ARTICLE IN PRESS International Journal of Nursing Studies 45 (2008) 442–457 www.elsevier.com/locate/ijnurstu Review Service user views and expectations of UK-registered mental health nurses: A systematic review of empirical research Penny Beea,, John Playlea, Karina Lovella, Pamela Barnesa, Richard Grayb, Philip Keeleya a School of Nursing, Midwifery and Social Work, University of Manchester, Coupland III Building, Oxford Road, Manchester M13 9PL, UK b Institute of Psychiatry, London, UK Received 9 November 2006; received in revised form 8 February 2007; accepted 18 February 2007 Abstract Objectives: To review national (UK) literature in order to (i) examine service user and carer views of UK-registered mental health nurses; (ii) identify the diversity of populations from which these views have been collected; (iii) assess the methodological rigour of the current knowledge base and (iv) evaluate the extent to which service users and carers have been involved in the development and execution of this work. This paper reports only on service users’ views. Design: Systematic review. Data sources: Electronic and evidence-based databases, reference checking and hand searching of key academic journals, national policy and user/carer organisational websites. Review methods: Two reviewers independently undertook study eligibility judgements and data extraction. Eligible studies were sub-classified according to service setting (inpatient/residential, community/non-residential or mixed/ unspecified). Each study was assessed against key quality criteria. Data were synthesised in a narrative format. Results: One hundred and thirty two studies were included in the review. The majority were small-scale academic studies biased towards white, adult service users. Few studies provided evidence of user collaboration. Service users regard mental health nursing as a multi-faceted role delivering practical and social support alongside more formal psychological therapies. Service users report inadequate information provision, poor inter-professional communication and a lack of opportunities for collaborative care. Service users perceive inpatient mental health nurses as particularly inaccessible. Conclusions: UK-registered mental health nurses should be equipped with both therapeutic clinical skills and generic skills associated with relationship building, engagement and communication. Future research should be conducted in collaboration with service users and include clear and effective mechanisms for the dissemination and implementation of research findings. In particular, the views of children and adolescents, the elderly and black and minority ethnic groups, currently under-represented in research, should be examined. r 2007 Elsevier Ltd. All rights reserved. Keywords: Mental health; Nursing care; Patients; Service users; Systematic review; Views Corresponding author. Tel.: +44 0161 275 5343; fax: +44 0161 275 7566. E-mail address: penny.bee@manchester.ac.uk (P. Bee). 0020-7489/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2007.02.008 ARTICLE IN PRESS P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 443 Contents 1. 2. 3. 4. 5. What is already known about this topic? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What this paper adds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Methods of the review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Quality appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. User views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3. General indicators of satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Opportunities for nursing contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5. Clinical skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6. Satisfaction with nursing attributes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. Implications for education, practice and research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What is already known about this topic?  Mental health nurses make up the largest proportion of the UK NHS mental health services workforce.  User and carer experiences of mental health nursing are a key quality indicator and a recognised marker of national service performance. What this paper adds  Many existing empirical studies suffer methodologi  cal shortcomings that limit the validity and generalisability of their findings. A systematic review of the current evidence base suggests that service users expect mental health nurses to demonstrate sufficient flexibility to fulfil a range of different roles. Both the education and training of UK-registered mental health nurses and the systems of care within which they operate need to be tailored to meeting these needs. 1. Introduction Mental health problems are the most common cause of disability and premature death, accounting for 23% of the burden of disease experienced by high-income countries (WHO, 1999). In response, The World Health Organisation Mental Health Unit of the Regional Office 443 443 443 444 444 444 444 446 446 446 446 447 447 449 450 451 453 453 454 for Europe has prioritised action to reduce stigma, counteract depression and audit the quality and efficacy of mental health services. As part of this international agenda, the UK National Service Framework (NSF) for Mental Health (DH, 1999) states that UK mental health service providers need to ensure adequate service user and carer involvement, indicating that the experience of users and carers, including those from black and minority ethnic groups, is a recognised national marker of service performance. Within UK NHS mental health services, nurses make up the largest proportion of the workforce. In 2004, 96 269 mental health nurses were registered in the UK (NMC, 2004a), their predominance within mental health services providing them with a pivotal role in the delivery of the NSF. In the foreword to their White paper consultation document, ‘A first class service: quality in the new NHS’ (DH, 1998), the UK government emphasised their commitment to ensuring that standards of professional self-regulation are rigorous and in line with the valid expectations of service users. Reviewing mental health service user and carer expectations is, therefore, one important factor in advancing understanding of the contribution qualified mental health nurses can make to the modernisation of UK mental health-care provision. The importance of engaging service users in the development, organisation and delivery of healthcare is being increasingly recognised (Sitza and Wood, 1997). Over the past 15 years, the NHS has experienced a general shift towards a more consumerist ethos in which ARTICLE IN PRESS 444 P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 consumer satisfaction has gained widespread recognition as a key quality indicator. A growing desire to collate users’ perspectives has led to an increased emphasis on people-centred services and public involvement in the planning of statutory health care (NHS Executive, 2000). Prior to the rise of