Issues in Mental Health Nursing, 34:846–854, 2013 Copyright © 2013 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.831505

Participant Satisfaction with Wellness Recovery Action Plan (WRAP) Jessica M. Wilson, BSN Vanderbilt University Medical Center, Nashville, Tennessee, and University of Tennessee, College of Nursing, Knoxville, Tennessee, USA

Sadie P. Hutson, PhD, RN, WHNP, BC and Ezra C. Holston, PhD, RN University of Tennessee, College of Nursing, Knoxville, Tennessee, USA

Outpatient programs are often promoted as vehicles for mental health recovery. Yet, few programs include patients’ perspectives about their satisfaction with these programs. This descriptive, cross-sectional survey investigated patients’ satisfaction with Wellness Recovery Action Plan (WRAP). Participants completed the Mental Health Statistics Improvement Program instrument (n = 26) and qualitative interviews (n = 18). Data were analyzed using multivariate statistics (α = .05) and content analysis. Three composite variables explained 48% of the variance (p = .00) in patient satisfaction. Four themes emerged: Retrospective Desire for Early WRAP Introduction, Pay It Forward, Unconditional Relational Support, and It Takes Time. Future research is warranted to promote WRAP’s use in broader settings.

Lucock et al. (2011) argued that “Recovery is identified as a key process leading towards well-being and functioning” (p. 612). In any case of infirmity, recovery is a necessary aspect of the healing process and the return of well-being. In psychiatry, outpatient recovery programs are used extensively to promote recuperation and self-reliance. Significant themes contributing to recovery in outpatient recovery programs include autonomy, social support systems, and enabling factors such as education and health insurance. In addition, education on recovery and implementation of groups led by peer facilitators also contribute to patient recovery. The Wellness Recovery Action Plan (WRAP) is the most widely used self-management recovery program in the US, The authors thank the participants and the outpatient mental health facility, especially Dr. Mary Nelle Osborne, Manager of Recovery Services. JMW also expresses gratitude to the University of Tennessee Nursing Honors Program as well as the Chancellor’s Honors Program for the opportunity to conduct this research while an undergraduate student and to enhance my perception of nursing research’s impact on mental health and social issues. Address correspondence to Jessica M. Wilson, University of Tennessee, School of Nursing, 1200 Volunteer Blvd, Knoxville, TN 37996. E-mail: [email protected]

Canada, British Isles, Japan, Hong Kong, New Zealand, and Australia (Cook et al., 2011). Also, WRAP is one of the few evidence-based programs endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA). WRAP was developed in 1997 by the collaborative efforts of participants in an eight-day recovery skills seminar for psychiatric symptoms in Vermont (Copeland, 2001). The goal was to construct a self-monitoring and response system that provides structure through wellness tools to relieve and eliminate symptoms, and to stay well. In addition, individualized tools and responses are identified to help decrease symptoms and promote wellness. These tools are then incorporated into WRAP, which includes: (1) a daily maintenance plan, (2) strategies to identify and respond to triggers, (3) strategies to identify and respond to early warning signs, (4) strategies to recognize and respond when things are breaking down, (5) a crisis plan or advanced directive, and (6) a post crisis plan” (Copeland, 2001). WRAP emphasizes five key recovery concepts: hope, personal responsibility, education, self-advocacy, and support. With WRAP, participants recognize personal wellness resources and incorporate them in their everyday lives in addition to identifying and dealing with symptom triggers, exacerbations, and crises (Cook et al., 2012). WRAP is unique in that the certified peer facilitators have participated in their own WRAP before undergoing a five-day training session to become certified (Cook et al., 2010). The literature does not mention the presence of psychiatric nurses in WRAP probably due to the nature of a peer facilitated program. Davidson (2005) emphasizes the professionals’ role in recovery to be that of a “companion or fellow traveler rather than as expert” because those who had utilized mental health services themselves were often the most effective in instigating change. Cook et al. (2010) acknowledges the effectiveness of peer-led interventions to promote the spread of WRAP although, “The notion that peers can teach other peers skills, attitudes, and behaviors that enable them to self-manage their mental illness is not widely accepted” (p. 113). Jonikas et al. (2011) supports

