Introduction
The importance of involving service users and members of the public in health and social care services has been a recurring theme in a number of recent Irish policy documents and was given most prominence with the publication of the ‘National Strategy for Service User Involvement in the Health Service 2008–2013’(HSE, 2008). The philosophy of achieving service user involvement at all levels of the mental health system was identified as a key recommendation in the development of ‘A Vision for Change’ (HSE, 2006) and the need to provide a patient-centred service was a guiding principle in the ‘Quality Framework for Mental Health Services in Ireland’ (MentalHealthCommission, 2007a), which recognised the importance in evaluating and considering patient satisfaction with mental health services in the development of service planning and assessment.
The assessment of patients’ satisfaction with general health services has been examined since the early 1970s (Davy etal. Reference Davy, Keizer, Croquette, Bertschy, Ferrero, Gex-Fabry and Bondolfi2009). The measurement of patient satisfaction is an important aspect of service quality as an indicator of structure and delivery (Ruggeri etal. Reference Ruggeri, Salvi, Perwanger, Phelan, Pellegrini and Parabiaghi2006) and in determining treatment continuity and treatment outcome (Holcomb etal. Reference Holcomb, Parker, Leong, Thiele and Higdon1998; Berghofer etal. Reference Berghofer, Lang, Henkel, Schmidl, Rudas and Schmitz2001). Satisfaction can be considered as an emotion related to certain situations or outcomes (Westerbrook and Oliver, Reference Westerbrook and Oliver1991) or as an attitude, in terms of a patients general orientation towards the experience of health care. Satisfaction as an outcome variable has been hypothesised to be multifactorial in origin, relating to expectations about services, self-esteem, illness behaviour, previous experiences with services and service characteristics (Barker etal. Reference Barker, Shergill, Higginson and Orrell1996; Ruggeri etal. Reference Ruggeri, Lasalvia, Bisoffi, Thornicroft, Vazquez-Barquero, Becker, Knapp, Knudsen, Schene and Tansella2003). Sociodemographic characteristics have not been shown to consistently predict patient satisfaction with mental health services, although associations have been found between female gender (Blenkiron and Hammill, Reference Blenkiron and Hammill2003; Davy etal. Reference Davy, Keizer, Croquette, Bertschy, Ferrero, Gex-Fabry and Bondolfi2009) and older age (McIntyre etal. Reference Mcintyre, Farrell and David1989) and higher satisfaction levels. Factors associated with the perceived quality of care received by patients can also affect satisfaction levels, with items such as longer outpatient waiting times, ineffective communication and poor interpersonal empathy found to be associated with lower patient satisfaction (Saila etal. Reference Saila, Mattila, Kaila, Aalto and Kaunonen2008). Individuals with psychotic illnesses have been reported to be less satisfied (Ruggeri, Reference Ruggeri1994) and duration of untreated psychosis has been linked with a decrease in satisfaction with care among first episode psychosis patients (Mattsson etal. Reference Mattsson, Lawoko, Cullberg, Olsson, Hansson and Forsell2005). Multiple studies have shown outpatient treatment settings to be associated with higher patient satisfaction levels when compared with inpatient treatment settings (Haycox etal. Reference Haycox, Unsworth, Allen, Hodgson, Lewis and Boardman1999; Henderson etal. Reference Henderson, Phelan, Loftus, Dall'agnola and Ruggeri1999; Berghofer etal. Reference Berghofer, Lang, Henkel, Schmidl, Rudas and Schmitz2001).
There is little published data on patient satisfaction with psychiatric treatment in outpatient settings in Ireland. One study conducted in 2002 reported outpatient client satisfaction levels of 80% among 79 patients (Hill etal. Reference Hill, Turner, Barry and O'callaghan2009), and a more recent survey of mental health outpatient services demonstrated satisfaction levels of 86% among 192 responders (Jabbar etal. Reference Jabbar, Casey, Schelten and Kelly2011).
The de-institutionalisation of the large psychiatric hospitals in Ireland commenced in the 1960s and led to a dramatic change in the way in which mental health services were delivered in Ireland, with the move to community-based service models becoming more clearly established in the 1980s and 1990s. This often meant that outpatient facilities were delivered from psychiatric day hospitals and dedicated mental health centres, however, some facilities remained linked to general hospital settings especially in urban areas.
The aim of this study was to assess patient satisfaction levels with outpatient treatment and their relationship with sociodemographic and clinical characteristics. This study differs from others in that the setting for outpatient treatment is located in a tertiary care university hospital rather than a dedicated mental health centre in a community-based setting. We therefore also assessed patient preference for outpatient treatment in a hospital or a dedicated community facility.