consumerism, however, the assessment of service satisfaction amongst people with severe mental health problems had been relatively neglected. A concern of clinicians and researchers alike was that a lack of insight in many service users may ultimately compromise the validity of their self-reported views (Fitzpatrick, 1991). Much of this concern has since been discounted with clear evidence that service users do have opinions about their care, and that it is possible to elicit valid and useful views from the majority of individuals (Noble et al., 1999, 2001). Credence has been given to the fact that as consumers of health services, users can usefully contribute to quality assurance both by directly evaluating care and by providing information to others (Donabedian, 1992). Irrespective of the method that is adopted, it can be argued these people remain the most appropriate individuals to inform nurses about the quality of their care (Reynolds et al., 1999). To date, only two systematic reviews of mental health service provision provide data relating to user and/or carer views of modern mental health-care staff (Noble et al., 1999, 2001; Quirk and Lelliott, 2001). The first (Noble et al., 1999, 2001) reports that, over the last two decades, service users’ expectations of mental health care have been assessed in a variety of international settings. Findings indicate that users expect professionals to positively influence their mental health and assume that they will use a range of interventions to assist with this process. Where these expectations are found to be incongruent with the services received, poorer clinical outcomes are likely to be present. A recent update to this work (Noble and Douglas, 2004) has extended this view further, demonstrating that, in addition to a desire to receive clinically effective interventions, users also expect good relationships with their service providers that include at their core adequate information exchange and clear communication pathways. A separate systematic review of literature pertaining solely to adult UK mental health acute inpatient environments presents similar findings (Quirk and Lelliott, 2001). Focussing primarily on research conducted during the 1990s, this review concludes that even though the duration of nurse contact may have declined during this time, the quality of the relationship between the nurse and the user continues to be identified by users as an important aspect of care. Much but not all of the evidence on which this conclusion was based directly examined the views of service users. Other empirical studies have linked users’ attitudes and beliefs about mental health care to the initial uptake of services and to subsequent treatment withdrawal (Briteen, 1998; Evans et al., 1986; Jellinek, 1978). Thus, service user satisfaction should be viewed not only as an important measure per se but also as a crucial process factor influencing other outcomes (Ruggeri et al., 1994). 2. Study objectives The objectives of this study were to review national (UK) literature in order to (i) examine service users’ and carers’ views of UK-registered mental health nurses; (ii) identify the diversity of populations from which these views have been collected; (iii) assess the methodological rigour of the current knowledge base and (iv) evaluate the extent to which studies report service user collaboration as a feature of the research team. Due to a lack of studies incorporating the perspective of carers, this paper focuses solely on the views of service users. 3. Method 3.1. Data sources Full details of the search strategy employed in the review are given in Fig. 1. Academic papers were identified via (i) searches of electronic and evidencebased databases and (ii) hand-searches of key journals within the mental health nursing field. All electronic searches were conducted in July 2005. Reference lists from identified papers were searched by hand. Since service users may ultimately ask different questions, and elicit very different responses, to those working in a professional capacity (Repper, 2000), electronic searches were augmented by searches of the non-academic, or ‘grey’, literature. Due to the scope of the literature available and the relatively short timescale in which to undertake the review, grey literature searches were limited to national policy documents and key user and carer organisational websites. All websites were identified in collaboration with a user and carer reference group. Brief reports of other research conducted by non-academic groups were included in the review providing they were indexed in electronic databases and provided sufficient methodological detail to enable data extraction. 3.2. Methods of the review Service user views of mental health nurses were defined as any expressed opinion relating to any aspect of the nurse–user relationship outside of formal therapeutic interventions (e.g. CBT) or goal-directed nursing tasks (e.g. care-planning, medication management). ARTICLE IN PRESS P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 445 Electronic Databases: • MEDLINE (1966-2005) • PsycInfo (1967-2005) • EMBASE (1980-2005) • CINAHL (1982-2005) • Sociological Abstracts (1963-2005) • AMED (1985-2005) • ASSIA (1987-2005) • British Nursing Index (1985-2005) • Cochrane Library (CENTRAL, CDSR, DARE) • National Research Register (Completed and ongoing studies) Hand Searches: • Journal of Psychiatric & Mental Health Nursing (1990-2005) • Psychiatric Bulletin (1990-2005) • Social Science & Medicine (1990-2005) • Journal of Mental Health (1990-2005) • British Journal of Psychiatry (1990-2005) Websites: • Department of Health • King’s Fund Independent Charitable Foundation • National Institute for Mental Health In England (NIMHE) • Sainsbury’s Centre for Mental Health • MIND • Mental Health Foundation • The Healthcare Commission Search terms used ($ denotes pleural or other truncation) : • Population - user$, patient$, client$, famil$, carer$, caregiver$ • Setting - mental health nur$, psychiatric nur$, mental health service$, psychiatric service$ • Outcomes - relation$, belief$, attitude$, perspective$, thoughts, considerations, outlook, expectation$, view$, acceptability, satisfaction, quality of care, perception$ Fig. 1. Data sources for the review. All studies from 1994 to June 2005, written in English language and focussed on UK-registered mental health nurses or mental health nurse-led teams were eligible for inclusion. The 1994 date limit was set to coincide with the last published mental health nursing review (DH, 1994). Whilst it is acknowledged that several surveys of user and carer views were conducted prior to this date, their relevance to modern UK mental health services is uncertain. Since the early introduction of community care approaches there has been a growing emphasis on movement away from UK hospital/institutional-based care towards the provision of a greater range and diversity of community-based services. Studies conducted under earlier care paradigms were, therefore, excluded. Because