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the efficacy of peer-led self-management of mental health recovery by reporting that WRAP participants were significantly more likely to engage in self-advocacy than participants who received usual outpatient care. Furthermore, more people were introduced to WRAP by those who have personal experience with mental illness and even more so by those who have used WRAP themselves (Hill, Roberts, & Igbrude, 2010). For example, Mariam Aziz became a Certified Peer Facilitator after using WRAP to live with her bipolar disorder. Although she has a B.S. degree in Psychology, she describes peer led services as enabling her “to connect with others, not on a clinical level, but as a friend or mentor. I am open and honest with others, sharing my story and helping them to see possibilities” (Aziz, 2010, p. 34). However, there is a lack of research involving patient satisfaction specific to aspects of recovery programs. Not only are many instruments limited by their compilation of items, which focus on professional views of quality care instead of patient perspectives, but Perreault et al. (2006) also found that participant responses tend to cluster around the “highly satisfied” side of scales which is therefore a major limitation of standardized instruments. Qualitative approaches are vital to further explore significant sources of satisfaction and dissatisfaction (Perreault et al., 2010). However, qualitative approaches are not consistently included in all instruments, and the impact of patient satisfaction results is often lessened due to the lack of direct contact between decision makers, service providers, and service users. Furthermore, in understanding a program’s efficacy, the patients’ perspectives of satisfaction need to be considered and applied to specific aspects of outpatient mental health recovery programs. Therefore, the purpose of this descriptive, cross-sectional survey was to investigate and clarify the patient-oriented factors that contribute to patient satisfaction for outpatients in a mental health facility using WRAP.

BACKGROUND The efficacy of recovery programs is often based on symptom reduction and decreased hospital recidivism; however, it is vital to take patient perspectives and satisfaction into account when evaluating efficacy of recovery programs in assuring quality of care. In doing so, efforts to improve health care services and interventions, through evidence-based research, will be more pertinent to patient expectations and can therefore be correlated and implemented in other programs. Although the World Health Organization (WHO) outlined the need to measure client satisfaction as part of the evaluation of health services (Vuori, 1991), there is a deficit of research regarding patient satisfaction specific to aspects of care and WRAP (Perrault et al., 2010). In addition, a comprehensive review of the literature identified only five published studies of WRAP outcomes, none of which included participant satisfaction (Cook et al., 2012). The following are outcomes of the WRAP studies: (1) WRAP workshops contributed to significant advances in recovery at-

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titude and knowledge with no differences between consumers and professionals (Doughty, Tse, Duncan, & McIntyre, 2008); (2) There was an increased sense of hope and recovery with no decrease in symptoms after participating in WRAP (Starnino et al., 2010; (3) There were decreased symptoms and increased hope with no significant changes in self-perceived recovery (Fukui et al., 2011); (4) There was significant improvement in self-management, including positive attitudes, knowledge, and wellness skills (Cook et al., 2010); (5) There was decreased depression and anxiety, which was maintained over time; increased self-perceived recovery; and better outcomes with longer exposure to WRAP (Cook et al., 2012). Cook et al. (2010) notes that satisfaction with WRAP was implied by the open-ended comments participants left on their evaluation questionnaires regarding attitude, knowledge, and skills outcomes of WRAP in two states, although they did not identify what specific aspects of WRAP contributed to patient satisfaction. Perhaps understanding the types of quality of care will facilitate the identification of patient-oriented factors that lead to an effective evaluation of patient satisfaction. Many authors have reported that the types of quality of care may contribute to patient satisfaction with outpatient recovery programs. Siponen and Valimaki (2003) suggested that patient satisfaction includes two subjective sections: “The expectation of care and the evaluation of care” (p. 130). “Studies have shown patients generally rate care highly” (Schr¨oder, Ahlstr¨om, WildeLarsson, & Lundqvist, 2011, p. 445). What does high quality of care look like to patients? Schr¨oder et al. (2011) conducted a phenomenographic interview study to establish a comprehensible definition according to patients. Their findings consisted of five concepts: “the patient’s dignity,” “the patient’s sense of security with regard to care,” “the patient’s participation in the care,” “the patient’s recovery,” and “the patient’s care environment” (p. 446). With these patient perspectives, Schr¨oder et al. (2011) developed the Quality of Psychiatric Care-Outpatient instrument (QPC-OP) to measure patient satisfaction. The QPCOP provides a more accurate representation of the aspects of quality of care that are relevant and important to patients. In addition, it highlights aspects contributing to patient satisfaction for an effective program. Perreault et al. (2010) recognized the improvement in the strength of satisfaction surveys as evidenced by valid and reliable standardized questionnaires based on self-administered questionnaires and personal interviews. However, Schr¨oder et al. (2011) acknowledged “There are few published instruments for evaluating the quality of outpatient psychiatric care, specifically from the patients’ perspectives” (p. 446). The rarity of reliable and valid assessments of patient satisfaction within mental health care also is recognized in the Evaluation of Client Services Study (Berghofer, Castille, & Link, 2010). Therefore, Berghofer et al. constructed the Evaluation of Client Services (ECS), a 20-item instrument to measure treatment satisfaction. To determine convergent validity, Berghofer et al. (2010) used the Mental Health Statistics Improvement Program (MHSIP)

