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Patient Attitude,

Motivation and Perception

Assessment

PAMPA

www.psychology-services.uk.com

1

Page Numbers

Introduction 2

Development 3

Standardisation 5

Validation 6

Administration 7

References 8

Appendix 10

Contents

2

One problem within forensic services is how to motivate patients to change and engage in

therapy (Gudjonsson, Young & Yates, 2007). There is therefore a need for a comprehensive

assessment to measure not only information about a patient’s mental disorder and

personality, but also factors such as their perceptions of their illness, staff and clinical setting

which may hinder therapeutic success.

This manual presents the ‘PAMPA’ scales, developed to assess patients’ perception of their

stay in hospital involving their needs, satisfaction and motivation: the Patient Attitude

Questionnaire (PAQ), the Patient Motivation Inventory (PMI) and the Patient Perception

Questionnaire (PPQ).

The PAQ is designed to measure the extent to which a patient feels dissatisfied with their

care, such as being unfairly treated or feeling discouraged (Gudjonsson, Young & Yates,

2007). This can lead to the patient building up resentment against the healthcare team,

which may then lead to a lack of co-operation and will result in poorer health-related

outcomes and engagement in their care.

The PMI is designed to focus more directly on the internal motivation of the patient,

particularly towards their engagement in therapy, and whether they have confidence that

the healthcare setting will provide sufficient and adequate treatment aspects and care.

The PPQ is designed to measure a patient’s perceptions about their interest and

engagement in treatments, whether they are ready to be discharged back into the

community, and whether they can talk openly and honestly about their problems with

healthcare staff.

Together, the PAMPA scales will be useful within forensic services to identify perceptions and

attitudes that may hinder motivation to change or engage in treatment, which then can be

addressed by the multidisciplinary team and then assimilated into a patient’s care plan or

treatment. The scales can also be used to monitor changes over time, used to identify

differences between clinical settings and can be used for research purposes, such as for

identifying different motivational factors or patient dissatisfaction.

Each of the PAMPA scales have been found to have satisfactory internal consistency

indicating that they are conceptually meaningful scales with reasonably robust

psychometric properties.

Introduction

3

The Patient Attitude Questionnaire (PAQ)

Each item of the PAQ was selected due to its conceptual relevance to two underlying

constructs: 1) general dissatisfaction with care and 2) stress, which are measured on a seven-

point frequency scale from 1 (‘Never’) to 7 (‘Always’). Although 15 items were originally

factor analysed, two were eliminated after a scree test in order to retain the purity of the

other factors, resulting in a 13-item questionnaire (see Table 1). As seen in Table 1, the items

loaded on three separate factors.

Table 1. Factor loadings (varimax rotation) for the Patient Attitude Questionnaire (PAQ).* Factor 1 Factor 2 Factor 3

Dissatisfaction Stress Detachment

1. Does it occur to you that the staff are unkind and unfair to you? .78 .02 .21

2. Do you feel discouraged on the unit? .75 .02 .21

3. Do you get the feeling that staff don’t care about you? .69 .27 .21

4. Are you annoyed or irritable with others on the unit? .64 .39 .17

5. Are you bored on the unit? .58 .17 .32

6. Do you get uptight and stressed? .19 .84 .02

7. Do you feel worn out and low on energy? .12 .61 .17

8. Are you upset? .25 .58 .25

9. Are you worried about things? .14 .58 .39

10. Do you feel lazy and unmotivated? .02 .57 .35

11. Do you feel lonely and distant from others? .17 .23 .78

12. Are you awake when you want to fall asleep? .18 .22 .70

13. Are you concerned that you can’t keep up with all the things that you have to do? .37 .17 .65

Percentage of total variance accounted for 40.85 9.27 7.27

*Loadings of .40 or more in bold

The Patient Motivation Inventory (PMI)

The PMI consists of 16 items which are answered as either ‘True’ or ‘False’ by the patient. The

items for the PMI were selected based on previous work regarding motivation in substance

abuse treatment (Ryan et al., 1995), with concepts either relating to 1) internal motivation or

2) lack of confidence in the unit. Although 20 items were originally factor analysed, four were

eliminated after a scree test in order to retain the purity of the other factors. Therefore, this is

a 16-item questionnaire based on three factors: 1) internal motivation which compromises

seven items, 2) lack of confidence in the unit which comprises six items and finally 3) feelings

of failure which comprises three items (see Table 2).

