The Impact of 'Being There': Psychiatric Staff Attitudes on the Use of Restraint

A Scoping Review on Staff Attitudes towards the Use of Coercion in Mental Healthcare

Attitudes of mental health professionals towards the use of coercion are highly relevant concerning its use coercion in mental healthcare, as mental health professionals have to weigh ethical arguments and decide within a legal frame in which situations to use coercion or not. Therefore, assessment of those attitudes is relevant for research in this field. A vital instrument to measure those attitudes towards the use of coercion is the Staff Attitude to Coercion Scale. This scoping review aims to provide a structured overview of the advantages and limitations in the assessment of attitudes toward coercion. We conducted a scoping review in Medline, PsycINFO, CINAHL, and Web of Science, based on the PRISMA-ScR. Inclusion criteria were empirical studies on the attitudes of mental health professionals. We included 80 studies and systematically mapped data about the main results and limitations in assessing attitudes toward coercion. The main results highlighted the relevance and increased interest in staff attitudes towards coercion in mental healthcare. Still, the majority of the included studies relied on a variety of different concepts and definitions concerning attitudes. The data further indicated difficulties in developing new and adapting existing assessment instruments because of the equivocal definitions of underlying concepts. To improve the research and knowledge in this area, future studies should be based on solid theoretical foundations. We identified the need for methodological changes and standardized procedures that take into account existing evidence from attitude research in social psychology, nursing science, and other relevant research fields. This would include an update of the Staff Attitude to Coercion Scale based on the limitations identified in this review.

Experience of violence and attitudes of staff members towards coercion in psychiatric settings: observational study

BACKGROUND

Among important dimensions related to the use of coercive measures, professionals' attitude towards coercion is of particular interest. Little is known about how experiences of violence in the workplace might influence these attitudes.

AIMS

The present study aimed to investigate potential correlates of attitudes towards coercion, especially experiences of violence in the workplace.

METHOD

Mental health professionals were contacted through an online survey to assess their attitudes towards coercion using the Staff Attitude to Coercion Scale (SACS). The three subscales of the SACS (critical, pragmatic and positive attitudes) were analysed in a multivariate multiple linear regression, using a set of covariates including experiences of violence in the workplace. We hypothesised that experience of violence in the workplace would correlate with less critical attitudes of staff members towards coercion.

RESULTS

A total of 423 professionals were included in the regression analysis. Age, professional category, feeling of insecurity, having witnessed or used coercion, and the emotional burden associated with coercive measures had a joint significant effect on the three SACS subscales. A feeling of insecurity, but not the experience of violence, was associated with a less critical, more positive appraisal of coercive measures. The emotional burden related to the use of coercion was associated with a more critical attitude.

CONCLUSIONS

The present results highlight the importance of considering staff members' training and well-being regarding their feelings of insecurity when addressing attitudes towards coercion. The experience of patients should be integrated into staff training and coercion reduction programmes.

Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World

Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action 'FOSTREN' is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.

Contextual factors influencing the use of coercive measures in Portuguese mental health care

The use of coercive measures in mental health care is an important indicator of the quality of care being provided, and non-patient-related factors are increasingly recognized to contribute to their use. The study aimed to explore the perspectives of mental health care professionals who have first-hand experience with the use of coercion on the contextual factors that influence the use of coercion in the Portuguese mental health care. Five focus group discussions were conducted among 23 doctors and 17 nurses from five psychiatric departments in urban and rural regions of Portugal. Discussions were audio recorded, transcribed, and analyzed with the aid of MAXQDA. Four broad themes related to insufficient resources, staff-related factors, inefficient services, and socio-legal factors were derived. Participants highlighted how inadequate structures, staff shortages, staff attitudes, a lack of training, restrictive ward rules, an inefficient organization of services, the mental health legislation, and public attitudes contributed to the use of coercive measures. The COVID-19 pandemic complicated existing shortfalls in the system and increased the use of coercive measures. The study confirms that the use of coercive measures in mental health care is influenced by factors that are independent of patient characteristics. Addressing existing systemic problems is crucial for the successful implementation of interventions to reduce coercion in mental health care.

