lammers & Happell, 2003). Attitudes are a major barrier to consumers voicing their own perspective and providing input on the quality of service delivery (Goodwin & Happell, 2007b, 2008; Lammers & Happell, 2003), and one reason that actual change in day-to-day care has been incremental at best. Although consumer participation is a long-term plan to improve mental health services, and research on progress and fostering a consumer participation culture is obviously needed, the divergence between research, evaluation and policy emphasis is large (Browne & Hemsley, 2008; Stewart, Watson, Montague, & Stevenson, 2008). Consumer participation that benefits consumers by improving services requires a major commitment and knowledge-base, as arrangements for consumer participation can easily recede into tokenism, where consumers are selected into roles with the aim of being influential, but the environmental factors required to have an effective voice are not provided (Townsend, Pirkis, Pham, Harris, & Whiteford, 2006), and 45
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
the high demand environments of mental health care generate resistance to changing of the status quo. Moving toward more collaborative styles of care and more effectively meeting consumer needs in a holistic way will require system-wide changes, including a nursing workforce ready for and receptive to consumer participation. Although there is research on staff views (McCann, Baird, Clark, & Lu, 2008) and that of consumer participants on the experience of consumer participation (Callander et al., 2011), there is a shortage of research on students’ views and surveys of attitudes held by all those involved in mental health care. Measures of attitudes on consumer participation are useful for quantifying the level of endorsement of consumer participation and for evaluating if nursing education is adequately moving the next generation of workers toward the principles of consumer participation. The Mental Health Consumer Participation Questionnaire (MHCPQ) is a measure for these purposes. Happell, Moxham, and Platania-Phung (2010) found that the MHCPQ addresses attitudes on consumer involvement in their care, consumer capacity for active participation, and participation in formal organizational processes. Ratings on the MHCPQ also revealed that while nursing students think consumer participation should be implemented with respect to decision-making and involvement in treatment, views on the level of participation in organizational processes were more varied. The context of the current research was an undergraduate nursing program in a regional university in Australia. The interest was in evaluating students’ attitudes and whether they would change from before the course to after the course. This article aimed to report on the students’ attitudes before undergoing a course on mental health, such as the degree to which students are open to the idea of consumer participation, and if so, in what ways. The corresponding aim was to evaluate the MHCPQ as an approach to tracking progress in attitudinal change.
graduate mental health nursing students’ views on consumer participation. The measure involved rating statements on different types of consumer participation (24 overall). Before students are asked to rate their level of agreement or disagreement with each statement, they were provided with definitions. This was presented as follows:
Method
The study was approved by the university ethics committee. Participants were asked for their names in order to match responses to after the course. Prospective participants were informed that only the researchers would have access to names, and that only aggregate responses would be reported.
Participants Undergraduate nursing students from one Australian university were invited to participate in this research. One hundred sixteen undergraduate students participated. Most of the sample were women (n = 108, 93.1%). The age distribution was a follows: 18–29 years (42.2%), 30–39 years (27.6%), 40–49 (20.7%), and 50 and older (9.5%). Eleven participants (9.5%) had taken part in a mental health clinical placement before the current course. Measures The MHCPQ is a self-report questionnaire developed by Happell, Pinikahana, and Roper (2002) to measure post46
A “mental health consumer” or “consumer” is defined as a person who is currently using (or in the past has used) mental health services as either an in-patient or out-patient. You may hear them referred to as patients. A “consumer academic” is defined as a person with lived experience of mental health service use, who is employed in an academic position, and is actively involved in the education of mental health professionals (nurses in this instance). The rating scale was an anchor response format with numbers ranging from 1 to 7 and the end points were “strongly disagree” and “strongly agree,” respectively. Based on a principal components analysis, Happell et al. (2010) found evidence for three underlying attitudinal domains of the Consumer Participation Questionnaire, and reliability in the region of 0.70 and 0.80. The MHCPQ has a second section asking students to state their views on what consumer participation is about and its main elements. This article is focused only on the quantitative data derived from the survey. Procedure The MHCPQ was administered to students completing the mental health nursing component of the nursing program. Data were collected in the second half of 2012. Students were informed that it was a two-stage study, so that they would be invited to participate in a follow-up survey. Ethical Issues
