The Journal of Forensic Psychiatry & Psychology

ISSN: 1478-9949 (Print) 1478-9957 (Online) Journal homepage: https://www.tandfonline.com/loi/rjfp20

A mixed-methods examination of patient

feedback within forensic and non-forensic mental
healthcare services

Trixie Mottershead, Najat Khalifa & Birgit Völlm

To cite this article: Trixie Mottershead, Najat Khalifa & Birgit Völlm (2020) A mixed-
methods examination of patient feedback within forensic and non-forensic mental
healthcare services, The Journal of Forensic Psychiatry & Psychology, 31:1, 106-122, DOI:
10.1080/14789949.2019.1680726

To link to this article: https://doi.org/10.1080/14789949.2019.1680726

Published online: 17 Oct 2019.

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THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY
2020, VOL. 31, NO. 1, 106–122
https://doi.org/10.1080/14789949.2019.1680726

A mixed-methods examination of patient feedback

within forensic and non-forensic mental healthcare
services
Trixie Mottersheada, Najat Khalifa b
and Birgit Völlmc
a
Centre for Autism, Neurodevelopmental Disorder and Intellectual Disability (CANDDID) and
Learning Disability, Neurodevelopmental Disorders and Acquired Brain Injury Care Group,
Cheshire and Wirral Partnership NHS Foundation Trust, Macclesfield, UK; bDepartment of
Psychiatry, Queen’s University, Kingston, Canada; cClinic and Polyclinic for Forensic
Psychiatry, University Medical Centre Rostock, Rostock, Germany

ABSTRACT
Background: The literature surrounding patient feedback is limited, despite
government policy integrating patient feedback into how the care quality of
the National Health Service (NHS) is assessed. The aim of the study is to examine
the detailed contextualised accounts of patient feedback within forensic and
non-forensic settings through qualitative and quantitative analyses.
Method: Responses which reflected positive or negative/neutral overall feedback
were analysed using Chi-Square tests on a total of 906 patient responses in a large
NHS Trust in England. Conventional content analysis was conducted on 222
patient free-text comments, deriving codes and distributing these into categories.
Findings: Forensic patients were more likely to give negative feedback on
mental healthcare services than non-forensic patients. The service’s level of
security-impacted patient’s willingness to engage with giving feedback. The
qualitative analysis provided further insight into these differences by identify-
ing themes in the data.
Conclusion: The findings of the present study highlight the challenges faced by
staff and volunteers when collecting patient feedback, exploring important
differences between services. The study makes recommendations to practice-
based interventions to reduce the consequence of these challenges and
explores recommendations for future research.

ARTICLE HISTORY Received 9 May 2019; Accepted 9 October 2019

KEYWORDS Patient feedback; forensic; non-forensic; mental healthcare; NHS

Introduction
Exploring patient involvement and satisfaction is central to government policy
in health service provision in the UK. Patient satisfaction has been identified as
a valuable measure of the National Health Service (NHS) performance by the
Department of Health (1997, 2002). The concept of the patient as an evaluator

CONTACT Trixie Mottershead trixie.mottershead@outlook.com

© 2019 Informa UK Limited, trading as Taylor & Francis Group
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 107

rather than a passive recipient of healthcare has become an important aspect of

service evaluation and service improvement (Carlin, Gudjonsson & Yates, 2005).
Public enquiries into failing services, such as the Francis Enquiry, which high-
lighted poor care practices and high mortality rates within hospital care, has
illuminated the adverse consequences of a service that is unresponsive to
patient needs and wishes (Bamford & Benton, 2015; Francis, 2013).
Patient feedback aims to capture various aspects of the patient’s views and
opinions towards the care they receive (Baldie, Guthrie, Entwistle, & Kroll, 2017;
Picker Institute, 2009). Systematic patient feedback surveys are now being under-
taken by many public health services globally. NHS Trusts are required to collect
and report patient feedback to the Care Quality Commission (CQC) as a regulatory
body (Brookes & Baker, 2017). These reports are becoming increasingly important
due to reductions in government funding, thereby encouraging healthcare
providers to demonstrate the quality, efficiency and financial viability of the
services they provide. In support of this idea, a cross-sectional observational
study of all NHS acute hospital Trusts revealed significant correlations between
patient feedback and objective measures of clinical quality, such as mortality and
infection rates (Greaves et al., 2012). It is therefore important to conduct a critical
review of previous literature, whilst examining issues such as bias in the collection
of patient feedback, difficulties in reaching a broad population sample and factors
that may influence data collection in forensic settings. These issues in the relia-
bility and validity of patient feedback, amongst others, will be explored further.
Early research into patient satisfaction reported consistent findings relating to
characteristics of the therapeutic relationship between staff and patients being
conducive to higher levels of satisfaction across care services in general (Cleary &
McNeil, 1988). Specifically, good communication skills and staff empathy pre-
dicted positive patient evaluations of care (Goodwin, Holmes, Newnes & Waltho,
1999). Patients are often frustrated by ‘petty rules’ and policies (Myers, Leahy &
Shoeb, 1990), which enforce punitive institutional controls (Hinsby & Baker,
2004). However, therapeutic relationships were found to reflect more positive
reports of ‘talking, counselling and listening’, ‘respect’, ‘care’ and ‘sympathy’
(McIntyre, Farrell & David, 1989). Wood and Alsawy (2016) conducted
a systematic review, implementing a thematic synthesis of qualitative evidence
which supported earlier findings; highlighting collaborative and inclusive care,
positive relationships, and safe and therapeutic hospital environments as super-
ordinate themes of positive feedback from patients.