of the difficulties associated with applying scientific quality criteria to lay person’s views (Dixon- Woods and Fitzpatrick, 2001), no restriction was placed on study design. However, studies presenting single person views were excluded in an attempt to limit bias from potentially non-representative data. Two reviewers independently undertook study eligibility judgements and data extraction. No formal measure of the reliability of data extraction was calculated but disagreements were resolved by discussion with other members of the project team. A standardised data extraction form was used to record information on the context, population, outcomes and quality of each study. Methods for compiling the results of research about people’s views are relatively new and only limited guidance on assessing hierarchies of qualitative evidence are available (Khan et al., 2001). It has previously been suggested that a systematic review of patient views should not exclude studies on the basis ARTICLE IN PRESS 446 P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 of methodological quality unless they are deemed impossible to understand (Garcia et al., 2002). All eligible studies were therefore included in the present review. In order to identify threats to validity, key quality indicators were established. These were based on accepted guidelines for reviewing non-randomised, observational and qualitative literature (Khan et al., 2001) and included the dimensions of the study site (single or multiple), response rate, sample size, selection process and representativeness. The extent of user involvement in the study team was also assessed. 3.3. Data synthesis All data were sub-classified according to service setting (inpatient/residential, community/non-residential or mixed/unspecified services). Within each category, quantitative and qualitative data were analysed separately, the results being integrated into a single narrative synthesis aimed at answering the study objectives. Due to heterogeneity in study design and the populations and outcomes studied, a formal meta-analysis of quantitative satisfaction survey data was not performed. Instead, satisfaction levels were recorded as mean (SD) values or percentage frequencies as originally reported. All qualitative data were extracted and presented according to the primary study’s reporting framework, this descriptive data being used to identify prominent themes. User representatives were invited to comment on the findings of the review. 4. Results Searches identified a total of 14 649 potentially relevant studies, of which 728 were deemed to warrant further examination on the basis of their abstract. One hundred and thirty two met criteria for inclusion in the final review. Together these studies equated to a total sample of more than 36 793 users. Only one study explicitly focussed on services for the elderly (Brooker and Dinshaw, 1998) and a further 6 studies concentrated on child and adolescent services (Holyoake, 1997; Macleod et al., 2000; Hart et al., 2005; Callaghan et al., 2004; Buston, 2002; Street, 2004). However, clear delineations between different stages of the lifespan were difficult to make, with 17 of the 132 studies pertaining to adult settings including participants outside of the traditional 18–65 yr age range. Full details of included and excluded studies are available from the authors. 4.1. Quality appraisal Clear quality distinctions existed between those studies located within the academic and professional literature and those derived from grey literature sources (Table 1). Of the 120 studies published in academic and professional journals, almost half (41%) were single-site investigations collecting data from one or more wards of a specific residential unit or non-residential service team. Only 18% sought to collect satisfaction data from all service users, of which only three studies carried out a repeated measures census over an extended study period (Spence et al., 1997; Leese et al., 1998; Cullen, 1997). 12% of studies employed a random sampling technique either drawing their participants from the entire service population, an epidemiologically representative sub-sample or a population limited by pre-defined inclusion and exclusion criteria. A further 9%purposefully selected their sample to reflect a range of demographic or service characteristics. All other studies (61%) relied on opportunistic, self-selected or unclear (and, therefore, potentially non-representative) samples. Only 16% of studies published in academic and professional journals provided full explanations for nonparticipation and only one study (Hostick and Newell, 2004) presented non-respondent data, making it difficult to rule out the possibility of selection biases. Less than half of all studies (46%) provided data relating to the age and/or gender of participants and less than one third (n ¼ 40) reported service users’ ethnicity. Of those studies that provided the relevant demographic data, only 25% related exclusively to black and minority ethnic groups. Just 11% of all academic and professional studies reported service user collaboration as a feature of the research team. Compared to the academic research base, studies published in the ‘grey’ literature were generally larger and of higher quality. Only two studies (SCMH, 2003; Mental Health Foundation, 2004) failed to report details of the study setting, the remainder (83%) all being multisite investigations. Although eight studies (67%) relied on self-selected samples, most recruited participants from a wide geographical area, several reporting comparative demographic data from non-respondents or other service user populations. One study explicitly examined the views of black service users (SCMH, 2002 and another three (Barker, 2000; Rose et al., 1998; SCMH, 2001) included substantial proportions of non-white participants. None of the ‘grey’ literature studies documented the validity of their survey instruments, although the majority were conducted in collaboration with service users, with six of the 12 studies involving users in data collection (Barker, 2000; Mind, 2004; Wallcraft et al., 2003; Rose et al., 1998; SCMH, 2001, 2002). 