Data Analysis The data approach was confirmatory factor analysis—a rigorous method of assessing scales. Mplus 6.1 (Mplus, Los Angeles, CA, USA) was the analytic platform for the current research. The missing data in this study was minimal—the maximum missing data per item was two cases out of the 116. Missing cases were replaced with values from expected maximum likelihood estimation, in the Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, IL, USA). Perspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
Criteria for evaluating the factor models took into account different approaches to model fit (cf. Byrne, 2012): goodness of fit χ2 statistic with a p value of over .05; less than 0.08 for the root mean square error of approximation (RMSEA); less than 0.05 for the root mean square residual, and over 0.95 for the comparative fit index (CFI) and Tucker Lewis fit index (TLI) of over 0.95, and a standardized root mean square residual (SRMR) of .05 or under. The maximum likelihood estimator was applied. Reliability was assessed through the Cronbach (1951) internal consistency index. Results Students’ Views Table 1 presents the proportion of responses for the 24 items. In order to simplify description of the distributions, ratings
from 1 to 3 were classified as“toward disagree,”a rating of 4 was classified as “neither toward disagree nor agree” and ratings from 5 to 7 as “toward agree.” The pattern of responses shows that participants were mainly in agreement about consumer involvement in their own care, while there were varied opinions on the outcomes of consumer participation and organizational types of participation (e.g., decision-making on staff). Structure of Items: Confirmatory Factor Analysis Following the findings of Happell et al. (2010), a threefactor model was applied: consumer as staff, consumer involvement, and consumer capacity. Consumer as staff refers to attitudes to the notion of the consumer as a staff member or as someone active in staff processes (such as interview panels) and in the education of staff (e.g., consumer academic); consumer involvement includes involve-
Table 1. Distribution of Responses Statement: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
Mental health consumer involvement and participation should be fully supported by all mental health services Consumers should be actively involved in identifying the goals for their treatment Consumer input should be central in the planning of mental health services Consumers should always be involved in the evaluation and diagnosis of their presenting problems Consumers should be involved in the process for the hiring of all new staff of mental services Consumers should have the opportunity for genuine input into the planning of their own treatment Consumers should be encouraged to contribute to the writing of their own notes and records Consumers are already given sufficient opportunity to participate in the care they receive The medications used in mental health are very complex and consumers should only have limited input into deciding the most appropriate medications to be used Consumers should be involved in the planning and delivery of all staff education and professional development sessions A consumer academic should be a member of staff in all mental nursing courses An experienced mental health nursing academic can present a good understanding of the consumer perspective I need to be taught by a mental health consumer academic to more fully understand how a consumer might experience the mental health system People with mental illness can’t handle too much responsibility All mental health service committees should have at least one consumer member Mental health services work as well as they can and we shouldn’t use valuable resources trying to change them Consumers should be the ones to decide what a quality mental health service is Consumers use mental health services because they need help and therefore they shouldn’t be burdened with how these services are being provided Mental health services would not change significantly if consumers were employed by the services Medications should be explained in detail to consumers in ways that they can understand so they are fully informed and can make choices Mental health services would be likely to improve if consumers were involved in the planning and delivery of those services Increased consumer involvement in mental health services would probably increase the stress levels for service providers Consumers do not understand the language and complexities of mental health services, which makes it difficult for them to have meaningful input Consumers do not have enough self-confidence to become involved in the planning and delivery of mental health services
Perspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
Disagree (%)
Midpoint (%)
Agree (%)
0.0 5.2 0.0 10.3 70.7 0.9 56.0 45.7 43.1
5.2 4.0 8.6 16.4 20.7 11.2 19.8 35.3 31.0
94.0 99.1 89.7 72.4 7.8 87.1 23.3 17.2 25.0
57.8
20.7
20.7
16.4 12.9
37.9 19.8
44.8 65.5
13.8
28.4
56.0
64.7 7.8 72.4
24.1 25.9 17.2
10.3 65.5 8.6
19.8 37.1
33.6 37.9
45.7 24.1
50.9 2.6
37.9 6.0
24.1 90.5
9.5
27.6
62.1
44.0
37.9
16.4
50.0
29.3
19.8
58.6
31.0
9.5
47
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
.52
Consumer Capacity
Involvement would probably increase the stress levels for service providers
.71 Do not understand the language/complexities of MHS, difficult to have input .77 Do not have enough self-confidence to become involved planning/delivery MHS