The present study

In 2012, the Department of Health funded the NHS Patient Feedback
Challenge nationally. This programme aimed to illuminate good and innova-
tive practice for the employment of patient feedback to improve healthcare
services (Department of Health and Social Care, 2012). ‘Partnerships Inspiring
108 T. MOTTERSHEAD ET AL.

Change’ was one of the nine funded projects in the UK. The project aimed to
capture and collect patient feedback to inform service improvement (Institute
for Innovation and Improvement, 2013). Forensic mental health services in
the UK are high cost and low volume services. These services are delivered in
forensic secure hospital settings and the community, and consume 1% of the
total health budget in England and Wales alone (Centre for Mental Health,
2013). Therefore, in the current economic climate, it is important for these
services to demonstrate the quality, efficiency and financial viability of the
services they provide by collecting reliable and valid feedback from patients.
As part of the ‘Partnerships Inspiring Change’ initiative, the NHS Trust detailed
in the paper, has been collecting patient feedback from both forensic and non-
forensic mental healthcare services. It is from this data, available to the public
online, from which this study has been conducted. Research comparing forensic
and non-forensic (general) mental healthcare services is limited. Using the rou-
tinely collected data on patient feedback collected by the Trust, this study aims to
assess differences in feedback among patients treated in forensic and non-
forensic mental healthcare services, whilst exploring levels of security (low,
medium and high) and the reliability and validity of the data collected.

Aim and objectives

The aim of the study is to examine the patient feedback data collected across
a large NHS Trust in England; to extend the literature on examining patient
feedback within forensic and non-forensic mental healthcare services.
More specifically the study aims to:

(1) Examine the differences in feedback between forensic and non-

forensic services.
(2) Examine the differences in feedback across different levels of security.
(3) Examine qualitative data to explore the contextualised accounts of the
patient.

Method
Study design
A mixed-method design was employed in this study, utilising both quantita-
tive and qualitative data.

Sample and settings

The study was conducted in a large NHS Trust in England. The Trust provides
specialised mental healthcare, intellectual disability and community health
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 109

services in a large geographical area in England. Up to 9000 members of staff

provide these services across the community through to acute wards as well
as secure forensic settings. The sample comprised 906 patients who received
mental healthcare services in the Trust over the 6-month period between 01/
01/2017 and 30/06/2017.
The sample represents patients who have engaged in the Service User
Care Experience (SUCE) survey conducted within the NHS Trust. Participants
from both forensic and non-forensic services were receiving care for a mental
health problem, male and female and were over the age of 18.

Data collection
Data were collected by the NHS Trust volunteers on a 6-monthly basis across
forensic services. Within the community forensics directorate and the general
adult (non-forensic) services, the feedback was collected regularly by mem-
bers of staff, who were encouraged to distribute the survey when possible.
The sample of forensic patients (n = 111) consisted of patients under the care
of community forensic services and those residing in low, medium and high
secure forensic services. The sample from non-forensic services (n = 795) was
collected from the Adult Mental Health and Substance Misuse services of the
Trust as well as from the Local Partnerships Division of the Trust. All participants
were receiving treatment for a mental health disorder at the point of
participation.

Feedback questionnaire
The SUCE form (see Table 1) consists of seven items/questions which have
been used to collect the quantitative data for patient feedback.
Additionally, the SUCE form also invites open-ended comments from the
respondents via the free-text boxes ‘What could we do better?’ and ‘What did
we do well?’ displayed below the ‘friends and family test’ (question one).
Further free-text comments were prompted by the statement ‘Please tell us
why you gave this response?’ under the remaining six questions.

Data analysis
Quantitative analysis
The data were analysed using IBM SPSS Statistical Software version 22.
Categorical labels were assigned to the data as presented in the SUCE
forms. The ‘feedback score’, ‘ward response rate’ and ‘security level’ were
recorded for each participant for analysis. Chi-Square statistics were used to
analyse categorical data.
110 T. MOTTERSHEAD ET AL.