4.2. User views Of the 132 studies included in the review, 40 included quantitative data in which service user satisfaction was assessed according to pre-defined criteria. Many more investigations (n ¼ 99) presented qualitative data in which detailed service user views had been collected ARTICLE IN PRESS P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 447 Table 1 Key methodological features of studies included in the review Literature source Setting Inpatient/residential Community/non-residential Mixed/unspecified Data typea Quantitative Qualitative Dimensions of study site: Single Multiple (local area/single health-care trust) Multiple (regional/more than one trust) Multiple (national) Unclear/not reported Sample size Range Unclear/not reported Response rate: % Range Not reported Sample selection procedure: All Users/consecutive referrals Random Purposeful/theoretical Opportunistic Unclear/not reported a Academic/professional (n ¼ 120) Grey (n ¼ 12) Total (n ¼ 132) 38 (32) 51 (43) 31 (26) 4 (33) 1 (8) 7 (58) 42 (320 52 (39) 38 (29) 35 (29) 91 (76) 5 (42) 8 (67) 40 (30) 99 (75) 49 (41) 17 (14) 34 (28) 13 (11) 7 (6) — — 2 (17) 8 (67) 2 (17) 49 (37) 17 (13) 36 (27) 21 (16) 9 (7) 3–503 9 (8) 42–27 389 2 (17) — — 14–100 70 (58) 4–100 5 (42) — — 22 14 11 43 30 1 (8) 2 (17) 1 (8) 8 (67) — 23 16 12 51 30 (18) (12) (9) (36) (25) (17) (12) (9) (39) (23) Some studies present more than one data type. via open-ended questioning. Whilst some studies provided a generic indication of service user satisfaction, others reported more specific opinions relating to particular aspects of care. In both instances, service user views varied depending upon the setting in which they received the majority of their care. 4.3. General indicators of satisfaction Twelve studies presented quantitative data relating to generic levels of service user satisfaction. All but one of these focussed on non-residential or mixed services. Within these settings, the overall pattern of findings indicates that service users generally hold mental health nurses in high regard. Three academic studies (Lelliott et al., 2001; Blenkiron and Hammill, 2003; Macpherson et al., 2005) measured satisfaction by employing a questionnaire developed in collaboration with service users, their findings suggesting that the majority of respondents (64–85%) were satisfied with their care. Other studies (Macpherson et al., 1998; Cutting and Henderson, 2002) report comparable findings (Table 2). Only one quantitative study (Rogers and Pilgrim, 1994a, b) specifically assessed user satisfaction with mental health nurses within inpatient settings. This study, which presented data from 475 users, reported similar levels of satisfaction to those observed in community settings. Almost 60% of service users reported that they were either satisfied or very satisfied with their nursing care, 32.4% of participants ranking the helpfulness of their nurse as higher than both that of psychiatrists and fellow users. Qualitative data, however, demonstrated a more mixed picture. A number of studies included in the review suggest that comparatively lower levels of satisfaction may be reported by inpatient service users compared to those in the community, a finding that may partially be explained by service users’ tendency to perceive ward-based mental health nurses as much more inaccessible. Negative views of nurse availability arose more frequently than any other topic in the studies reviewed and constituted the main criticism of inpatient care. 4.4. Opportunities for nursing contact Although quantitative assessments of user satisfaction with nurse availability were few, those studies that were reviewed suggested that the majority of inpatients felt ARTICLE IN PRESS 448 P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 Table 2 Quantitative measures of service user satisfaction Reference Setting Macpherson et al. (2005) Blenkiron and Hammill (2003)a Vaughan and Stevenson (2002) SCMH (2001)a Lelliott et al. (2001)a Specialist mental health services in 1 location 148 N Community Mental Health Team 86 Y Community services 50 N Community services from 7 sites Mixed services in 32 locations 500 449 N N Macpherson et al. (1998) Cullen (1997) One SMI rehabilitation service 174 N Intensive clinical case management (CM) vs. 70 standard service (SS) Mental health inpatient services from multiple 516 sites N Rogers and Pilgrim (1994a, b)a a Sample Validated instrument? no. N Variable measured % Satisfied Relationship satisfaction Relationship satisfaction CPN satisfaction 83.2 CPN satisfaction Relationship satisfaction Keyworker support satisfaction Keyworker satisfaction Satisfaction with nursing care 87 70 42–73 63.8 79 87–100 (CM), 80–100 (SS) 60 Study included substantial user-involvement. mental health nurses spent insufficient time with service users. One study (Ford et al., 1999) which randomly sampled 37 users from a medium secure unit reported that, whilst 73% found talking to nurses to be helpful, only 57% felt that the amount of time that nurses spent with them was always or usually enough. A national user-led study of 343 inpatients (Barker, 2000) reported similar findings, with more than half (57%) of all surveyed saying that they did not have enough contact with staff, the majority (82%) reporting less than 15 min of interaction per day. A large number of qualitative comments relating to this issue repeatedly referred to users finding it difficult to secure sufficient time with their named nurse, with the effect that many experienced only a passing relationship with this person (Street, 2004; Barker et al., 1999; Smith, 2002; Ricketts, 1996; Higgins et al., 1999; Chiesa et al., 2000; MacGabhann, 2000). In some studies participants attributed this partly to problems created by high nursing workloads (Barker et al., 1999; Morrison et al., 1996) but more frequently, service users highlighted an inherent lack of enthusiasm amongst nursing staff that not only reduced opportunities for contact but also made users feel undeserving of inpatient care (Smith, 2002). Whilst student nurses were viewed favourably for being ‘ward-centred,’ qualified nurses were more often seen as ‘office-bound,’ the more longer serving members of staff being perceived as particularly apathetic. Other open-ended responses from the qualitative studies reviewed suggested that one of the main requirements of service users was continuity of care, a concept grounded in the consistency and regularity of nurse–patient interactions (Buston, 2002; Adam et al., 2003; Bryant et al., 2004; Godfrey and Wistow, 1997; Kai and Crosland, 2001). Negative comments provided by inpatient service users in relation to this issue included the potentially damaging impact of high staff turnover (Watts and Priebe, 2002), high staff sickness (Baker, 2002) and an organisational reliance on agency staff perceived by service users to have relatively little invested in patient care (Street and Svanberg, 2003; Bonner et al., 2002). The main consequence of this ‘conveyer belt’ approach was that users often experienced only a passing relationship with their named nurse (Higgins et al., 1999; Bonner et al., 2002), a practice that was not only believed to be de-motivating but also dangerous in terms of risking relapse (Bryant et al., 2005). One multi-site study of people with enduring mental health problems (Kai and Crosland, 2001) reported changes in health-care providers and the repeated reviewing of case histories to be particularly frustrating for users. Other studies suggest that the discomfort caused by continual disclosure of personal problems to different nurses was sufficient to undermine the entire nurse–user relationship (Bryant et al., 2004; Watts and Priebe, 2002). In addition to the importance of stable relationships, users also highlighted a desire to spend distinct and increasing amounts of time with mental health nurses. Endorsed by the majority of users in the studies reviewed, these interactions were often required for two very different reasons. In some instances the opportunity to talk through problems was paramount (Edwards, 1995; Barker et al., 1999; Gray and Baulcombe, 1996), with purposeful interactions being central to a user’s ability to express emotion and identify potential solutions to their problems (Adam et al., 2003; McLaughlin, 1999; MacGabhann, 2000). This appeared ARTICLE IN PRESS P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 particularly so during periods of severe illness (Barker et al., 1999). Elsewhere, however, the desire for increased nurse contact seemed to relate to a more constant desire for social inclusion (Street, 2004). In discussing their views of mental health nursing, some service users referred directly to a perceived duality of nursing roles. One small scale survey of mixed services (Barker et al., 1999) concluded that people wanted nurses to be ‘both ordinary and professional.’ Other studies did not state this belief quite so explicitly although an analysis of open-ended responses confirmed that users consistently conceptualised a good nurse as having both ‘professional’ and ‘human’ qualities. In comparison to inpatient studies dissatisfaction with nurse availability arose much less frequently in studies in non-residential settings. One quantitative study of mental health rehabilitation services (Valentine et al., 2003) suggested that 87% of participants mostly or always felt that they received sufficient attention from nurses, with 70% also reporting that their views and choices were mostly or always taken into account. Where negative views were reported in non-residential settings they tended to relate less to a lack of staff contact and more to the inherent limitations of service provision. Within this context, respondents particularly highlighted the difficulties associated with high staff turnover, (Watts and Priebe, 2002), non-24 h services (Shanley et al., 2001) and inadequate access to crisis care (Cullen, 1997). 4.5. Clinical skills Service users views of mental health nurses’ clinical skills varied little between service settings. Eight studies (Leese et al., 1998; Secker et al., 2001; Parkman et al., 1997; Henderson et al., 2003; Boardman et al., 1999; Tyson et al., 2001; Ruggeri et al., 2000; Thornicroft et al., 2004) involving a total of 862 community-based service users employed the same validated Verona Satisfaction Scale (VSS) to quantitatively measure three key aspects of staff-based care. As part of this questionnaire, user attitudes towards ‘professional skills and behaviour’, ‘relative’s involvement in care’ and ‘provision of information’ were rated on a 5-point scale from 1 (terrible) to 5 (excellent). Three of these studies (Tyson et al., 2001; Thornicroft et al., 2004; Ruggeri et al., 2000) analysed the views of people with schizophrenia reporting service users to be relatively more satisfied with ‘professional skills and behaviour’ and relatively less satisfied with the ‘provision of information’ and ‘relative’s involvement in care’(Table 3). These findings are comparable to most other quantitative studies employing the same measure. One notable exception is a study which compared the views of 50 users of a primary care mental health team with 35 users of an extended day hospital (Secker et al., 2001). This 449 study reports substantially lower scores on all three dimensions for both settings. However, whether or not these differences reflect differences in the study setting or merely inherent differences in the target population remains unclear. No study of inpatient services reported mean values obtained by the same pre-validated instrument. The only study that did employ the VSS (Henderson et al., 1999) presented data as response frequencies to individual items within the questionnaire. This study, like those conducted in non-residential services, concluded that service users were particularly dissatisfied with nurses’ ‘provision of information’. A small number of other quantitative studies also provided data relating to this issue (Johns and Bell, 1995; Bowers, 1997; Boardman et al., 1999; Rose, 2001). Although often relying on the use of non-validated measures, these less rigorous surveys demonstrated poor knowledge of diagnoses and treatment options amongst service users in a wide range of service settings. Qualitative evidence from studies reviewed suggested that many users ultimately desire a wide variety of information related not only to their illness (Pollock et al., 2004), but also to the social and legal implications of their care (Callaghan et al., 2002; Marriott et al., 2001), the characteristic features of the environment in which they receive this care (Street, 2004; Greasley et al., 2001; MacGabhann, 2000), and the identification of other organisations, both statutory and voluntary, that may be able to help (Cunningham and Slevin, 2005; Simpson, 1999). Where relevant information was not made available or was withheld, service users were more likely to perceive mental health staff as impersonal or paternalistic (Edwards, 2000; Pollock et al., 2004; Greenwood et al., 1999; Watts and Priebe, 2002), with potentially negative consequences for treatment adherence (Bowers et al., 1999; Chiesa et al., 2000). Other studies (Callaghan et al., 2004; McSweeney and Smith, 1995; Callaghan et al., 2002; Beech and Norman, 1995) report that service users want mental health professionals to discuss fully the range and implications of different interventions, with a smaller number of studies also highlighting a desire to include family members and carers in consultations (Simpson, 1999; Bowers, 1997; Cutting and Henderson, 2002; Cunningham and Slevin, 2005). Open-ended responses from the studies reviewed suggested that, within the context of diagnosing and explaining mental health problems, service users perceive nurses to be the professional experts and in so doing expected them to have the necessary skills, confidence and training to identify problems and offer appropriate solutions (Barker et al., 1999; Simpson, 1999; Higgins et al., 1999; Forchuk and Reynolds, 2001). More specifically, service users want mental health nurses to show adequate insight and understanding, ARTICLE IN PRESS P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 450 Table 3 VSS assessment of user satisfaction with nursing skillsa Ref Setting Sample size Mean VSS score (SD/95CI) Professional skills/ behaviour Secker et al. (2001) Primary care mental health team (PMH) Tyson et al. (2001) Ruggeri et al. (2000) Henderson et al. (2003) Leese et al. (1998) Parkman et al. (1997)b 50 PMH PMH: 2.29 (0.83) Extended day hospital (EDH) 38 EDH Mixed services for schizophrenia Mixed specialist services Hospital services 52 83 48 Intensive community care (IC) 131 (total) Standard care (SC) Mixed services for psychosis 202 Relatives involvement Information provision PMH: 2.60 (1.26) PMH: 2.55 (1.11) 2.49 (0.91) 2.12 (0.79) EDH: 