Table 2. Factor loadings (varimax rotation) for the Patient Motivation Inventory (PMI).*

Factor 1 Factor 2 Factor 3

Internal

motivation

Lack of confidence

in unit

Feeling of

failure

1. I am interested in getting help with my problems .76 -.19 .13

2. It will be important to work closely with others .67 .02 .12

3. I accept the fact that I need help and support .60 -.21 -.02

4. It is a relief to share my concerns with others .60 .02 .18

5. I want treatment because it is important to me personally .58 -.20 .47

6. I want to share my concerns and feelings .57 -.02 -.02

7. Getting treatment is the best way to help myself .50 -.36 .35

8. I am not sure that this unit will work for me -.17 .72 .02

9. I don’t think being on this unit will help me solve my problems -.02 .72 -.19

10. I only engage in treatment because I am pressured to do so -.24 .65 .03

11. I doubt being on this unit will help me stop getting into trouble in future -.13 .55 -.10

12. I came to this unit because I had no choice .12 .53 -.02

13. I came to the unit because I wanted to .02 -.56 .29

14. I will feel like a failure if I do not get treatment .22 .03 .73

15. I am responsible for this choice of treatment .02 -.26 .65

16. I feel bad about myself if I am not receiving help with my psychological problems .14 -.02 .67



Development

4

The Patient Perception Questionnaire

The items for the PPQ were selected due to its conceptual relevance to concepts such as: 1)

relevance to treatment engagement, 2) reluctance to be open/honest on the unit and 3)

perceived readiness to be discharged, which are measured on a seven-point frequency

scale from 1 (‘Not at all’) to 7 (‘Very much so’). Although 36 items were factor analysed,

seven were eliminated after a scree test in order to retain the purity of the other factors.

Therefore, this is a 29-item questionnaire (see Table 3).

Table 3. Factor loadings (varimax rotation) for the Patient Perception Questionnaire (PMI).*

Factor 1 Factor 2 Factor 3

Treatment

engagement

Reluctance to

open up

Readiness for

discharge

1. Do you find one to one sessions with your primary nurse as being helpful? .76 -.27 .15

2. Do you see nursing as being helpful with your problems? .71 -.17 -.21

3. Do you think that you are being informed enough by staff about your progress on the unit? .69 -.21 -.21

4. Does your medication help with your illness? .66 -.25 -.24

5. Do you think that you are adequately informed about your rights by the staff on the unit? .65 -.25 -.11

6. Do you think that the unit can help you with your problems? .59 -.27 -.33

7. Do you see group treatments as being helpful with your problems? .57 .02 -.17

8. Is it in your best interests to open up and talk about your problems with staff? .54 -.39 -.02

9. Do you feel that staff on the unit understand you and your problems? .55 -.24 -.40

10. Do you see occupational therapy as being helpful with your problems? .51 .03 -.14

11. Does being on the unit help with your problems? .51 -.27 -.49

12. Do you think a patient’s stay on the unit is therapeutic? .48 -.32 -.41

13. Do you see social work as being helpful with your problems? .47 .02 .02

14. Do you see psychological treatment as being helpful with your problems? .42 -.03 -.23

15. Do you think that filling in psychology questionnaires will get you into trouble? .02 .65 -.17

16. Do you think that you would be punished if you told staff about your problems? -.02 .65 -.02

17. Do you think that there are too many restrictions for patients on the unit? -.15 .58 -.40

18. Do you think it is a waste of time being on the unit? -.23 .57 -.14

19. Do you think that you are given too much medication? -.16 .55 -.49

20. Do you feel that you are being punished here? -.18 .52 -.41

21. Do you think that the nursing staff are too punitive (i.e. they punish the patients too much

when things go wrong)? -.32 .52 .02

22. Do you think the staff are too controlling in the way they treat you? -.34 .52 .21

23. Is it in the patient’s best interest not to tell staff about their problems? -.23 .46 -.04

24. Do you think it would be of great help to you if you had more leave away from the unit? .02 .44 .32

25. Do you think it would be a great help to you if you were to see your consultant more often? .33 .43 .02

26. Do you feel that you are now ready to be discharged into the community? -.19 .02 .74

27. Could you be safely discharged back into the community now? -.24 -.03 .73

28. Do you think that being discharged from this unit will solve all your problems? .02 .27 .66

29. Do you have psychiatric (mental illness) problems? .25 .13 -.65



5

The PAMPA scales were first introduced in a paper by Gudjonsson, Young and Yates in 2007.