Table 1. SUCE form question layout.

Question Likert Scale Format
1. How likely are you to Extremely Likely Neither likely nor Unlikely Extremely Don’t know
recommend this service to likely unlikely unlikely
friends and family if they
needed similar care or
treatment?
2. How good was the service you Excellent Good Fair Poor Very poor
received?
How good were our services at:
3. Listening to you?
4. Communicating with you? Excellent Good Fair Poor Very poor
5. Showing you respect? Excellent Good Fair Poor Very poor
6. Involving you in decisions Excellent Good Fair Poor Very poor
about your care or treatment?
7. Making a positive difference to Excellent Good Fair Poor Very poor
your health and wellbeing?

Qualitative analysis
Free-text comments were analysed using a conventional approach to content
analysis due to limited existing theory and research (Hsieh & Shannon, 2005).
The data were separated into two groups in answer to the questions ‘What
did we do well?’ and ‘What could we do better?’. The data were systematically
transformed from a large amount of text into a highly organised and concise
summary of key results (Erlingsson & Brysiewicz, 2017). This method of
analysis encourages codes to emerge from the data as a way of categorising
the content of similar comments such as ‘hot food’ and ‘portion size’. These
codes were then put into themes as they themselves are categorised into
specific groups with regard to how they are related, such as ‘food’.

Approval issues
The study utilised anonymous data available in the public domain online, and
as such, it did not require participant consent. The study received approval
from the Faculty of Medicine and Health Sciences Research Ethics Committee
at the University of Nottingham and the Research and Innovation
Department of the NHS Trust.

Results
Sample characteristics
The sample comprised a total of 906 participants, 111 forensic patients and
795 non-forensic patients (see Table 2). Due to Trust confidentiality further
demographic information has not been supplied.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 111

Table 2. Characteristics of the patient group.

Number of
patients who Services provided by the
Forensic Directorates Number of beds participated Directorate
Community Forensics N/A 12 Patients discharged from prison
and secure units
Wells Road 92 10 Men and Women with a Mental
Disorder and Men with
a Learning Disability.
Arnold Lodge 102 13 Male Mental Illness, Male
Personality Disorder and
Women’s Services.
Wathwood 76 15 Male Mental Disorder
Rampton 340 61 Male: Mental Health Service,
Learning Disability Service, Deaf
Service, Personality Disorder and
Women’s Service
Non-Forensic Directorates
Adult Mental Health Mix of inpatient and 643 Men and women diagnosed with
outpatient population. a Mental Disorder receiving
treatment within a non-forensic
service
Substance Misuse Mix of inpatient and 152 Men and women diagnosed with
outpatient population. a Mental Disorder alongside
Substance Misuse issues
receiving treatment within a non-
forensic service.

Forensic vs. Non-forensic service

A significant difference was found (x2(1) = 60.11, p < .001) between the
feedback given by patients within forensic mental healthcare services and
non-forensic mental healthcare services. Patients in non-forensic services
rated the service that they had received more positively (93.7%) than those
within forensic services (71.2%). Furthermore, significant differences were
found between forensic patients and non-forensic patients on every single
question of the SUCE form. In sum, patients in non-forensic services returned
more positive ratings on six out of the seven questions (question 2, 3, 4, 5, 6
and 7). However, question one (friends and family question) shows that
patients from forensic services were more likely to recommend the service
to friends and family if they needed similar care (26.5%) than the non-forensic
patients (5.2%) (see Table 3).

Level of secure care and response rates in forensic services

Due to the violation of the assumption for expected frequencies, which is
required to report the Pearson Chi-Square value, within the level of secure
care analysis, the Likelihood Ratio has been used to interpret the results. The
likelihood ratio revealed a significant difference (LR(6) = 21.75, p = .001)
between ward response rate (low secure and community forensics, medium
 112

Table 3. Patient feedback percentage.

Extremely Likely Likely Neither Likely Nor Unlikely Unlikely Extremely Unlikely Chi- Square Equation
Q1: Promoter Forensic 15.7% 10.8% 4.9% 37.3% 31.4% (x2(4) = 82.60, p < .001)
T. MOTTERSHEAD ET AL.