2.09 (0.83) 2.18 (0.79) 1.99 (0.76) 3.98 (0.56) 3.46 (0.40) 3.54 (3.35–3.73) 2.51 (1.41) 1.86 (0.77); EDH: 2.59 (1.63) 2.03 (0.98) 1.80 (0.90) 3.52 (0.72) 2.91 (0.67) 3.02 (2.79–3.25) 3.37 (1.12) 2.31 (1.14) EDH: 2.44 (1.14) 3.01 (1.40) 2.09 (0.85) 3.69 (0.74) 3.26 (0.65) 3.23 (2.93–3.53) IC: 3.60–3.83 IC: 3.35–3.37 IC: 3.25–3.39 SC: 4.01–4.00 3.45 (3.16–3.74) SC: 3.69–3.57 3.31 (2.86–3.76) SC:3.34–3.33 2.90 (2.55–3.24) 3.93 (3.72–4.14) 3.86 (3.74–3.97) 3.73 (3.39–4.07) 3.27 (2.78–3.76) 3.52 (3.32–3.72) 3.29 (2.22–4.37) 3.40 (3.07–3.73) 3.24 (3.08–3.41) 3.15 (2.70–3.61) a Comparable data not reported by Boardman et al. (1999) or Thornicroft et al. (2004). Scores refer to Black Caribbean UK-born, Black Caribbean Non UK-born, White UK-born and White Non UK-born, respectively. b both to recognise and anticipate their needs and to respond effectively to deteriorations in their mental health (Barker et al., 1999; Edwards, 1995; Godfrey and Wistow, 1997). Other expectations of staff described by service users include working to reduce stigma (Edwards, 1995), providing structure and safety (Edwards, 1995; Beech and Norman, 1995), preventing individual feelings of isolation (Wood and Pistrang, 2004) and providing practical support (Cullen, 1997; Hatfield et al., 1996; Repper et al., 1994; Rose and Muijen, 1998; Hayward et al., 2004), including liaising with other agencies (Meddings and Perkins, 1999). When asked what they would most like to change about their professional caregivers, service users variously cited better one-to-one communication skills (Edwards, 2000; Ricketts and Kirshbaum, 1994; McLaughlin, 1999), increased responsiveness and flexibility (MacGabhann, 2000; Coffey et al., 2004) and improved liaison within and between services (Simpson, 1999; Cunningham and Slevin, 2005; MacGabhann, 2000). 4.6. Satisfaction with nursing attributes Although the professional and clinical skills of mental health nurses were frequently reported to be of key importance to service users, they were often seen as being mediated by more personal attributes that the nurse brings to the nurse–patient relationship. One core group of studies indicated a desire for service users to be cared for by a nurse with similar demographic characteristics, particularly in terms of their age (Hart et al., 2005), ethnicity (McLean et al., 2003; Hatfield et al., 1996; Rose and Muijen, 1997, 1998) and gender (Hart et al., 2005; Hatfield et al., 1996; Repper et al., 1998). Most of these studies, however, explored the views of minority groups and as such could not be assumed to be representative of the whole population. Elsewhere, the ethnic background of mental health nurses has been shown to be less important than the empathy they portray. One survey of the views of 26 users of an AfroCaribbean mental health resource centre (Secker and Harding, 2002) reported that staff were able to build close relationships with clients not primarily because they were black but because they offered ordinary opportunities for warmth, friendship and understanding. The importance of mental health nurses possessing such positive personal qualities emerged as a prevailing theme throughout the studies reviewed, and the most frequently endorsed category in user responses. Both large scale user-led surveys and published academic studies alike identified a set of common expectations that appeared to transcend all service users and settings and included at their centre a desire for empathy, respect ARTICLE IN PRESS P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 and compassion (e.g. Breeze and Repper, 1998; Hart et al., 2005; Edwards, 2000; Greasley et al., 2001; Forrest et al., 2000; O’Toole et al., 2004; SCMH, 2003; MHF, 2004). More negative characteristics that were identified as undesirable nursing attributes included being dismissive (Goodwin et al., 1999) or judgemental (Goodwin et al., 2003; Fallon, 2003), trivialising users’ symptoms (Wolf et al., 2000) and adopting a coercive approach (Beech and Norman, 1995; Watts and Priebe, 2002). Most quantitative studies conducted within nonresidential settings reported a relatively high level of satisfaction with the attitudes of mental health nurses. The largest of these investigations was a multi-site national study of 27 398 service users (Healthcare Commission, 2004). Of those service users who had seen a Community Mental Health Nurse (CMHN) in the previous 12 months, 85% felt that they had definitely been treated with respect and dignity, a further 12% reporting that they had been treated with respect and dignity to some extent. Two smaller studies that measured service users’ views of staff attitudes in nonresidential services reported similar findings (Cullen, 1997; Graham et al., 2005). Amongst more detailed qualitative data in the studies reviewed, CMHNs have variously been described as ‘friendly’, ‘informal’, ‘approachable’ and ‘empathic’ (Shanley et al., 2001; Barker et al., 1999; Reed et al., 2002; Diaz-Caneja and Johnson, 2004; Hostick and Newell, 2004). Only one study (Bailey, 1997) explicitly reported service users as experiencing difficulties in establishing trusting relationships with non-residential mental health staff, though it is acknowledged within the study that this may have arisen from prior negative experiences of mental health staff whose approach was deemed unsatisfactory. Studies quantifying levels of service user satisfaction with the attitudes of mental health nurses within residential settings remain much less conclusive. One user-led survey of 335 current or recent psychiatric inpatients (Mind, 2004) reported that only one in five respondents felt that they were treated with dignity and respect by hospital staff, another 17% stating that they were never treated in this way. However, whilst the results of this study are undoubtedly important, its reliance on an opportunistic sample of user group members limits generalisibilty. Two smaller studies that recruited samples from consecutive service referrals presented more positive findings (Valentine et al., 2003, Spence et al., 1997). These studies which were conducted within the same residential rehabilitation unit found that between 62% and 73% of service users perceived staff as approachable, although one of these studies (Spence et al., 1997) concluded that further improvements in communication were still necessary. Qualitative data collected within residential settings largely confirms these quantitative findings. Whilst some studies suggested that mental health nurses do respond 451 to inpatients in an appropriate way (Breeze and Repper, 1998; Godfrey and Wistow, 1997; Morrison et al., 1996), the majority made reference to more negative nursing attitudes (Greenwood et al., 1999; Cutting and Henderson, 2002; Wood and Pistrang, 2004; SCMH, 1998; Fallon, 2003; Jones and Mason, 2002; Longo and Scior, 2004). One large investigation examined the experiences of 60 black inpatients recruited from 3 different acute mental health wards in England (SCMH, 2002). The findings of this study demonstrated that service users frequently perceived staff to be confrontational and condescending, with many nurses demonstrating an autocratic use of power that failed to acknowledge the needs of individual users. Other studies involving predominantly white samples report similar findings (Bailey, 1997; Lilly et al., 1999). 