The sample consisted of 116 mentally disordered offenders (predominately male) from three

medium secure units and one open forensic ward. The mean age was 35.9 years (SD = 7.8)

and they were from a wide range of ethnic backgrounds. Over half of the index offences of

the patients (52%) involved physical violence, whilst others included robbery or theft (18%),

sexual offences (10%), and other offences (e.g., arson, criminal damage, harassment) (20%).

Mean and Standard Deviation Scores

Table 4 displays the total mean scores and standard deviations (SD) for the four groups on

each different factor on each questionnaire. Analysis of covariance was performed on the

data in view of possible ethnic differences, for each questionnaire on each unit (fixed factor)

with ethnicity as a covariate. A significant difference was only found on one of the nine

factor scores (PPQ: reluctance to open up) with the ethnic minority patients’ scores reported

as higher on this factor than the Caucasian patients’ scores. There was also a significant

overall effect of this factor (F=4.65, df=4, p=.002; ethnic effect: F=5.625, df=1, p=.02; unit

effect: F=2.921, df=3, p=.038). The effect size between the two ethnic groups for this factor

(reluctance to open up) was medium (Cohen’s D =.62).

As there was generally an absence of ethnic effect, a one-way ANOVA was performed to

compare differences between units on the factor scores for each test. Significant differences

were found on all the PAQ factor scores, with the strongest relating to dissatisfaction (F=5.6,

df=3, p<.001), then detachment (F=4.9, df=3, p<0.1), then stress (F=2.8, df=3, p<.05).

On the PMI, Factor 2 (lack of confidence in the unit) differed significantly between the units

(F=3.4, df=3, p<.05).

Regarding the PPQ, Factors 2 (reluctance to open up) and 3 (readiness for discharge)

differed significantly between the units (F=3.9, df =3, p< .05 and F=3.3, df= 3, p <.05), but

none of the post-hoc Sheffe tests were significant between the individual units.

Table 4. Mean and standard deviation scores on each factor for the three scales

Mentally Disordered Offenders (N= 98-116)

Scales Mean SD

PAQ Dissatisfaction 15.6 7.4

Stress 16.7 6.8

Detachment 9.1 4.6

PMI Internal motivation 4.9 2.3

Lack of confidence in unit 2.8 2.0

Feelings of failure 2.8 1.2

PPQ Treatment engagement 65.0 19.9

Reluctance to open up 45.0 14.2

Readiness for discharge 21.3 6.3

Standardisation

6

In the original study (Gudjonsson et al. 2007), all three subscales of the PAQ, PMI and PPQ

were psychometrically robust and had satisfactory internal consistency (Cronbach’s alpha),

apart from Factor 3 of the PMI.

In a study conducted in a large medium-secure unit (River House), Beazley and Gudjonsson

(2011) found that the Cronbach’s alpha for the three PMI subscales were 0.79, 0.75 and 0.65

for ‘Internal Motivation’, ‘Lack of Confidence in the Unit’, and ‘A Feeling of Failure’,

respectively. This was consistent with the results found in the original validation study. The

Cronbach’s alpha was highest for the Total Score (0.83), which suggests that the Total score

of the PMI is the one best utilised. In this study, the Total Motivation score correlated

significantly with positive ward atmosphere and negatively with feelings of depression. The

total mean PMI score was 11.00 (SD = 3.7).