Non-Forensic 3.6% 1.6% 2.7% 22.6% 69.5%

Very Poor Poor Fair Good Excellent
Q2: Service Forensic 0.9% 8.3% 18.3% 40.4% 32.1% (x2(4) = 97.82, p < .001)
Non-Forensic 2.2% 1.0% 4.1% 21.2% 71.6%
Q3: Listening Forensic 2.8% 6.4% 22.9% 37.6% 30.3% (x2(4) = 105.10, p < .001)
Non-Forensic 2.7% 1.1% 3.8% 22.2% 70.2%
Q4: Communication Forensic 3.6% 6.3% 15.3% 52.3% 22.5% (x2(4) = 90.34, p < .001)
Non-Forensic 2.4% 1.1% 5.3% 23.8% 67.3%
Q5: Respect Forensic 1.9% 10.2% 16.7% 35.2% 36.1% (x2(4) = 114.53, p < .001)
NonForensic 2.2% 0.6% 3.8% 17.4% 76.0%
Q6: Involvement with Care Forensic 4.5% 9.1% 15.5% 39.1% 31.8% (x2(4) = 47.02, p < .001)
Non-Forensic 2.6% 2.0% 6.7% 27.4% 61.4%
Q7: Positive Forensic 2.7% 10.8% 18.9% 42.3% 25.2% (x2(4) = 100.31, p < .001)
Non-Forensic 3.3% 0.7% 7.1% 25.4% 63.5%
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 113

secure and high secure). Patients within lower levels of secure care engaged
less frequently (10.1%) than those within medium secure care (28.3%) and
high secure services (61.6%).

Level of secure care and feedback within forensic services

A non-significant difference was found (x2(2) = 3.520, p > .05) between the
feedback given by patients within Low Secure and Community Forensics,
Medium Secure and High Secure forensic mental healthcare services (see Table 4).

Content analysis across both forensic and non-forensic services

Analysis of the free-text comments left by patients within forensic and non-
forensic services supports previous quantitative findings. Key themes have been
identified throughout the free-text data within both forensic and non-forensic
populations. Five themes have been found to be consistent throughout both
populations alongside three additional themes identified within the forensic
population only. Factors relating to staff, service and ward environment have
been identified within both population comments. Additionally, organisational
demands, quality of life and personal development themes have been identified
within the forensic population only. The codes identified within these themes
highlight some similarities and differences between the two populations.

Staff
Both populations commented positively about the interpersonal relation-
ships between patient and staff, specifically, communication and support.
However, forensic patients were more likely to highlight the negative char-
acteristics of ‘staffing quality’, ‘patient-staff power divide’ and ‘bullying’
within forensic services. Patients felt that the staff did not understand their
needs fully and that they felt subordinate to staff.

Employ more band 3 and people that know about forensics.

I don’t feel included staff/patient divide. Because when moved from Emerald no
discussion as to why move was happening.

Table 4. Percentages of feedback within the security level.

Negative/Neutral Positive
Security Feedback Feedback
Low Secure and Community 18.2% 81.8%
Forensics
Medium Secure 36.1% 63.9%
High Secure 21.4% 78.6%
114 T. MOTTERSHEAD ET AL.

Furthermore, non-forensic patients were more likely to comment upon ‘car-

ing staff’ and ‘supporting staff’ as aiding their recovery, often making an extra
effort to make the patient feel comfortable.
The care I was given was 100%. Nothing was ever too much trouble.
Everything – all staff have been brilliant.

Service
Both patient populations commented positively regarding the ‘service’
theme as supporting their needs. Patient comments referred to service
‘amenities’ and ‘access to services’ as positive aspects of the service.
Better meals and able to have mobile phone. (Non-Forensic)
Food is nice. Can have a shower when I want. Given money to spend in the
shop. The shop is good. Sufficient clothing has been supplied. (Forensic)

Forensic patients were more likely to comment upon the ‘service under-
standing’ of their mental illness and treatment procedures positively.
Meeting patient needs was highly valued and the services ability to address
this was prioritised.
Help very well with managing and understanding my illness and ensuring there
is always someone to talk to.
I feel the service has and is making a positive difference to my health and well-
being.

Non-forensic patients were more likely to comment positively about the

characteristics of the services such as ‘supporting future’, ‘information’
given by the service and service ‘organisation’. Patients felt that the service
encouraged personal skills and was prepared to deliver the service.
‘It helped build my confidence’

Ward atmosphere
Both populations valued the service ‘atmosphere’ and ‘feeling safe’ as an
important aspect of the service environment which guided positive comments.
‘Great environment – professional and friendly’ (Non-Forensic)
‘It’s like a home, not like being in a hospital. It’s friendly with a homely feel to it’
(Forensic)

Additionally, forensic patients discussed that it was important to feel ‘cared

for’ within the environment. Patient access to available ‘activities’ was
regarded to aid their recovery and promote positive comments about the
service environment.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 115

‘I get all the care and support genuine’

‘We have a timetable of activities and therapies’

Additional themes within the forensic population

Personal development. Forensic patients commented regularly on three
additional themes that were not identified within non-forensic patients
which may give some insight into the patient view of the secure setting.
Personal development was highlighted as a positive theme of the service,
such as aiding ‘future hope’ and increasing ‘patient understanding’ of them-
selves and their mental illness.
‘Look after people make them well giving people hope and a brighter future
than the past’
‘Help very well with managing and understanding my illness and ensuring there
is always someone to talk to’