Methods
This study was conducted at the psychiatry outpatient department (OPD) of University Hospital Galway (UHG), Ireland. This is the psychiatric outpatient setting for Galway city within the West Galway Mental Health Services (WGMHS) catchment area serving a population of ∼130 000, of whom 100 000 reside within 15 km of Galway city with the remainder distributed in the sparsely populated region of Connemara. The structure of the WGMHS in Galway city is not sectorised, with four general adult and one later life team accessing the OPD facility at UHG. This is the only psychiatry outpatient clinic serving the entire city area (including the suburban communities), which is located in the grounds of the University Hospital. Within the West of Ireland region, it is the only psychiatry outpatient clinic that is directly attached to a general hospital.
Outpatient services in outlying parts of the rural catchment area are provided close to patients’ homes in local psychiatric day centres (e.g. in Clifden, Carraroe). The catchment area service is relatively poorly resourced compared with national norms and there is a deficiency of community-based facilities in the city, with only one stand-alone psychiatric day hospital, two psychiatric day centres and an undersupply of supported accommodation. As part of the development of community-based services in the region, there are tentative proposals to transfer outpatient services to dedicated mental healthcare facilities in suburban settings in the city, with possible links to primary care centres.
We conducted a cross-sectional survey of individuals’ satisfaction levels with the outpatient treatment, which they were receiving. Participants were living in the community and were attending the outpatient facility for continuing psychiatric treatment and support provided by the adult psychiatric services. The study was advertised by a poster in the outpatient waiting area and all attendees at the outpatient clinic, over a 1-month period in April 2011, were invited to participate in the study. All participants were provided with a letter of information; a post box was provided for the finished questionnaires and anonymity was assured.
All individuals attending the general adult psychiatry outpatient clinic over the 4-week study period in April 2011 were eligible to participate and there were no exclusion criteria.
Demographic data including gender, age range, and ethnicity, duration of attendance at outpatients and distance of residence from the outpatient setting was collected. The diagnosis (self-reported) and service attended by the patient was also recorded.
Data on patient satisfaction levels were collected through a self-administered quantitative questionnaire, the Client Satisfaction Questionnaire (CSQ-8). The CSQ-8 (Larsen etal. Reference Larsen, Attkisson, Hargreaves and Nguyen1979) is a well-validated measure of patient satisfaction, which has demonstrated high reliability and validity, including in mental health service settings (Attkisson and Zwick, Reference Attkisson and Zwick1982; Soelling and Newell, Reference Soelling and Newell1983). The scale assesses respondents’ opinions and attitudes towards services they are currently receiving. Responses are recorded for eight items on a four-point Likert-like scale (e.g. ‘How satisfied are you with the amount of help you have received?’ with the following response options: 1 = ‘Quite dissatisfied’, 2 = ‘Indifferent or mildly dissatisfied’, 3 = ‘Mostly satisfied’, 4 = ‘Very satisfied’). An overall score is produced by summing all of the item responses, which for the CSQ-8 range from 8 to 32, with higher values indicating higher satisfaction. The summed scores were categorized into three distinct levels, low satisfaction (8–20), medium satisfaction (21–26), and high satisfaction (27–32; Larsen etal. Reference Larsen, Attkisson, Hargreaves and Nguyen1979).
The questionnaire also included items regarding the patients’ evaluation of confidentiality in the outpatient setting, respectful treatment by staff members, the length of time they waited from referral to initial appointment, and their attitudes towards the potential transition of outpatient care to dedicated community mental health treatment facilities in suburban parts of Galway city. Each participant provided an evaluation at one single outpatient visit and this was made during their clinic visit.
Statistical analysis
Statistical analysis was performed using the Statistical Package for Social Sciences 18.0 for Windows (SPSS Inc., Chicago, Illinois, and USA). We utilised the student's t-test and analysis of variance (ANOVA) for parametric data and the χ 2-test and Fisher's exact test for non-parametric data where appropriate. All statistical tests were two-sided and the α-level for statistical significance was 0.05.
Results
One hundred and sixty-two patients completed the survey. The sociodemographic and attendance characteristics of the sample are displayed in Table 1. Most patients in the study population had self-reported diagnoses of depression (55%), bipolar affective disorder (16%), and schizophrenia (12%). The majority of the patients were of Irish ethnicity (89%).