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as a comparison measure of treatment satisfaction (Cronbach α = 0.89). Factor analysis of ECS found the following four factors explained two-thirds of the total variance in treatment satisfaction: (1) treatment management and treatment outcome, (2) treatment relationship, (3) communication and information exchange, (4) reachability of treatment facilities. Other instruments also have been used to collect quantitative data. The Verona Service Satisfaction Scale is commonly used with psychiatric outpatients; however, this scale is a challenge to complete for people with chronic mental illnesses who may have impairments in attention and cognition. The Client Satisfaction Questionnaire (CSQ-8) does not distinguish specific aspects of care delivery; however, it only consists of eight items, limiting the data. The 30-item QPC-OP has been “deemed viable” in measuring patient satisfaction because of an acceptable level of internal consistency (Cronbach α = 0.95) (Schr¨oder et al., 2011, p. 450). It emphasizes aspects specific to outpatients such as encounter, participation, support, discharge, secure environment, and next of kin. “The ‘encounter’ dimension acquired the highest ratings, with research indicating that interpersonal relationship is a central factor for quality of care from the patient’s perspective” (Schr¨oder et al., 2011, p. 450). The lowest satisfaction was reported in the “participation-information” and “discharge” dimensions. The Charleston Psychiatric Outpatient Satisfaction Scale (α = .87) notes predictors of satisfaction with care include helpfulness of the services (r = .86) and respect for patients’ opinions (r = .84) (Pellegrin, Stuart, Maree, Frueh, & Ballenger, 2001). Therefore, patient perspectives and limitations of the instruments must be taken into account when developing and implementing an instrument to evaluate specific aspects of recovery programs. Also, any possible effect(s) from those administering the instruments must be considered. External evaluators and internal evaluators may introduce biases that are derived from the professional view and not the patient perspective. Perreault et al. (2010) found that most satisfaction surveys implemented by external evaluators may “lack the same intensity that direct interaction may convey” (p. 486). On the other hand, internal evaluators may sway patient responses due to fear of loss of resources and confidentiality. In understanding a program’s efficacy, further studies involving implementation of instruments need to be based on patient perspective of satisfaction and applied to specific aspects of outpatient mental health recovery programs. Therefore, the obvious absence of the patient’s perspective about satisfaction in these instruments substantiates this survey as a way to clarify the patient-oriented factors that contribute to patient satisfaction for outpatients in a mental health facility using WRAP. METHODS Design and Setting A descriptive, cross-sectional design was used for our survey study to identify the factors related to patient satisfaction with WRAP from the patients’ perspective at a specific point

in time. We also used a qualitative approach to provide insight into specific patients’ perspectives regarding satisfaction and dissatisfaction with aspects of the program. The setting was a mental health facility in East Tennessee that uses WRAP and peer support facilitators who completed the WRAP. It also has a high visibility in the community. Participants and Procedure We recruited participants using a convenience sample from a Southeastern outpatient mental health facility that uses WRAP, as described above. Participants were (1) involved in WRAP for at least one month, (2) over 18 years of age, and (3) able to speak and read English. Individuals were excluded from the study if they were (1) experiencing a mental health crisis at the time of data collection, (2) unable to answer questions regarding participant satisfaction of WRAP, or (3) a WRAP participant for less than one month. The protocol for this study received IRB approval. The principal investigator (JMW) recruited participants in conjunction with the WRAP peer facilitators. After a verbal announcement about the study, the WRAP peer facilitators informed the principal investigator of interested individuals. A study flier, containing the elements of informed consent, was given to all interested individuals. We requested a waiver of written informed consent because no patient identifiers were collected. Data collection sessions commenced one week after recruitment. These sessions occurred over three consecutive days in January 2013 beginning with a short introduction and review of the purpose statement by the investigator. Distribution and reading of the quantitative Mental Health Statistics Improvement Program (MHSIP) instrument followed. Following the administration of the quantitative instrument, participants who volunteered for the qualitative interviews (69%) individually met the investigator in a private room for the one-on-one, 15–45-minute interview. Instrument Using the MHSIP, the descriptive, cross-sectional survey consisted of quantitative, objective questions and open-ended narrative, or qualitative questions. Permission was granted to use the current version of MHSIP. “MHSIP has been used for measuring satisfaction of severely mentally ill service users receiving comprehensive community services” (Berghofer et al., 2010, p. 402). Reliability of the MHSIP was high in a study investigating inpatient satisfaction (Cronbach α = .96), and subscale alphas were .88 and above (Howard, El-Mallakh, Rayens, & Clark, 2003). All participants (n = 26) completed the 41-question MHSIP instrument as a group while the investigator (JMW) read each question, enabling any questions asked to be answered for the entire group and providing structure. A five-point Likert scale was used with a rating from 1 (strongly agree) to 5 (strongly disagree). For each item there also was the possibility of answering “not applicable.” The instrument also included six demographic questions.