Organisational demands. The institutional setting guided negative evalua-

tions of the service. Patient comments regarding the organisational demands
highlighted ‘staffing numbers’, ‘seclusion practices’ and the ‘availability of
therapy’ as being of detriment to the patient recovery process.
‘Dignity in seclusion via shower facilities including ways to help dry body or deal
with periods’
‘More staff would provide a more concise activity facilities, but that’s a major
issue across the board’

Quality of life. Additionally, patients commented upon the quality of life

within these settings, highlighting ‘respect and dignity’ as being neglected
within the confines of institutional control. The patient quality of life was
perceived as negative due to the distance from family and the service not
understanding the ‘patient need’.
Dignity – once when I was unwell I stripped down naked and then held me in
seclusion when I was naked I think it was wrong.

Discussion
Summary of findings
From the analysis of patient feedback, forensic patients were more likely to
give negative overall feedback on the mental healthcare service than non-
forensic patients. However, forensic patients were more likely to recommend
the service that they received to friends and family if they required similar
116 T. MOTTERSHEAD ET AL.

care. A significant difference was found between patient involvement (as

indexed by the response rate) and the level of security: high secure services
had a higher overall response rate than lower secure services (community
forensics, low and medium). Further analysis into forensic patient feedback
revealed no significant differences in feedback across the level of security
(community forensics and low, medium and high).
An investigation into patient comments gave further insight into the
differences between forensic and non-forensic patients regarding their ser-
vice experience. For example, both forensic and non-forensic patients com-
mented upon the interpersonal relationship with staff which reflected
positive feedback. However, forensic patients were more likely to be dissa-
tisfied with the staffing quality and power differential between patients and
professionals. Additionally, the institutional practice of the service deter-
mined more negative comments within the forensic population, such as
organisational demands and the impact upon quality of life.

Characteristics of the forensic environment

Overall the response rates in forensic services were low in comparison to the
entirety of the data set, only 12% of the data set represented patients from
forensic services. Additionally, over half of the data collected from forensic
services were represented by the high secure forensic service alone (55%).
This raises questions with regard to both the validity and reliability of the data
across the forensic services. The heavy weighting towards high secure foren-
sic services reduces the generalisability of the forensic population sample
overall. There may be sampling bias in the feedback collected, for example,
patients within high secure forensic services may have been compelled to
participate in the feedback process, due to the assumption that this beha-
viour may have some positive influence upon their progression through to
lower secure services. This increases the risk of bias in patients reporting more
positive feedback. Although this may give insight into the high response rates
within the high-security forensic service, overall forensic patients reported
more negative patient feedback than the general population overall. This
suggests that the possible presence of bias to report positive feedback does
not overcome the differences in feedback given by forensic patients in
comparison to non-forensic patients.
Although forensic patients were more negative in the overall feedback
given, it was found that they were more likely to recommend the service to
friends and family. This may suggest that although patients may have been
biased to report positive feedback on the first question, further exploration of
the service’s more specific characteristics outlined negative patient feedback.
After launching the friends and family test in 2013, the NHS have conducted
a development project which has adapted the friends and family test to invite
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 117

feedback on the patient’s overall experience; these changes aim to make it

a more useful tool for collecting the patient perspective whilst driving service
improvement, to be implemented in 2020 (NHS England, 2019).
Fortunately, the availability of qualitative ‘free text’ comments gives a more
in-depth examination of the differences found in quantitative analysis. Forensic
patients’ negative comments about service staff highlight the difficult practice
of balancing the staff/patient power divide within forensic settings. Patients
reported that they felt they were being bullied by staff. These findings support
the literature recognizing that balancing the power dynamic within services
that are restrictive and controlling can be a complex process (Völlm, Foster,
Bates, & Huband, 2017). There are many procedures within secure forensic
settings that are deemed necessary to maintain security within a therapeutic
environment. However, these security procedures may give rise to a cultural
ethos of control and surveillance (Rask & Hallberg, 2000) This cultural paradigm
within forensic mental healthcare services can negatively impact the therapeu-
tic relationship, and the delivery of care (Mason, 2002); establishing the balance
between security and therapy is likely to influence patient perspectives of their
interpersonal relationship with clinical staff.