5. Discussion This review has shown that, irrespective of setting, service users typically expect mental health nurses to fulfil a multi-faceted role in which practical and social support are provided alongside the delivery of more formal psychological interventions. In order to fulfil this role, users expect mental health nurses to exhibit both specific clinical skills and more generic skills and attributes related to effective interpersonal communication. These findings are tempered by the fact that many of the studies reviewed suffer methodological shortcomings that often make it difficult to establish the validity and wider generalisability of their results. Despite the fact that the majority of eligible studies were from academic and published literature, most were small-scale, singlesite investigations involving largely non-representative samples with a clear potential for selection bias. As such, findings reflect the perceptions of service users who may not necessarily be representative of the broader service user population. Although mean response rates were similar for studies sourced from the academic and grey literature (40% and 44%, respectively), the latter was more likely to involve larger, multi-site investigations. Once again, however, sample recruitment typically relied on opportunistic sampling with many participants being recruited through prominent national user and carer groups. Whilst there is some evidence to suggest that such groups may resemble those of a more randomly selected sample (Crawford and Rutter 1994), other studies report a greater tendency for lay community health representatives to be white, more highly educated and of a higher social class than service users in general (Thomas, 1999; Pickard et al., 2002). Very few studies included in the present review provided data relating to non-respondents and rarely were findings stratified ARTICLE IN PRESS 452 P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 according to participants’ ethnic background. Moreover, only a very small number of studies specifically sought the views of Black and minority ethnic groups. With current UK Government initiatives seeking to achieve a greater inclusion of marginalised groups in the design and delivery of culturally sensitive services, this evidence gap is striking. These limitations accepted previous research has consistently identified a core set of views amongst service users that provide a wealth of information capable of informing current and future mental health nursing. Previous work suggests that there has traditionally been a delineation between two distinct, and at times seemingly opposing, conceptualisations of mental health nursing (Repper, 2000). Advocates of the first emphasise the interpersonal and relational aspects of nursing, viewing the process of mental health nursing as an activity in which attention is primarily focussed on the quality of the relationship between the nurse and service user. Within such a view the conditions and attributes of the relationship are often seen as the key influences on user satisfaction often with an implicit assumption that the demonstration of such conditions is in itself adequate for effective outcomes (e.g. Barker, 1998; Barker and Reynolds, 1996). Advocates of the second, often seen as opposing view, tend to place much greater emphasis on the value of specific treatments and interventions (Gournay, 1995) which at times it has been argued, lacks attention to the interpersonal and relational aspects of the nursing process (Repper, 2000). The present review suggests that service users are unlikely to describe the nursing profession as relying solely on either one of these conceptualisations and hypotheses. Rather, service users draw on a number of different models of mental health nursing and in so doing expect mental health nurses to demonstrate sufficient flexibility to fulfil a range of different roles. From a professional perspective, service users expect mental health nurses to be equipped with the necessary skills to recognise symptoms and deliver appropriate and effective interventions and treatment options in an efficient and effective manner. Central to this notion are clear requests for open and adequate information, a greater provision of choice and increased user involvement in the assessment and planning of care. However, the extent to which such processes are viewed as successful by service users ultimately appears to rest with their perceptions of a nurses’ propensity to listen, empathise and understand. Despite the value that users attribute to professional and clinical skills, therefore, an equal if not greater emphasis is placed upon the more personal attributes of the mental health nurse. This is not necessarily counter to a focus on the need for mental health nurses to use professional skills to deliver specific evidence-based interventions. As highlighted above, a number of the studies in this review suggest that for many service users there is an almost taken for granted assumption, whether rightly or wrongly, that mental health nurses as professionals should be equipped with the necessary skills, confidence and training to offer appropriate interventions (Barker et al., 1999; Simpson, 1999; Forchuk and Reynolds, 2001. However, research suggests that relationships built around respect and compassion may not only influence the efficacy of more formal psychological interventions but also have considerable therapeutic value of their own (Meddings and Perkins, 1999; Rogers and Pilgrim, 1994a, b). The currently ability of UK mental health nurses to meet the expectations of mental health service users remains unclear. Studies that have relied largely or solely on quantitative data often conclude that service users hold mental health nurses in relatively high regard. The measures employed by such studies have however, been criticised on both theoretical and methodological grounds. The most significant long standing problem with satisfaction-based questionnaires is their tendency to record consistently positive responses (Lebow, 1983). Evidence suggests that when qualitative approaches are adopted, more wide-ranging experiences and views are often detected (Williams et al., 1998; McIver and Meredith, 1998). The majority of studies included in the present review utilised at least some open-ended questioning methods. Comparisons between these studies suggest that lower levels of satisfaction are most likely to be expressed by users of inpatient mental health services. Negative opinions of the nurses working within these settings were largely attributed to an increased tendency to view ward-based staff as inaccessible, providing little opportunity for