Attitudes about Mechanical Restraint Use in Mental Health Hospitalization Services: A Spanish Survey

The aim of this study was to analyze the attitudes of professionals in Mental Health Services throughout Spain who are directly or indirectly involved in the use of mechanical restraint and the barriers perceived to reduce its use. The study involved an online anonymous survey using Google Forms completed by Spanish mental health professionals working with service users; the survey assessed their involvement in and general attitudes and beliefs towards mechanical restraint. The survey was completed by 225 participants. Only 13.30% of the participants considered that mechanical restraint use was never necessary to guarantee the safety of users/staff in dangerous situations. Poor staff training (38.0%) and a lack of resources/staff (34.7%) were the most frequent barriers identified for the reduction of mechanical restraint. In the multivariate analysis, participation in learning programs to prevent the use of mechanical restraint was associated with lower acceptance of the use of mechanical restraint, but the result was barely significant (p = 0.050). A high percentage of mental health staff still consider mechanical restraint use necessary for safety reasons. According to the results, the participants perceived that more staff and resources and better training could reduce the use of mechanical restraint in Mental Health Hospitalization Services.

Influence of mental health professionals' attitudes and personality traits on decision-making around coercion: Results from an experimental quantitative survey using case vignettes

OBJECTIVE

Research on coercion in mental healthcare has recently shifted to the investigation of subjective aspects, both on the side of the people with mental disorders affected and the staff members involved. In this context, the role of personality traits and attitudes of staff members in decision-making around coercion is increasingly being assessed. This study aimed to examine the role of staff attitudes towards coercion and staff members' personality traits in decision-making around coercion in an experimental setting.

METHODS

We assessed the attitudes towards coercion and (general) personality traits of mental health professionals in psychiatric hospitals with a quantitative survey. Furthermore, we developed case vignettes representing cases in a 'grey zone' and included them in the survey to assess staff members' decisions about coercion in specific situations.

RESULTS

A general approving attitude towards coercion significantly influenced decisions around coercion in individual cases-resulting in a more likely approval of applying coercion in the cases described in the vignettes. Personality traits did not seem to be relevant in this regard.

CONCLUSION

Strategies to reduce coercion in mental healthcare institutions should focus more on the role of staff attitudes and encourage staff members to reflect on them critically.

Experience of mental health nurses regarding mechanical restraint in patients with psychomotor agitation: A qualitative study

AIM

To explore mental health nurses' experiences whilst managing a patient with psychomotor agitation, and the factors that influence the decision to use mechanical restraints.

BACKGROUND

Psychomotor agitation is considered a potentially violent psychiatric emergency. The management of disruptive behaviours includes mechanical restraints as the last resort although its use has consequences for patients, professionals and the therapeutic relationship.

DESIGN

A qualitative study design with a hermeneutical approach was developed.

METHODS

A total of 31 nurses were purposively sampled from six short- and medium-stay mental health inpatient units. Data were obtained from semi-structured interviews. A thematic content analysis following the seven steps of Colaizzi's method was performed. Three researchers independently conducted an inductive analysis within a perspective of a hermeneutic paradigm. The COREQ checklist was followed in carrying out this research.

RESULTS

Four themes emerged from the analysis: 1) Nurses' perceptions of restraint methods, 2) Factors influencing decision-making, 3) Consequences for professionals of the use of mechanical restraint and 4) Alternatives to mechanical restraint.

CONCLUSIONS

Aspects such as the importance of teamwork, the issue of cognitive dissonance, ethical conflict and barriers to effecting the withdrawal of these measures affect the mental health nurse's decision-making process. The understanding of these aspects is crucial to further reducing its incidence and negative consequences and achieving the elimination of mechanical restraints.

RELEVANCE FOR CLINICAL PRACTICE

Knowing how nurses feel during the patient's episode of psychomotor agitation and which factors influence the decision on whether to apply coercive methods can guide us on the quality of care offered.

Development of the Japanese version of Staff Attitude to Coercion Scale

BACKGROUND

An important factor in proceeding the efforts to reduce coercion in psychiatry is the attitudes of clinical staff toward its use. We aimed to develop the Japanese version of the Staff Attitude to Coercion Scale (SACS) and clarify its psychometric properties.

METHODS

After the translation and back-translation of the SACS, which includes 15 items consisting of three subscales, we conducted an anonymous self-administered questionnaire survey of clinical staffs working in 17 wards in two psychiatric hospitals. We administered the second survey to some of the participants to confirm the test-retest reliability. Additionally, we obtained information regarding the 17 wards from the institutions. Internal consistency was assessed using Cronbach's alpha coefficients. Test-retest reliability was assessed using intraclass correlation coefficients (ICC). Structural validity was examined using confirmatory factor analysis (CFA) and exploratory factor analysis (EFA). For construct validity, the correlation of the SACS score within wards and its association with the actual use of seclusion/restraints were explored using multilevel multivariate linear regression analyses.