Staff burnout and the therapeutic relationship

Existing evidence suggests that there may be a negative association
between staff burnout and patient satisfaction, which is likely to impact
the quality of the therapeutic relationship between care staff and their
patients; particularly in forensic services. Higher levels of assault, threat of
assault, self-injury, threat of self-injury and verbal abuse were more likely to
occur in forensic than non-forensic services. It is likely that in services where
members of staff are more exposed to the risk of physical violence and
verbal abuse, the ability to be empathetic, caring, give sympathy and
respect may be compromised (Wood & Alsawy, 2016). Therefore, patients
within forensic services may be less likely to develop a positive therapeutic
relationship with service staff, due to the nature of the forensic environ-
ment, in comparison to non-forensic services.
Additionally, the ‘image’ of the forensic psychiatric hospital and reputation
perceived by the general public, medical students, health professionals and
the media within forensic services may lead to negative stereotypes about
both staff and patients (Angermeyer, Van-Der-Auwera, Carta & Schomerus,
2017). In an examination of the differences in attitudes held by staff within
secure forensic services, no significant difference in attitudes towards
patients within low and medium secure services was found (Lammie,
Harrison, Macmahon, & Knifton, 2010). Although the difference in public
perceptions between the securities of forensic settings is unfounded, the
difference in perceptions of forensic as opposed to non-forensic settings is
118 T. MOTTERSHEAD ET AL.

pronounced (Angermeyer et al., 2017). The wider societal culture, in which

the systems of forensic settings function, may have a negative impact upon
perceived care.

Practice issues
The findings of the present study contribute to knowledge within mental
healthcare, teaching and future research. Forensic mental health practice
must reflect strong values and standards of both personal and ethical frame-
works alongside balancing the need to manage patient risk; all contributing
to the culture of forensic mental healthcare practice (Vinestock, 1996). This is
embodied in official policy which gives a guide to relational security, promot-
ing safe relationships for staff and patients in forensic settings (Department of
Health and Social Care, 2010).
Low response rates in forensic services may reflect practice issues; in these
settings, the authentic voice of the patient is likely to be compromised by
staff surveillance when giving feedback, alongside patients feeling pressured
to engage/dis-engage with volunteers to win the approval of peers or staff
within the ward (Völlm et al., 2017). The investigator observed the feedback
collection methods within the NHS Trust from which the data reviewed in this
paper were collected. The presence of staff required within the secure foren-
sic services did have some influence on patient engagement. In some
instances, patients asked if they could complete the feedback away from
staff surveillance. This is likely to be a common problem in patient feedback
studies due to the nature of the methodology.

Limitations and future research

Unfortunately, no systematic evaluation of the ‘Partnerships inspiring Change’
initiative has yet been conducted; an important gap in the literature. The
present study aimed to evaluate the data that has been collected by the
Trust; however, future research may aim to look at how the Trust uses the
data and how it is fed back to individual services to help the service tailor future
quality improvements. There is a significant need for services to better develop
their evidence base for the reporting and impact of patient feedback in NHS
healthcare services (Mockford, Staniszewska, Griffiths, & Herron-Marx, 2011).
In terms of the Trust’s patient feedback collection method, the SUCE form
collects additional information about the patient: gender, ethnic group, dis-
ability, religion/belief, sexual orientation, age, relationship status and preg-
nancy information. However, this additional information has not been made
available for the present study due to confidentiality considerations. The
availability of more descriptive data from the patient population may help
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 119

to illuminate confounding variables, such as the influence of age, gender and

mental health diagnosis on the results of the study.
Unfortunately, due to the low response rates collected within forensic
services, the validity of the data may be compromised. For a more informative
analysis of patient feedback, future research should consider employing focus
groups to examine current findings; further exploration may give strength-
ened insight into the patient view of ‘practice issues’ which may present as
a barrier to feedback within forensic settings. Additionally, focus group inter-
views encourage the collection of a rich source of information that may better
extract the authentic patient voice (McLafferty, 2004).
The inconsistency of methods and results between studies within the
literature makes it difficult to compare findings, such as the process of
collection and the way in which surveys have been presented (Evans,
Edwards, Evans, Elwyn, & Elwyn, 2007). The design and implementation of
a universal feedback survey, specific to the patient population (forensic and
non-forensic) within mental healthcare services, would allow for the transfer-
ability and generalisability of findings to promote knowledge sharing within
the NHS, and service improvement nationally.

Recommendations
The Trust, from which the data has been collected, has employed strategies in
the hope that the rate and quality of feedback that is collected is unbiased.
For example, the use of volunteers to encourage feedback within the forensic
setting. However, the role of ‘being a volunteer’ may influence the way that
the patients respond to their presence. Volunteers are considered advanta-
geous as they present as separate from the service, which may encourage
patients to be honest in their feedback; improving the validity of the data. All
feedback is anonymous and once completed, the survey is sealed by the
patient so that the feedback cannot be viewed by anyone at the time of
completion. This strategy is thought to reassure the patient that their feed-
back they give cannot be viewed by the staff they work with.
We recommend, from our findings that staff should be trained to be aware
of the practical issues highlighted above, and take actions to reduce their
consequence (Coffey, 2006). Prior to volunteer arrival, patients should be
informed by a designated staff member that all the information they give
will be confidential. This is likely to increase involvement, allowing patients to
think about their decision to engage prior to any contact with volunteers.
Furthermore, it is important that volunteers do not ask leading questions
when prompting free-text comments so that the patient response is influ-
enced as little as possible by the presence of the volunteer (Ritchie, Lewis,
Nicholls, & Ormston, 2013). Patient feedback helps to inform action plans for
each ward; communicating the process and progress of the action plan will
120 T. MOTTERSHEAD ET AL.