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Open-ended questions were developed by the research team and included the following: 1. What aspects of WRAP are most beneficial to you? 2. Do you feel that any part of your WRAP training was not helpful in your recovery? If so, what? 3. Did the way the information was presented to you allow you to understand and learn? If so, why? If not, why not? 4. Did you find the information you have learned in WRAP helpful on your road to recovery? If so, why? If not, why not? 5. What suggestions do you have for improving WRAP? 6. Do you have any additional information that you want to provide regarding WRAP? Johannson and Eklund (2003) identified that the reason mental health patients consistently report high levels of satisfaction is due to measuring methods that lack factors of dissatisfaction. Therefore, with questions two and five, and by asking “if so” or “if not” questions on questions three and four, we presented the opportunity for participants to report any dissatisfaction. Responses were transcribed directly during the interview; therefore, no audio-taping was necessary. Data Analysis Data were analyzed with SPSS 20.0 (Windows). The principal investigator (JMW) collected and entered all data. Data consisted of continuous variables (age of participant and length

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of program participation) and categorical variables (questions from MHSIP) as well as composite variables generated from selected continuous variables. We created composite variables to identify the MHSIP items related to the patient’s perspective about patient satisfaction in order to accurately measure the targeted outcome. This effort facilitated our ability to identify and describe specific factors related to patient satisfaction. It also allowed us to avoid the collapsing of these MHSIP items into other MHSIP items or other variables. We computed composite variables by calculating the mean of selected MHSIP items: Service Composite is the mean of questions 1–18 (services offered in the WRAP facility); Result Composite is the mean of questions 19–31 (patient outcomes or results from being in the WRAP facility); Support Composite is the mean of questions 32–35 (support from community). The items for the composite variables of Service and Result were correlated to determine which items would constitute significant composite variables based on the items significant association with questions specific to patient satisfaction. Table 1 lists the significant composite variables: Patient Autonomy Composite is the mean of questions 5–7, 9–10, 14–15, and 17 (patientdetermined actions and behaviors that significantly correlated with patient results); Significant Services Composite is the mean of questions 1–2, 4–7, 9–10, and 15–17 (services that significantly correlated with patient results); and Significant Length of Program Participation is the mean of questions 1, 5, and 17 (services that significantly correlated with length of program participation).

TABLE 1 Significant Composite Variables Patient Autonomy

Significant Length of Program Participation

Services

Staff returned calls within 24 hours Staff willing to see me as often as I need Services available at good times for me I felt free to complain I felt comfortable asking about my treatment/medication I, not staff, decided my treatment goals Wishes respected about who is/is not given information Help obtaining information to take charge of managing my illness Staff willing to see me as often as I need I like the services that I received here Help obtaining information to take charge of managing my illness If I had other choices, I would still get services from this agency I like the services that I received here The location of services was convenient Staff willing to see me as often as I need Staff returned calls within 24 hours Services available at good times for me I felt comfortable asking about my treatment/medication I felt free to complain I, not staff, decided my treatment goals Staff were sensitive to my cultural background Help obtaining information to take charge of managing my illness