RESULTS

We used 261 (67.1%) responses, 35 responses of which were also used to examine test-retest reliability. Cronbach's alpha coefficients (0.761) and ICC (0.738) indicated good reliability. The results of CFA based on the original three-dimensional structure did not indicate a good fit (CFA = 0.830, RMSEA = 0.088). EFA suggested a four-factor structure, two of which were almost consistent with the original two subscales. The correlation of the SACS score within wards was confirmed while a positive association with the actual use of seclusion/restraints was not identified.

CONCLUSION

While the original three-dimensional structure was not replicated, construct validity was partially confirmed. Reliability of the total scale was good. In Japan, although using the subscales was not recommended, using the total scale of SACS seemed acceptable.

Coping with Criticism and Embracing Change—Further Reflexions on the Debate on a Mental Health Care System without Coercion

In August 2019, a manuscript was published in this journal that aimed at imagining a mental health care system that renounces the judicial control to better focus on the will and preferences of those who require support. Alternative scenarios for dealing with risk, inpatient care, and police custody were presented that elicited strong and emotionally laden reactions. This article adds further reflections to this debate, aiming at contributing explanations for this unsettlement. A productive notion of criticism is discussed, and ways to achieve change toward a more human rights-oriented psychiatric practice are outlined.

Mental health professionals' feelings and attitudes towards coercion

BACKGROUND

Despite absence of clear evidence to assert that the use of coercion in psychiatry is practically and clinically helpful or effective, coercive measures are widely used. Current practices seem to be based on institutional cultures and decision-makers' attitudes towards coercion rather than led by recommendations issued from the scientific literature. Therefore, the main goal of our study was to describe mental health professionals' feelings and attitudes towards coercion and the professionals' characteristics associated with them.

METHOD

Mental health professionals working in the Department of Psychiatry of Lausanne University Hospital, Switzerland, were invited to participate to an online survey. A questionnaire explored participants' sociodemographic characteristics, professional background and current working context, and their feelings and attitudes towards coercion. Exploratory Structural Equation Modelling (ESEM) was used to determine the structure of mental health professionals' feelings and attitudes towards coercion and to estimate to which extent sociodemographic and professional characteristics could predict their underlying dimensions.

RESULTS

130 mental health professionals completed the survey. Even if a large number considered coercion a violation of fundamental rights, an important percentage of them agreed that coercion was nevertheless indispensable in psychiatry and beneficial to the patients. ESEM revealed that professionals' feelings and attitudes towards coercion could be described by four main dimensions labelled "Internal pressure", "Emotional impact", "External pressure" and "Relational involvement". The personal as well as the professional proximity with people suffering from mental disorders influences professionals' feeling and attitudes towards coercion.

CONCLUSIONS

As voices recommend the end of coercion in psychiatry and despite the lack of scientific evidence, many mental health professionals remain convinced that it is a requisite tool beneficial to the patients. Clinical approaches that enhance shared decision making and give the opportunity to patients and professionals to share their experience and feelings towards coercion and thus alleviate stress among them should be fostered and developed.

Influence of nursing staff attitudes and characteristics on the use of coercive measures in acute mental health services-A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Aggressive behaviour is a major problem in clinical practice of mental health care and can result in the use of coercive measures. Coercive measures are dangerous for psychiatric patients and international mental healthcare works on the elimination of these interventions. There is no previous review that summarizes the attitude of nursing staff towards coercive measures and the influence of nursing staff characteristics on attitude towards and the use of coercive measures. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The attitude of nurses shifted from a therapeutic paradigm (coercive measures have positive effects on patients) to a safety paradigm (coercive measures are undesirable, but necessary for the wards' safety). Nurses express the need for less coercive interventions to prevent seclusion and restraint, but their perception of intrusiveness is influenced by how often they use specific coercive measures. The knowledge from scientific literature on the influence of nursing staff on coercive measures is highly inconclusive, although the feeling of safety of nurses might prove to be promising for further research. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is need for increased attention specifically for the feeling of safety of nurses, to better equip nurses for their difficult work on acute mental health wards. ABSTRACT: Introduction The use of coercive measures generally has negative effects on patients. To help prevent its use, professionals need insight into what nurses believe about coercion and which staff determinants may influence its application. There is need for an integrated review on both attitude and influence of nurses on the use of coercion. Aim To summarize literature concerning attitude of nurses towards coercive measures and the influence of staff characteristics on the use of coercive measures. Method Systematic review. Results The attitude of nurses changed during the last two decades from a therapeutic to a safety paradigm. Nurses currently view coercive measures as undesirable, but necessary to deal with aggression. Nurses express the need for less intrusive interventions, although familiarity probably influences its perceived intrusiveness. Literature on the relation between staff characteristics and coercive measures is inconclusive. Discussion Nurses perceive coercive measures as unwanted but still necessary to maintain safety on psychiatric wards. Focussing on the determinants of perception of safety might be a promising direction for future research. Implications for practice Mental health care could improve the focus on the constructs of perceived safety and familiarity with alternative interventions to protect patients from unnecessary use of coercive interventions.