keep patients informed and interested with feedback and future involvement
(Picker Institute, 2009). An investigation into patient involvement across
a variety of mental healthcare services revealed that involvement was encour-
aged by the care system; patient-centred care and treatment alongside
a good therapeutic patient-professional alliance (Laitila, Nummelin,
Kortteisto, & Pitkänen, 2018).
Forensic services often support challenging, high risk or extremely vulner-
able people whose behaviour may present as a risk to both themselves or to
others (Spiers, Harney, & Chilvers, 2005). Capturing the patient perspective in
these settings involves overcoming many practical problems of access, capa-
city to give consent, risk of coercion and appropriately trained staff/volun-
teers to work in these challenging settings. The findings of the paper
illuminate that what is important to patients within forensic and non-
forensic services may vary. The findings suggest that forensic populations
may require the design of a survey to address their unique need in a more
individualistic format, focusing on the therapeutic relationship, for example.
Grouping forensic and non-forensic populations under the same ‘mental
health’ group is likely to increase the risk of neglecting important feedback
that may inform the practice within a specific service setting. Ongoing
innovation to NHS service designs, such as this, is crucial in the development
of healthcare practice.

Acknowledgments
I would like to thank Nottinghamshire Healthcare NHS Foundation Trust’s Involvement,
Experience and Volunteering Team. Their passionate participation and input has
inspired me to critically analyse the way in which patients are listened to and involved
with service delivery.

Disclosure statement
No potential conflict of interest was reported by the authors.

ORCID
Najat Khalifa http://orcid.org/0000-0002-2690-9736

References
Angermeyer, M. C., van der Auwera, S., Carta, M. G., & Schomerus, G. (2017). Public
attitudes towards psychiatry and psychiatric treatment at the beginning of the 21st
century: A systematic review and meta-analysis of population surveys.
World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 16(1),
50–61.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 121

Baldie, D. J., Guthrie, B., Entwistle, V., & Kroll, T. (2017). Exploring the impact and use of
patients’ feedback about their care experiences in general practice settings—A
realist synthesis. Family Practice, 35(1), 13–21.
Bamford, K., & Benton, C. (2015). Gathering meaningful service user feedback regard-
ing a community forensic service. Journal of Intellectual Disabilities and Offending
Behaviour, 6(2), 81–93.
Brookes, G., & Baker, P. (2017). What does patient feedback reveal about the NHS?
A mixed methods study of comments posted to the NHS Choices online service.
BMJ Open, 7(4).
Carlin, P, Gudjonsson, G, & Yates, M. (2005). Patient satisfaction with services in
medium secure units. Journal Of Forensic Psychiatry & Psychology, 16(4), 714-728.
doi:10.1080/14789940500328245
Centre for Mental Health (2013). Guidance for commissioners of forensic mental health
services. Retrieved from https://www.jcpmh.info/wp-content/uploads/jcpmh-
forensic-guide.pdf
Cleary, P. D., & McNeil, B. J. (1988). Patient satisfaction as an indicator of quality care.
Inquiry, 25(1), 25–36.
Coffey, M. (2006). Researching service user views in forensic mental health: A literature
review. The Journal of Forensic Psychiatry & Psychology, 17(1), 73–107.
Department of Health. (1997). The patient’s charter. Retrieved from: https://assets.
publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/
file/266003/newnhs.pdf
Department of Health. (2002). Modernising mental health service: Inspection of men-
tal health services. Retrieved from https://assets.publishing.service.gov.uk/govern
ment/uploads/system/uploads/attachment_data/file/250880/5103.pdf
Department of Health and Social Care (2010), See Think Act, Retrieved from https://
assets.publishing.service.gov.uk/government/uploads/system/uploads/attach
ment_data/file/320249/See_Think_Act_2010.pdf
Department of Health and Social Care (2012). NHS Patient Feedback Challenge uses
online crowdsourcing to collect ideas and support projects, Retrieved from https://
www.gov.uk/government/news/nhs-patient-feedback-challenge-uses-online-
crowdsourcing-to-collect-ideas-and-support-projects.
Erlingsson, C., & Brysiewicz, P. (2017). A hands-on guide to doing content analysis.
African Journal of Emergency Medicine, 7(3), 93–99.
Europe, Picker Institute, (2009), Quality improvement: the help you need, Retrieved
from http://www.nhssurveys.org/Filestore/documents/QIFull.pdf.
Evans, R. G., Edwards, A., Evans, S., Elwyn, B., & Elwyn, G. (2007). Assessing the
practising physician using patient surveys: A systematic review of instruments
and feedback methods. Family Practice, 24(2), 117–127.
Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust public inquiry:
Executive summary, London: The Stationery Office, (Vol. 947). Retrieved from https://
assets.publishing.service.gov.uk/government/uploads/system/uploads/attach
ment_data/file/279124/0947.pdf
Goodwin, I, Holmes, G, Newnes, C, & Waltho, D. (1999). A qualitative analysis of the
views of in-patient mental health service users. Journal Of Mental Health, 8(1), 43-54.
doi:10.1080/09638239917634
Greaves, F., Pape, U. J., King, D., Darzi, A., Majeed, A., Wachter, R. M., & Millett, C. (2012).
Associations between Web-based patient ratings and objective measures of hospi-
tal quality. Archives of Internal Medicine, 172(5), 435–436.
122 T. MOTTERSHEAD ET AL.