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Descriptive analyses were used to characterize the data. Statistical analysis included Kendall Tau-b to describe the association among the data and determine the composite variables. The Kruskal-Wallis Test was used to determine if the significant composite variables differed across the Length of Program Participation. Linear regression was used to determine what factors might explain any variance in the Results Composite variable since it represented patient satisfaction at a WRAP facility. The level of significance was .05 with a moderate effect size of .24, and post-hoc power of .66 (G∗ Power) for a 2-tailed linear regression analysis. Qualitative content analysis was used to (1) identify the individual themes, (2) recognize any relationships or patterns among the themes, and (3) understand how the thematic relationships and patterns contribute to the recovery of WRAP participants (Corbin & Strauss, 2008). RESULTS The sample (n = 26) had a mean age of 42.23 years ± 14 years; 50% of the sample were female (n = 13), 60% identified as Caucasian (n = 15), 32% identified as African American (n = 8), and 8% of the sample identified as mixed (n = 2). All participants were insured, and 39% had participated in the WRAP program for 1–5 months (n = 10), 19% for 6–12 months (n = 5), and 42% had participated for greater than 12 months (n = 11). Eighteen participants (69%) completed the qualitative interview. Quantitative Using correlational analysis, we found that several variables (single and composites) were significantly associated. The Results Composite significantly correlated with the items that comprised the Patient Autonomy Composite (r = .36–.44, p = .01–.05). The Results Composite significantly correlated with 61% of the items of the Service Composite (r = .40–.57, p = .00–.04). The Length of Program Participation Composite consists of the three items from the significant correlation between the length of program participation variable and the Results Composite and Service Composite Correlation (r = –.38– –.46, p = .01–.04). These significant correlations indicated that the composite variables were correctly aligning with the individual items related to patient satisfaction. These significant correlations also were instrumental in determining what variables should be used for further analyses. The variables for multi-analysis were Patient Autonomy Composite, Significant Services Composite, and Significant Length of Program Participation Composite, which were all significantly correlated (r = .71–.90, p = .00). With KruskalWallis Test, there was no significant difference in either one of the composite variables by Length of Program Participation. This result suggested that all three composite variables might contribute to patient satisfaction and should be included in further analysis. With a linear regression using the forward method, the three composite variables were used to explain the amount of variance in the patient satisfaction. Patient Autonomy Com-

posite, Significant Services Composite, and Significant Length of Program Participation Composite explained 48% of the variance in participant satisfaction (F-statistic (df = 3,22) = 6.69, p = .00). The regression equation is: Patient Satisfaction = (.56 ± .27) + ((1.4 ± .69)∗ Significant Services Composite) − ((.09 ± .31)∗ Significant Length of Program Participation Composite) − ((.55 ± .64) Patient Autonomy Composite)

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For the current sample, the lowest score for patient satisfaction was 1.32 ± .01 and the highest score for patient satisfaction was 2.31 ± .45, with a score of ≥1.86 indicating high patient satisfaction. Qualitative Four major themes contributing to improved mental health were inductively derived from the interview data: (1) Retrospective Desire for Early WRAP Introduction; (2) Pay it Forward; (3) Unconditional Relational Support; and (4) It Takes Time. Table 2 presents selected quotes that are representative of each of the four themes characterizing patient satisfaction for improved mental health. The theme, Retrospective Desire for Early WRAP Introduction, includes exposure to the concepts taught in WRAP at a younger age. This theme suggests that mental health can be improved by proactive recognition of personal wellness resources and incorporation of them into one’s everyday lives (the aspects of WRAP). This awareness establishes a certain level of self-stability that will contribute to the efficacy of treatment for improved mental health. The current participants, who are in the early middle-age stage (mean age = 42.23 ± 14 years), believed they would have had a better opportunity for mental health recovery if they were aware of and utilized the aspects of WRAP during their adolescent or young adult years. The theme, Paying it Forward, describes the desire to share one’s story in order to positively change someone else’s life by introducing them to the hope of recovery and a better quality of life. By paying it forward, persons can find constructive ways to use their experiences. For the current participants, the theme, Paying it Forward, gave them a sense of worth because they could give back to the community through their experiences with WRAP. Unconditional Relational Support describes the need for support, whether it is family, friends, or peer facilitators and program participants. Within the current study, this theme reflected the level of comfort the participants had in coming to individuals in their lives for support and guidance. The theme, It Takes Time, depicts the acceptance that recovery does not happen overnight, but is an intentional process that one must work for every day. Many participants reported that they were not ready to commit to recovery and the program