.07 .77
Should be involved in process for hiring of new staff of MHS
.68
Consumer as Staff
.12
Should be encouraged contribute to writing of own notes/records .70 Should be involved in planning/delivery staff education and PD sessions
.02 .74 .87
Consumer Involvement
.77
Consumer participation should be fully supported by all MHS Should be actively involved in identifying the goals for their treatment Input should be central to planning MHS
.51 .73
Should always be involved in the evaluation and diagnosis of their presenting problems Should have the opportunity for genuine input into planning their own treatment
Figure 1. Standardized Factor Loadings and Inter-Factor Correlations for the Consumer Participation Questionnaire MHS, mental health services; PD, professional development.
ment in own treatment and services, views on consumers as an active and valuable part of own treatment, and mental health care planning and management; and consumer capacity is whether consumers can contribute to better mental health care on the basis of their skills and confidence, including mental health service management and planning, involvement in own treatment. Confirmatory factor analysis indicated that there were several low loading items especially for consumer capacity. Single-step refinements to the factors by removing “lowperforming” items were conducted. The final model showed reasonable fit: χ2 (41) = 42.92, p = .39, RMSEA = 0.02 (90% CI: 0.00, 0.07), CFI = 0.99, TLI = 0.99, SRMR = 0.06. Figure 1 presents the standardized factor loadings for the three-factor model. Factor coefficients ranged from 0.51 to 0.87. There was good discriminant validity among the three factors; the largest inter-factor correlation was 0.12 between consumer involvement and consumer capacity.
Differences in Students’ Views Items for each score were summed and averaged. The average ratings showed that students were consistent with the pattern for the full set of items for the questionnaire— students were most endorsing of consumer involvement (M = 5.99, standard deviation [SD] = 0.83), followed by consumer capacity (M = 4.64, SD = 1.07), and more toward disagreement with consumer involvement as staff (M = 2.85, SD = 1.39). Spearman rank correlations suggest that age was not associated with views on consumer as staff (rs = −0.03, p > .05), nor consumer capacity (rs = −0.02, p > .05), but was associated with consumer involvement (rs = 0.21, p < .05), with older students tending to agree more with involvement. As less than 1 in 10 students reported doing a mental health placement in the past, and less than 1 in 10 students were male, few inferences could be made into how these aspects of nurse background differentiate views on consumer participation.
Reliability Cronbach’s internal reliability alpha was in the moderate to good range for the respective scales: 0.70 for consumer capacity, 0.76 for consumer as staff, and 0.82 for consumer involvement. 48
Discussion The discussion begins, first, with attitudes on consumer participation, and second, with the findings on the quality of the MHCPQ and student differences in attitudes. Perspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
Students’ Attitudes on Consumer Participation
Differences in Attitudes on Consumer Participation
Although the current measure is different from others on consumer participation, and studies have looked at views of service providers (Kent & Read, 1998) more than students, the current findings reflect the limited broader literature (Happell, Pinikahana, & Roper, 2003b; Happell et al., 2002). The common finding was favorable views on consumer participation in terms of choice and autonomy in individual treatment and care, and not as favorable attitudes toward other forms of consumer participation, such as involvement as staff in the organization of mental health services, and involvement in the education of nurses. For instance, no participant (0%) disagreed with the notion that “consumers should be actively involved in identifying the goals for their treatment,” and in contrast, 58% disagreed that “Consumers should be involved in the planning and delivery of all staff education and professional development sessions.” Although the level of student observation or experience of actual mental health services was unclear, this cohort did indicate that they thought services can be conducted better. For instance, only 17.2% agreed that “consumers are already given sufficient opportunity to participate in the care they receive.” Nevertheless, students’ views on the level of consumer participation that should take place were a more contestable issue for them. While students endorsed representation of consumers in general, such as having at least one on committees (65.5% agree to this arrangement), and there was a high proportion of students who believed that consumers would have sufficient self-confidence to take part in mental health services—reservations were more frequent on consumer participation of a higher degree, such as decisionmaking in mental health care services (e.g., hiring of staff). This is consistent with the wider literature reporting that people (to be) involved in mental health sector are reluctant about the notion of formal organizational input of consumers (Happell et al., 2010; Kent & Read, 1998), and reflects the lack of consumer participation that actually takes place at an organization of mental health care (Storm, Hausken, & Knudsen, 2011).
