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Int J Nurs Stud. 2012 Nov;49(11):1403-10. doi: 10.1016/j.ijnurstu.2012.06.001. Epub 2012 Jul 11.

Views of the Therapeutic Environment (VOTE): stakeholder involvement in measuring staff perceptions of acute in-patient care.

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Department of Psychology, Institute of Psychiatry, Kings College London, United Kingdom.



The impact of staff perceptions of daily work pressures on burnout requires further exploration because both issues may be adversely affecting the quality of staff interactions with service users.


To use a model of 'stakeholder involvement' to develop and test a self-report instrument capturing nursing staff perceptions of the daily pressures of working in acute in-patient mental health wards.


Measure development followed a participatory methodology, followed by psychometric testing of the new measure of the daily pressures of working on an acute ward (VOTE).


Acute in-patient wards in an inner London mental health trust.


All nursing staff from acute in-patient settings are eligible for this study. In total 376 staff (qualified nurses and healthcare assistants) were involved at the various stages of measure development and testing.


Focus groups of nursing staff met to discuss their perceptions of acute wards. A twenty item measure was generated through thematic analysis of these data and staff feedback. Reliability and validity were tested and the effects of demographic characteristics on VOTE, and VOTE on burnout were examined.


Staff found VOTE easy to understand and complete. Test-retest reliability and the internal consistency of the measure and subscales were good. A test of criterion validity showed that staff with negative perceptions of the daily pressures of the working on an acute ward also had negative perceptions of job satisfaction and high levels of burnout. Regression modelling showed that VOTE had a significant effect on burnout.


VOTE is a concise measure which combines aspects of care provision as well as the organisational and professional stressors of acute ward working. VOTE can be used to further explore how staff perceptions of the daily pressures of acute ward working affect the quality of care delivered.

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