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TABLE 2 Qualitative Themes Retrospective Desire for Early WRAP Introduction “I wish I would have found it [WRAP] a long time ago” (2) “I feel like this should be in public school” (15) “I wish I could have learned earlier in life about WRAP and my wellness tools. Everyone should take up WRAP” (6) “Everyone should be interested in WRAP . . . it helps so much in everyday things to take care of ourselves” (12) “I suggest having WRAP in high school, because you’re not the only one feeling that way” (18) Pay it Forward “I want to spread the word. I pass out fliers when I barbecue. I’m proud to go to a place like this and I want to let people know there is help out there. I just want to be able to help someone” (6) “My goal is to work with DCS and let people understand that there are programs to help and not to fake it . . . I can’t get my kids back but I could help someone else” (13) “I want to help people. I live in a nursing home and help people in wheelchairs and talk with them. I get joy out of helping people” (12) Unconditional Relational Support “They are my second family” (2) “I’m not alone. We’re all together and all support each other” (12) “We hold each other accountable and give positive feedback to each other” (13) “I got so comfortable so I can talk to them [program counselor]. He can help me realize some things are blessings” (6) It Takes Time “It’s all right to mess up and come back” (13) “In the beginning I didn’t really care. I wanted to get in and get out” (6) “At first I didn’t want to show up because I thought it wasn’t going to help me, and then I realized that it did help me” (8) “When I first started I didn’t really understand it” (11) “At first I was lying to myself and them. I wasn’t trying. But now, to see it work. . .” (13) “Yes [WRAP] helped, but not at first. Further along I started to see how important it is. It takes awhile to get it all” (17) “I don’t have to be in a hurry to leave. I can leave when I’m ready” (3)

this first time they tried it, but with time they realized that the program is beneficial and would commit themselves to it. 100% of the participants (n = 18) reported that all parts of WRAP were helpful to recovery. Retrospective Desire for Early WRAP Introduction Having a desire for early WRAP introduction was a prominent suggestion by the participants. Many reported a period of time before and even after their diagnoses where they did not understand their feelings, triggers, or how to cope with the situations occurring in their lives. Participants reflected back on where they were and where they are now in their lives and hypothesized on the opportunity to have the quality of life they experience now at an earlier time had they been exposed to WRAP earlier. Pay it Forward Participants primarily spoke indirectly about their aspiration to pay it forward by mentioning their desire to introduce others to the possibility of a better quality of life. Many found meaning through the opportunity to share their story of recovery and each reported unique ways to do so revolving around their individual strengths, interests, and involvements, such as passing out fliers

at one participant’s barbecue stand and pursuing a job with the department of child services to tell other mothers, “You can’t fake it to make it.” Unconditional Relational Support Support throughout the process of recovery was very important to the participants. WRAP often was described as a “second home” and as a place where no one was judged and everyone was accepted. Participants report how helpful not only their peers are, but also their program counselors. Relational support captures these peer relationship in addition to supportive family relationships; however, many did not identify family relationship as a strong support system for them as family relationships were sometimes a trigger. It Takes Time Time became a recurrent theme throughout the interviews with WRAP participants. Many reported participating in WRAP multiple times or re-entering the group after thinking that they were finished. Participants reported that you “can’t fake it to make it” but have to truly want to work toward recovery. Personal responsibility is a key concept of WRAP in that you

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have to do what needs to be done in order to be well; however, participants acknowledge that the understanding of and trust in the program does not happen quickly; rather, it evolves as one starts to believe in the program, which may take some time. A randomized controlled trial found that the greater the participants’ exposure to WRAP, the more they reported a decrease in depression and anxiety symptoms and increased self-perceived recovery. This theme further supports “the ongoing availability of WRAP to ensure that participants obtain adequate exposure to affect their recovery” (Cook et al., 2012, p. 545). Because of their potential impact on addressing mental health while promoting self-reliance, self-awareness, and selfconfidence in persons with mental health conditions, further research is warranted to explore and substantiate the extent of these themes. Clinicians and peer facilitators can incorporate these themes in their recovery program since they have been identified as factors contributing to patient satisfaction with recovery programs. In general, utilizing these themes that are part of WRAP will be a way to advocate for patients’ selfsustainability from mental illness and for the use of available local recovery programs. Workshops on WRAP have shown that professionals and mental health care consumers share similar attitudes and knowledge about recovery, although the professionals probably had prior exposure to models of recovery programs before the workshop. Therefore, the training of mental health professionals will benefit by including education related to patients’ perspective of satisfaction in mental health programs like WRAP (Doughty et al., 2008).