Demographic and attendance characteristics of the sample
Fifty-five percent of patients lived within 5 miles and 88% within 10 miles of the outpatients’ service. The majority were attending to see a psychiatrist (71%), with 16% of responders attending a psychologist and 5% of responders attending a community mental health nurse.
The CSQ-8 scale data had a Cronbach's α of 0.93 indicating a high level of internal consistency.
The mean total CSQ-8 score was 26.7 (s.d. = 4.6) indicating a moderate to high level of satisfaction with the services. Ten percent of patients scored in the CSQ-8 low satisfaction category (total score 8–20), whereas 38% were satisfied (21–26) and 52% were very satisfied (27–32).
CSQ-8 items were ranked from highest to lowest in order to illustrate the features which patients were more satisfied with (Table 2). For CSQ-8 items, the highest rates of satisfaction were for recommending the service to a friend and for returning to the service if a future need arose, whereas the lowest rates were found for overall levels of satisfaction with service and for reporting that the outpatient service had met their needs (<38%).
Ranked satisfaction rates (by percentage of those who were very satisfied for each item) for the items of the CSQ-8 satisfaction questionnaire
CSQ-8, Client Satisfaction Questionnaire-8.
aCSQ-8 item score of 4 = highest satisfaction (i.e. very satisfied).
bCSQ-8 item score of ⩽2 = mildly/quite dissatisfied.
The association of total CSQ-8 scores with sociodemographic and clinical variables are shown in Table 3. There were no significant associations of satisfaction levels with gender, age, diagnosis, length of time attending clinic, mode of transportation, professional attended or preference for attending the OPD in a dedicated mental health facility. Those who reported being received with respect at the clinic had significantly increased mean CSQ-8 scores of 27.3 ± 4.2 compared with those who reported being disrespectfully treated (mean = 19.4 ± 2.9; t = −6.656, df = 160, p < 0.001). Those who reported being treated with respect during telephone contact from the clinic had mean scores of 26.9 ± 4.6, which were significantly higher than those who reported not being treated with respect (mean 24.7 ± 4.6; t = 1.737, df = 160, p = 0.042). The significant association between CSQ-8 and being treated with respect on the telephone does not survive correction for multiple comparisons, whereas the other association between CSQ-8 and being treated with respect in person does.
Association of CSQ-8 total scores with sociodemographic and clinical variables
aIndependent t-sample test.
bOther services attended include social worker, psychologist, community mental health nurse, occupational therapist.
cOne-way ANOVA.
The majority (61%, n = 99) of those who expressed a preference, stated that they would prefer to attend their outpatient clinic in the hospital setting as opposed to a dedicated mental health facility in a suburban setting.
Fifty-three percent (n = 87) of patients travelled by car to the outpatient setting, while 25% (n = 40) used public transportation and 22% (n = 35) walked. An ANOVA showed no significant differences between the mean CSQ-8 scores of each of these groups (Table 3).
Sixty-one percent of patients were in favour of retaining the outpatient services at the city centre university hospital setting, whereas only 20% were in favour of delivering outpatient services in designated mental health facilities located in suburban settings and 19% expressed no preference. When these responses (of those expressing a preference for moving the outpatient facility to a dedicated community mental health setting or those preferring to retain the facility in the hospital setting) were linked to mode of transport, 70% (n = 19) of those who used public transport were in favour of retaining the outpatient setting at the university hospital, which was significantly higher than those who travelled by car and expressed this preference [45% (n = 35), χ 2 = 5.221, df = 1, p = 0.022]. More patients who travelled by car expressed a preference for transferring the outpatient facility to a dedicated community setting [31%, (n = 24)], compared with those who travelled by public transport [7% (n = 2), χ 2 = 5.876, df = 1, p = 0.015].
Discussion
This study is one of a small number examining patient satisfaction levels with psychiatric outpatient services, with the majority of similar studies focusing on the inpatient setting (Greenwood etal. Reference Greenwood, Key, Burns, Bristow and Sedgwick1999; Ruggeri etal. Reference Ruggeri, Lasalvia, Bisoffi, Thornicroft, Vazquez-Barquero, Becker, Knapp, Knudsen, Schene and Tansella2003). This survey demonstrated moderate to high levels of satisfaction with the outpatient treatment service, which is in line with previous studies (Killaspy etal. Reference Killaspy, Gledhill and Banerjee1998; Barak etal. Reference Barak, Szor, Kimhi, Kam, Mester and Elizur2001). Our finding of a satisfaction level of 90% is in keeping with similar rates of patient satisfaction identified in other studies among outpatients in Ireland, which have shown satisfaction rates of 86% (Jabbar etal. Reference Jabbar, Casey, Schelten and Kelly2011) and 80% (Hill etal. Reference Hill, Turner, Barry and O'callaghan2009).