Gudjonsson, Savona, Green and Terry (2011) used the PMI and PPQ in a study investigating

the recovery model in River House. The Cronbach’s alpha of the three PPQ subscales

(Treatment engagement, Reluctance to open up, and Readiness for discharge) were 0.89,

0.81 and 0.76, respectively, confirming previous findings. The Cronbach’s alpha of the Total

score on the PMI was 0.80. The total mean score for the PMI in this study was 10.9 (SD = 3.7),

which is almost identical to that found in the Beazley and Gudjonsson (2011) study. The total

PMI and the PPQ Treatment engagement subscale scores correlated significantly (0.39 and

0.70, respectively) with the Recovery Journal Questionnaire (Green, Batson, & Gudjonsson,

2011), providing evidence for the validation of these scales as predictors of therapeutic

recovery.

Validation

7

A copy of each of the PAMPA scales can be found in the Appendix. The scales may be

administered either individually or in a group setting. Instructions are provided at the top of

each scale as follows:

“Please read each of the following questions carefully and circle the response which best

describes how you feel:”

For the PAQ and PPQ, the respondent is required to select and circle a number from 1 to 7.

For the PMI the respondent is required to circle True or False for each statement. In cases of

literacy problems, the items may be read out and explained to the respondent. If

respondents wish to change their response, they should be asked to place an ‘X’ through the

original response and then circle the correct response.

Scoring

For the PAQ, scores are obtained by summing the responses for the following items:

• Dissatisfaction – items 1, 2, 4, 9 and 10

• Stress – items 3, 5, 6, 7 and 12

• Detachment – items 8, 11 and 13

For the PMI, scores are obtained by awarding a score of ‘1’ for each of the following items:

• Internal motivation – items 2, 5, 6, 9, 10, 11 and 12 marked ‘true’

• Lack of confidence in the unit – item 1 marked ‘false’ and items 8, 13, 14, 15 and 16

marked ‘true’

• A feeling of failure – items 3, 4, and 7 marked ‘true’

For the PPQ, first reverse the score obtained for item 1 (e.g. a response of 7 scores 1, a

response of 6 scores 2 etc.). Then sum the responses for the following:

• Treatment engagement – items 2, 4, 7 8, 9, 10, 11, 13, 15, 23, 24, 27, 28 and 29

• Reluctance to open up – items 6, 12, 15, 16-22 and 26

• Readiness for discharge – items 1, 3, 5 and 25

Interpretation

Higher scores are indicative of greater dissatisfaction of the patient towards their healthcare

setting (PAQ), greater motivation (PMI) and a more positive perception regarding their future

progress (PPQ).

Administration

8

Beazley, P., & Gudjonsson, G. H. (2011). Motivating inpatients to engage with treatment: The

mediating role of depression and ward atmosphere. Nordic Journal of Psychiatry, 65,

95–100.

Green, T., Batson, A., & Gudjonsson, G. H. (2011). The Recovery Journal Questionnarie (RJQ).

The development and initial validation of a service-led measure for recovery of

mentally disordered offenders. The Journal of Forensic Psychiatry and Psychology, 22,

252-265.

Gudjonsson, G. H., Savona, C., Green, T., & Terry, R. (2011). The recovery approach to the

care of mentally disordered patients. Does it predict treatment engagement and

positive social behaviour beyond quality of life? Personality and Individual Differences,

51, 899-903.

Gudjonsson, G. H., Young, S., & Yates, M. (2007). Motivating mentally disordered offenders to

change. Instruments for measuring patients’ perception and motivation. The Journal of

Forensic Psychiatry and Psychology, 18, 74.

References

10

Appendix

Name: Date:

Please read each of the following questions carefully and circle the response which best

describes how you feel

Never Sometimes Always

1. Do you feel discouraged on the Unit? 1 2 3 4 5 6 7

2. Are you annoyed or irritable with others on the Unit? 1 2 3 4 5 6 7

3. Do you feel worn out and low on energy? 1 2 3 4 5 6 7

4. Are you bored on the Unit? 1 2 3 4 5 6 7

5. Do you get uptight and stressed? 1 2 3 4 5 6 7

6. Are you worried about things? 1 2 3 4 5 6 7

7. Are you upset? 1 2 3 4 5 6 7

8. Are you awake when you want to fall asleep? 1 2 3 4 5 6 7

9. Do you get the feeling that staff don’t care about you? 1 2 3 4 5 6 7

10. Does it occur to you that the staff are unkind or unfair to

you? 1 2 3 4 5 6 7

11. Are you concerned that you can’t keep up with all the things

you have to do? 1 2 3 4 5 6 7

12. Do you feel lazy and unmotivated? 1 2 3 4 5 6 7

13. Do you feel lonely and distant from others? 1 2 3 4 5 6 7

Patient Attitude Questionnaire PAQ


Name: Date:


describes how you feel:

1. I came to the Ward/Unit because I wanted to. True False

2. I want treatment because it is important to me personally. True False

3. I feel bad about myself if I am not receiving help with my

psychological/psychiatric problems. True False

4. I will feel like a failure if I do not get treatment. True False

5. Getting treatment is the best way to help myself. True False

6. I am interested in getting help with my problems. True False

7. I am responsible for this choice of treatment. True False

8. I only engage in treatment because I am pressured to do so. True False

9. I want to share my concerns and feelings. True False

10. It will be important to work closely with others. True False

11. It is a relief to share my concerns with others. True False

12. I accept the fact that I need help and support. True False

13. I am not sure this Unit will work for me. True False

14. I doubt being on the Unit will help me to stop getting into trouble in the

future. True False

15. I don’t think being on this Unit will help me solve my problems. True False

16. I came to this Unit because I had no choice. True False

Patient Motivation Inventory PMI


PPQ | Page 1

Name: Date:


describes how you feel:

Not at all Very much so

1. Do you have psychiatric (mental illness) problems? 1 2 3 4 5 6 7

2. Does being on the Unit/Ward help with your problems? 1 2 3 4 5 6 7

3. Could you be safely discharged back into the community

now? 1 2 3 4 5 6 7

4. Do you think a patient’s stay on the Unit is therapeutic? 1 2 3 4 5 6 7

5. Do you feel that you are now ready to be discharged into the

community? 1 2 3 4 5 6 7

6. Do you feel that you are being punished here? 1 2 3 4 5 6 7

7. Is it in your best interests to open up and talk about your

problems with staff? 1 2 3 4 5 6 7

8. Does your medication help with your illness? 1 2 3 4 5 6 7

9. Do you see occupational therapy as being helpful with your

problems? 1 2 3 4 5 6 7

10. Do you see psychological treatment as being helpful with

your problems? 1 2 3 4 5 6 7

11. Do you see social work as being helpful with your problems? 1 2 3 4 5 6 7

12. Do you think that you would be punished if you told staff

about your problems? 1 2 3 4 5 6 7

13. Do you see nursing as being helpful with your problems? 1 2 3 4 5 6 7

14. Do you find one to one sessions with your primary nurse as

being helpful?

1 2 3 4 5 6 7

Patient Perception Questionnaire

PPQ

PPQ | Page 2

Not at all Very much so

15. Do you think it would be of great help to you if you were to

see your Consultant more often?

1 2 3 4 5 6 7

16. Do you think it would be of great help to you if you had more

leave away from the Unit/Ward?

1 2 3 4 5 6 7

17. Do you think it is a waste of time being on the Unit/Ward? 1 2 3 4 5 6 7

18. Do you think that filling in psychology questionnaires will get

you into trouble? 1 2 3 4 5 6 7

19. Do you think there are too many restrictions for patients on

the Unit/Ward? 1 2 3 4 5 6 7

20. Do you think that the nursing staff are too punitive (i.e. they

punish the patients too much when things go wrong)? 1 2 3 4 5 6 7

21. Do you think that you are given too much medication? 1 2 3 4 5 6 7

22. Do you think that staff are too controlling in the way that they

treat you? 1 2 3 4 5 6 7

23. Do you feel that staff on the Unit understand you and your

problems? 1 2 3 4 5 6 7

24. Do you think that the Unit can help you with your problems? 1 2 3 4 5 6 7

25. Do you think that being discharged from this Unit will solve all

your problems? 1 2 3 4 5 6 7

26. Is it the patient’s best interest not to tell staff about their

problems? 1 2 3 4 5 6 7

27. Do you think that you are being informed enough by staff

about your progress on the ward? 1 2 3 4 5 6 7

28. Do you think that you are adequately informed about your

rights by the staff on the Unit/Ward? 1 2 3 4 5 6 7

29. Do you see group treatment as being helpful with your

problems? 1 2 3 4 5 6 7


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