DISCUSSION Recovery from mental illness and the capability of living the quality of life one desires can become a reality with programs such as WRAP; however, recovery is a lifelong process. This is the first study to investigate the outcome of patient satisfaction with WRAP using participant-derived factors as opposed to professional-identified factors. Our quantitative findings demonstrated that patient satisfaction was strongly related to patient autonomy, services, and length of program participation. In addition, our qualitative findings provided a depth of perspective on each of these areas. Satisfaction with recovery programs is multi-factorial; therefore, the three quantitative composites and four qualitative themes are not all-inclusive, but provide a better understanding of the aspects contributing to participant satisfaction and recovery. We are able to address gaps in the literature by using both quantitative and qualitative factors. This descriptive study has identified quantifiable measures with qualitative context about patient satisfaction as perceived by the patient, unlike previous measures of patient satisfaction for mental health recovery programs. The MHSIP is a patient-oriented instrument because it contains items specific to satisfaction that align with WRAP. The MHSIP does not include any items regarding satisfaction with psychiatrists or therapists. With the addition of the qual-

itative questions, patients can provide their perspectives about the recovery program and qualify their MHSIP responses. The qualitative interview presented the patient with the opportunity to tell their own story with prompts that were neutral regarding satisfaction and dissatisfaction. The qualitative themes further support our quantitative findings and provide an in-depth perception of not only levels of patient satisfaction, but also what brings about and what creates high or low satisfaction, factors that Johannson and Eklund (2003) have identified as having increased importance. The qualitative theme regarding time can explain why length of program participation is significant in understanding patient satisfaction. Supporting our qualitative finding that the recovery process takes time, Johannson and Eklund (2003) also found that “giving enough time” was significant for the satisfaction of psychiatric patients in their qualitative study (p. 342). In addition, Tehrani, Ewald, and Munk-Jorgensen (1996) acknowledged that a major factor contributing to patient dissatisfaction was lack of time with caregivers. Likewise, paying it forward and unconditional support empower the individual, which contributes to patient autonomy. Earlier introduction to WRAP leads to patient satisfaction because of the significant services offered. Similarly, autonomy, support, and services were said to be indicators of patient satisfaction, consistent with our findings (Lucock et al., 2011; Pellegrin et al., 2001). Our findings are substantiated by the current literature. The four identified themes are from qualitative content analysis of participants’ perspective about WRAP. Perreault et al. (2010) emphasized the importance of qualitative portions to further analyze factors contributing to patient satisfaction. Perreault et al. (2006) explain that verbatim quotes from participants prove to be influential when presenting results to decision makers, services providers, and service users; this emphasizes the importance of including qualitative approaches in all patient satisfaction instruments. In addition, Schr¨oder et al. (2011) further stressed the importance of viewing patient satisfaction from patients’ perspectives versus the professionals’. Although nurses are not usually actively involved in WRAP self-management outpatient recovery programs, it is important to be educated on the positive outcomes of the programs in order to promote recovery and advocate for patients. The patientidentified aspects contributing to satisfaction with this recovery program can be incorporated into inpatient settings where nurses and health care providers are part of the patients’ care.

Social Implications Our findings suggest that the use of WRAP can contribute to increased self-awareness to aid in coping with social/societal issues. As a patient-oriented program that encompasses the four identified themes, WRAP can assist persons in recognizing triggers of mental distress and identifying healthy coping mechanisms. It is said that, “While [WRAP] was developed by and for people who are dealing with troubling emotional symptoms,

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WRAP can be used by anyone to deal with any kind of physical or emotional illness or issue” (Copeland, 2001, p. 127). Therefore, WRAP can potentially be beneficial for anyone experiencing and dealing with crises, whether maturational or situational (i.e., divorce, deaths of loved ones, relationships, peer pressure, etc.). For example, adolescents often feel alone in their life situations. By utilizing the aspects of WRAP, they could realize the support available to them, and then, because they are not alone, they can continue to develop coping skills to strengthen their self-confidence and self-esteem. Additionally, applying WRAP can significantly contribute to decreasing the stigma of mental illness. The more Mariam Aziz spoke out about her bipolar disorder, the more she realized how many people were dealing with something similar. “Mental disorders are different from other disabilities because they are hidden from view. You can’t tell by looking at someone that they may be living with a mental illness” (Aziz, 2010, p. 34). Limitations This study was limited by its confinement to one clinic in a specific geographic region of the US. The small sample size and the low-moderate power for the analysis are also limitations of the study. Additionally, the use of means in the composite variables versus basic summation is a potential limitation as it may not provide a true representation of the data distribution. This study is further delimited by the lack of audio-recorded and transcribed interview data. Moreover, less structured interviews could have allowed further development of the qualitative themes identified in this study. Future research is warranted using a larger sample size over a longer period of time to investigate long-term efficacy of outpatient mental health treatment programs. Operationalization of Results within WRAP Our study identified that acknowledging individual patients’ strengths and interests throughout recovery programs allows them to explore ways to share their story of recovery, providing them with meaning and purpose. One of the ways participants may want to share their story is by becoming a WRAP facilitator. Peer facilitators in WRAP have been through the WRAP program as a student themselves to deal with their own mental illness or addictions; therefore, understanding, respect, and rapport between the facilitator and WRAP participants develop and contribute to facilitators being strong confidantea for the participants. “WRAP graduates who are actively using their own WRAP plan and who elect to participate in an intensive 5-day training . . . can earn a Mental Health Recovery Educator certificate” (Cook et al., 2010, p. 115). One study found that becoming a WRAP facilitator can enhance the well-being of the facilitators themselves, further contributing to the recovery journey of facilitators (Pratt, MacGregor, Reid, & Given, 2012). Having peer facilitators who experienced the symptoms, struggles, addictions, and relapses of mental illness and who