Our study showed lower ranking of satisfaction on the CSQ-8 questions about whether the service met the patients’ needs and as to whether they felt that they had received the service that they wanted. This is in line with findings from a Swiss study (Davy etal. Reference Davy, Keizer, Croquette, Bertschy, Ferrero, Gex-Fabry and Bondolfi2009), which also reported that patients ranked coming back to the service again and recommending it to a friend as items with associated lower levels of satisfaction. This indicates that patients acknowledge the quality of care that they are receiving in the outpatient setting but that a gap remains between patient expectations of the service and the actual service delivered. We did not assess what were the perceived deficiencies of the service in this regard but this could be a fruitful investigation for future studies.
We identified high levels of satisfaction associated with patient reports of being treated with respect by staff during face–face contact at the clinic. The degree of respect and courtesy that is displayed to patients has been shown to be an important contributor to positive patient experiences (Oltedal etal. Reference Oltedal, Garratt and Johannessen2007).
Determinants of patient satisfaction levels are multifactorial in origin and while our study did not identify clinical or demographic variables, which were significantly associated with patient satisfaction levels; this is an area in which future research may be initiated in order to ascertain the influence of other patient and clinical characteristics on patient satisfaction levels.
An important finding from our study was the higher levels of satisfaction among patients who expressed a preference to retain the outpatient setting in the grounds of the university hospital in preference to a move to dedicated community-based facilities, which is evidence that such a location can provide a satisfactory care to patients. While de-institutionalisation and the development of community-based facilities has successfully moved psychiatric care away from the asylum, most patients remain very satisfied with outpatient care in the general hospital setting in an urban environment, which is generally a non-stigmatising setting and which has good transport links. The benefit of transport links was underlined by the clear preference for retaining this option among those using public transport or walking, whereas those using cars preferred a dedicated facility in a suburban setting, presumably since this is perceived as having more readily available parking facilities.
We did not find any significant associations between patient satisfaction levels and gender, diagnosis or age, all of which have been identified in some studies (Greenwood etal. Reference Greenwood, Key, Burns, Bristow and Sedgwick1999; Wetherell etal. Reference Wetherell, Kaplan, Kallenberg, Dresselhaus, Sieber and Lang2004; Kessing etal. Reference Kessing, Hansen, Ruggeri and Bech2006). Other studies have also reported that demographic characteristics of psychiatric patients have a modest impact on satisfaction levels (Ruggeri etal. Reference Ruggeri, Lasalvia, Salvi, Cristofalo, Bonetto and Tansella2007).
A large number of participants provided data for the study and the spread of diagnoses, age and geographical location indicate the sample appears representative of those attending the outpatient services; however, the actual response rate and thus true representativeness of the study is unknown. Another limitation is the lack of control group in the study with which to compare the rates of CSQ-8 satisfaction levels. Further, the comparison of satisfaction levels across different settings (e.g. inpatient v. outpatient setting) was beyond the scope of this study. It is possible that a selection bias has been introduced into the collection of the data, with those who are in receipt of continuing care at outpatients more likely to respond and perhaps more likely to report higher satisfaction levels due to the continuity of their care. This is a limitation to patient satisfaction surveys, which has been demonstrated in other studies, which have highlighted that patient satisfaction may be overestimated overall, due to the higher response rate for the more satisfied patients (Mazor etal. Reference Mazor, Clauser, Field, Yood and Gurwitz2002). Another weakness is that we only included those patients who attended the outpatient service and thus excluded those who had defaulted on their clinic appointments. This may have been a sub-group who would have had higher levels of dissatisfaction.
Conclusion
This study demonstrates high levels of satisfaction with psychiatric outpatient care delivered in a university hospital setting. The majority of patients preferred the service to continue to be delivered in this setting. Community-based psychiatric care can be successfully delivered from a general hospital site in a small city, which carries the advantages of good public transport links and an unstigmatised environment.
Acknowledgements
The authors would like to thank the staff and patients of the West Galway Mental Health Services outpatient clinic, Galway city, for their assistance in the completion of this study. Specifically they would like to thank Mrs Peggy Gilligan and Ms Teresa Donohue for their assistance with the data collection.
Conflicts of Interest
None.