nurse–patient interaction. The need for a shift in the focus and quality of care within inpatient mental health units is well recognised within UK mental health nursing and extensive literature exists to provide explanations for the perceived limited quantity, quality and depth of interaction that users of these services experience (Quirk and Lelliott, 2001). Specific factors that have been identified in relation to this issue include rapid staff turnover, extensive use of bank and agency staff and low staff morale (Watts and Priebe, 2002; Street and Svanberg, 2003; Bonner et al., 2002). Findings from this review suggest that whilst some service users do indeed attribute some of these problems directly to high nursing workloads, others also identify negative personal attributes and behaviours amongst many nursing staff as a key explanatory factor for the reluctance amongst staff to engage more fully and meaningfully with users. Although a wide range of user views were reported, inpatient staff were more likely to be viewed as confrontational or dismissive and more likely to be perceived as coercing users into treatments. In contrast, criticisms of community mental health nurses were fewer ARTICLE IN PRESS P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 and where reported they focussed less on negative personal attitudes and more on inherent service limitations manifesting in a lack of nurse–user collaboration and inadequate provision of crisis care. The need to maintain ward order and manage severely ill users has previously been implicated in placing undue pressure on inpatient staff, who have been shown to cope by creating barriers to therapeutic engagement via custodial models of care (Ryrie et al., 1998). 5.1. Implications for education, practice and research Despite the acknowledged limitations of the studies reviewed, a number of implications for practice, education and future research arise. UK registered mental health nurses clearly need to be equipped with both therapeutic clinical skills, including the ability to deliver a range of psychological interventions, as well as more generic skills, attributes and values associated with service user centred engagement, relationship building, and interpersonal communication. In addition to the increasing emphasis on underpinning practice with core, user-centred values (DH, 2004), pre-registration mental health nursing curricula have increasingly highlighted the importance of the development of effective interpersonal communication (UKCC, 1999; NMC, 2004b). However, the evidence from the studies reviewed here suggests that many service users continue to highlight shortcomings in this aspect of care. The recent CNO review (DH, 2006a), informed by this systematic review, re-emphasises the importance of an appropriate value base for mental health nursing practice as well as the necessity for pre- and postregistration curricula to systematically teach and assess appropriate interpersonal and relational skills (DH, 2006b). Whilst it is hoped that the re-focussing of preregistration education and training for mental health nurses will, over time, begin to address these shortcomings in practice, it is equally important to recognise that without addressing the needs of already qualified staff and the systems within which they practice, little is likely to change. This review has identified particular problems within inpatient settings where mental health nurses are often viewed by service users as having negative attitudes, lacking enthusiasm, being confrontational, failing to demonstrate respect and being inaccessible, all factors which have the potential to negatively affect treatment adherence and outcomes. Clearly, there is a need to address each of these issues through education and training. However, this review has also highlighted other factors related to the wider system of care that service users acknowledge as both contributing to, and in some cases accounting for, such negative attitudes and behaviours. These include short-staffing, high staff turnover, an organisational reliance on bank 453 and agency staff and low staff morale. Unless actions to address these wider system issues are taken, further investment in training and education for staff may be unproductive. Service users expect and desire consistent relationships with mental health nurses who are equipped with both professional skills and the appropriate personal values to enable meaningful interactions. In order to achieve this, the environments, resourcing and systems of care within which mental health nurses operate must be conducive to the meeting service users’ needs. In terms of future research priorities, these must include further large-scale, robust research examining user and carer views of mental health nurses. It is notable that the majority of studies eligible for this review demonstrated little involvement of service users and/or carers in the design and implementation of the research process. It is, therefore, vital that future work is conducted within a cohesive programme of robust, userled studies that incorporate standardised measures developed in collaboration with service users and carers. In particular, studies need to include a broader crosssection of the population, with increased attention focused on services for children and adolescents, the elderly and black and minority ethnic groups. These investigations should be co-ordinated on a national basis and seek user views from larger, more representative samples. As is evidenced by the size of this review, there already exists a reasonably large knowledge base related to service user views and expectations. Despite the methodological shortcomings of this work, the messages emanating from this literature remain strikingly consistent over time, indicating a sustained lack of impact on practice. It is perhaps noteworthy that it was extremely rare for studies included in this review to offer any indication of feedback mechanisms or service changes resulting from their conduct. A requirement for future research planning and funding must be the inclusion of effective mechanisms for the dissemination and implementation of findings. Acknowledgements This review of mental health service user views of mental health nursing was commissioned by the Department of Health to inform the Chief Nursing Officer’s 2005 Review of Mental Heath Nursing in England and the National Review of Mental Health Nursing in Scotland. Funding was obtained from the UK Department of Health SDO programme. The views expressed in this manuscript are those of the authors and not necessarily those of the sponsors. ARTICLE IN PRESS 454 P. Bee et al. / International Journal of Nursing Studies 45 (2008) 442–457 References Adam, R., Tilley, S., Pollock, L., 2003. Person first: what people with enduring mental disorders value about community psychiatric nurses and CPN services. Journal of Psychiatric and Mental Health Nursing 10 (2), 203–212. Bailey, D., 1997. 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