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have become living exemplars of recovery instills hope for others and is a unique aspect of WRAP. We have reinforced the importance of assessing patient satisfaction from the patients’ perspective; similarly, it is beneficial for WRAP participants to be taught and supported by previous participants. Regardless of the medium used, participants are inspired to strive for recovery again and again by re-telling their story and by being given the opportunity to possibly change someone’s life as theirs has been changed. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Aziz, M. (2010). Hidden from view. Azizah, 6(1), 34. Berghofer, G., Castille, D., & Link, B. (2011). Evaluation of client services (ECS): A measure of treatment satisfaction for people with chronic mental illnesses. Community Mental Health Journal, 47(4), 399–407. Cook, J., Copeland, M., Corey, L., Buffington, E., Jonikas, J., Curtis, L., . . . Nichols, W. (2010). Developing the evidence base for peer-led services: Changes among participants following Wellness Recovery Action Planning (WRAP) education in two statewide initiatives. Psychiatric Rehabilitation Journal, 34(2), 113–120. Cook, J., Copeland, M., Floyd, C., Jonikas, J., Hamilton, M., Razzano, L., . . . Boyd, S. (2012). A randomized controlled trial of effects of Wellness Recovery Action Planning on depression, anxiety, and recovery. Psychiatric Services, 63(6), 541–547. Cook, J., Copeland, M., Jonikas, J., Hamilton, M., Razzano, L., Grey, D., . . . Boyd, S. (2011). Results of a randomized controlled trial of mental illness self-management using Wellness Recovery Action Planning. Schizophrenia Bulletin, 38(4), 881–891. Copeland, M. E. (2001). Wellness Recovery Action Plan: A system for monitoring, reducing and eliminating uncomfortable or dangerous physical symptoms and emotional feelings. New York, NY: Haworth. Corbin, J., & Strauss, A. (2008). Basics of qualitative research (3rd ed.). Thousand Oaks, CA: Sage. Davidson, L. (2005). Recovery, self-management and the expert patient: Changing the culture of mental health from a UK perspective. Journal of Mental Health, 14(1), 25–35. Doughty, C., Tse, S., Duncan, N., & McIntyre, L. (2008). The Wellness Recovery Action Plan (WRAP): Workship evaluation. Australian Psychiatry, 16(6), 450–456. Fukui, S., Starnino, V., Susana, M., Davidson, L., Cook, K., Rapp, C., & Gowdy, E. (2011). Effect of Wellness Recovery Action Plan (WRAP) participation on psychiatric symptoms, sense of hope, and recovery. Psychiatric Rehabilitation Journal, 34(3), 214–222. Hill, L., Roberts, G., & Igbrude, W. (2010). Experience of support time and recovery workers in promoting WRAP. The Psychiatrist, 34(7), 279–284. Howard, P., El-Mallakh, P., Rayens, M., & Clark, J. (2003). Consumer perspectives on quality of inpatient mental health services. Archives of Psychiatric Nursing, 17(6), 205–217. Johansson, H., & Eklund, M. (2003). Patients’ opinion on what constitutes good psychiatric care. Scandinavian Journal of Caring Sciences, 17(4), 339–346. Jonikas, J., Grey, D., Copeland, M., Razzano, L., Hamilton, M., Floyd, C., . . . & Cook, J. (2011). Improving propensity for patient self-advocacy through Wellness Recovery Action Planning: Results of a randomized controlled trial. Community Mental Health Journal. Lucock, M., Gillard, S., Adams, K., Simons, L., White, R., & Edwards, C. (2011). Self-care in mental health services: A narrative review. Health & Social Care in the Community, 19(6), 602–616.

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