This study found that older students tended to favor consumer participation more than younger students. While Happell et al. (2010) who used the MHCPQ, did find some links with student age, in that study, age was connected with more positive attitudes toward consumer capacity for participation, rather than consumer involvement. These divergent findings may be due to differences in operationalization of the scales between the two studies, where the current one was based on fewer items. Nevertheless, comparing the studies suggests that age may need to be considered in education (e.g., tailored instruction for students of different age groups), and the reasons for age differences addressed in depth through qualitative studies. The evaluation of the MHCPQ is an important step in improving the evaluation of the impact of nursing education, such as learning about consumer participation. Given the current finding that the MHCPQ has good reliability, further steps will be comparing views before the course with views after the course, including whether age-related differences endured. The next stages of research will include determining whether attitudes toward consumer participation are associated with other attitudes, such as toward mental health nursing and recovery. What will be especially important to identify is whether there are any changes in students’ views about the higher-level forms of consumer participation, such as involvement in decision-making on staff.
Psychometric Properties of the MHCPQ Although exploratory techniques have been applied to the MHCPQ in an educational context (Happell et al., 2010), to our knowledge, this is the first study of a confirmatory factor evaluation of this measure. Although there were several items of the MHCPQ that were not accounted for by the specified factors, there was good support for three domains of consumer participation. In addition, reasonable to good internal consistency was found for the final items for each scale. Perspectives in Psychiatric Care 51 (2015) 45–51 © 2014 Wiley Periodicals, Inc.
Limitations This study had a small sample size (n = 116), which limits the capacity to provide robust parameter estimates in confirmatory factor analysis. Although the sample size was small, it should be noted that small sample sizes are not uncommon in this area of research (e.g., McCann, Clark, Baird, & Lu, 2008). Another limitation is that in refining the MHCPQ, a large number of items were removed to optimize measurement of attitudes. The implication is that it is unlikely that the construct representation can be generalized to other cohorts. Given this, items that were not included in the final confirmatory factor model should not be discounted in future research; more psychometric evaluation of the full questionnaire is needed. Conclusion Establishing genuine consumer participation, as aimed for in mental health policy, will require tracking of views of those preparing for nursing, including changes in attitudes that coincide with cultural change. Measures of views and attitudes of students are critical to this function. This article demonstrates that the Consumer Participation 49
Attitudes of Nursing Students on Consumer Participation: The Effectiveness of the Mental Health Consumer Participation Questionnaire
Questionnaire is highly informative on students’ views, and also demonstrates adequate measurement properties, albeit after much refinement of scales. The views of students from a regional university in Australia were found to be remarkably similar to those of student and staff bodies in Australia and other countries, in that there was endorsement of the ideals of consumer participation, but less readiness for the levels of consumer participation enshrined in policy. The uniformity of views found thus far in the field suggests that a generic approach to changes toward consumer participation may be warranted.
Acknowledgments The authors sincerely thank the participants in this research for taking the time to complete these surveys. Also, thanks to the staff who assisted with the printing, distribution, and collection of surveys, and those involved with data entry, too many to mention, but all are greatly appreciated.
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