Hinsby, K, & Baker, M. (2004). Patient and nurse accounts of violent incidents in a
medium secure unit. Journal Of Psychiatric and Mental Health Nursing, 11(3), 341-
347. doi:10.1111/jpm.2004.11.issue-3
Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis.
Qualitative Health Research, 15(9), 1277–1288.
Institute for Innovation and Improvement (2013), Nhs patient feedback challenge,
partnerships inspiring changes – nottinghamshire healthcare trust. Retrieved from:
https://www.patientlibrary.net/tempgen/104920.pdf.
Laitila, M., Nummelin, J., Kortteisto, T., & Pitkänen, A. (2018). Service users’ views
regarding user involvement in mental health services: A qualitative study.
Archives of Psychiatric Nursing, 32(5), 695-701.
Lammie, C., Harrison, T. E., Macmahon, K., & Knifton, L. (2010). Practitioner attitudes
towards patients in forensic mental health settings. Journal of Psychiatric and
Mental Health Nursing, 17(8), 706–714.
Mason, T. (2002). Forensic psychiatric nursing: A literature review and thematic ana-
lysis of role tensions. Journal of Psychiatric and Mental Health Nursing, 9(5), 511–520.
McIntyre, K, Farrell, M, & David, A. S. (1989). What do psychiatric inpatients really want?.
bmj: british medical journal. 298(6667), 159.
McLafferty, I. (2004). Focus group interviews as a data collecting strategy. Journal of
Advanced Nursing, 48(2), 187–194.
Mockford, C., Staniszewska, S., Griffiths, F., & Herron-Marx, S. (2011). The impact of
patient and public involvement on UK NHS health care: A systematic review.
International Journal for Quality in Health Care, 24(1), 28–38.
Myers, D. H, Leahy, A, Shoeb, H, & Ryder, J. (1990). The patients' view of life in a
psychiatric hospital: a questionnaire study and associated methodological consid-
erations. The British Journal Of Psychiatry, 156(6), 853-860. doi:10.1192/bjp.156.6.853
NHS England (2019), NHS England and NHS improvement guidance: Using the friends
and family test to improve patient experience. Retrieved from https://www.eng
land.nhs.uk/publication/nhs-england-and-nhs-improvement-guidance-using-the-
friends-and-family-test-to-improve-patient-experience/
Picker Institute Europe, (2009), Quality improvement: the help you need, Retrieved
from http://www.nhssurveys.org/Filestore/documents/QIFull.pdf.
Rask, M., & Hallberg, I. R. (2000). Forensic psychiatric nursing care—Nurses apprehen-
sion of their responsibility and work content: A Swedish survey. Journal of
Psychiatric and Mental Health Nursing, 7(2), 163–177.
Ritchie, J., Lewis, J., Nicholls, C. M., & Ormston, R. (Eds.). (2013). Qualitative research practice:
A guide for social science students and researchers (pp. 190–193). London: Sage.
Spiers, S., Harney, K., & Chilvers, C. (2005). Service user involvement in forensic mental
health: Can it work? The Journal of Forensic Psychiatry and Psychology, 16(2),
211–220.
Vinestock, M. (1996). Risk assessment.“A word to the wise”? Advances in Psychiatric
Treatment, 2(1), 3–10.
Völlm, B., Foster, S., Bates, P., & Huband, N. (2017). How best to engage users of
forensic services in research: Literature review and recommendations.
International Journal of Forensic Mental Health, 16(2), 183–195.
Wood, L, & Alsawy, S. (2016). Patient experiences of psychiatric inpatient care: a
systematic review of qualitative evidence. Journal Of Psychiatric Intensive Care, 12
(1), 35-43. doi:10.20299/jpi.2016.001