Psychiatric nursing managers' attitudes towards containment methods in psychiatric inpatient care

AIMS

This research was conducted to examine psychiatric nursing managers' attitudes towards containment methods.

BACKGROUND

Nursing management is regarded as a key issue in the reduction of coercion and containment. However, there has been little research on managers' attitudes towards containment methods.

METHODS

This descriptive, cross-sectional study utilized a survey design. Finnish inpatient psychiatric nursing managers (n = 90) completed the Attitudes to Containment Measures Questionnaire (ACMQ). The results were described with statistics, and the associations between attitudes and background variables were analysed using parametric tests.

RESULTS

Psychiatric nursing managers had the most negative attitude towards net bed and mechanical restraint, and the most positive attitudes towards as necessary medication and intermittent observation. A few associations were discovered between attitudes and background variables such as gender and number of employees.

CONCLUSIONS

In general, Finnish psychiatric nursing managers' attitudes towards containment methods seem to be quite negative, but more research is needed.

IMPLICATIONS FOR NURSING MANAGEMENT

This study provides fresh and unique data on the attitudes of psychiatric nursing managers towards containment methods. Managers' attitudes are important because of their ability to encourage investment in coercion reduction by nursing staff.

Propensity to decide on involuntary hospitalisation in primary medical care: Dispositional or situational determinants?

BACKGROUND

The incidence of involuntary hospitalisations varies widely among and within countries. One factor that could account for these variations is the local profile of medical doctors deciding on involuntary admissions. The first goal of this study was to test whether to decide on an involuntary hospitalisation was an individual or a situational disposition. The second goal was to explore doctors' characteristics associated with the use of coercion in specific situations.

METHOD

Medical doctors of four French-speaking Swiss cantons with the competence, according to cantonal laws, to decide on an involuntary hospitalisation were invited to take part in an online survey. Respondents were asked whether they would decide on an involuntary hospitalisation or not in seven clinical vignettes. Propensity to decide on involuntary hospitalisation was estimated with a two-parameter logistic item response model and latent class analysis. Univariate logistic regression models were used to test whether individual factors were associated with the use of coercion in each situation.

RESULTS

192 medical doctors completed the online questionnaire. There was near-zero correlation between vignettes: an involuntary hospitalisation decided on by a doctor in one situation was not related to the use of coercion in another. No subgroup was more prone to generally resort to coercion. However, some individual characteristics were related to the use of coercion in specific situations.

CONCLUSIONS

Medical doctors' propensity to use coercion for mental health problems was better accounted for by situational rather than dispositional factors. Thus, the use of coercion should be examined as a multidimensional concept.

A German Version of the Staff Attitude to Coercion Scale. Development and Empirical Validation

Background: Individual staff factors, such as personality traits and attitudes, are increasingly seen as an important factor in the reduction of coercion in mental health services. At the same time, only a few validated instruments exist to measure those factors and examine their influence on the use of coercion. Aim: The present study aimed to develop and validate a German version of the Staff Attitude to Coercion Scale (SACS). Methods: The original English version of the SACS published was translated into German. Subsequently, it was empirically validated on a sample of N = 209 mental health professionals by conducting an exploratory factor analysis. Results: The three-factor structure in the original version of the SACS, consisting of critical, pragmatic and positive attitudes toward the use of coercion, could not be replicated. Instead, the German version revealed one factor ranging from rejecting to approving the use of coercion. Conclusion: The SACS is one of the first instruments created to assess staff attitudes toward coercion in a validated way. The version of the instrument developed in this study allows for a validated assessment of those attitudes in German. Our results highlight the ethical importance of using validated measurements in studies on the role of staff factors in the reduction of coercion.

Psychiatric nursing staffs' attitudes towards the use of containment methods in psychiatric inpatient care: An integrative review

One of the international objectives in psychiatric care is reducing the use of coercion. Containment methods are meant to keep patients safe, yet usually include coercion. Nurses play a key role in deciding whether or not containment should be used and, as such, their attitudes towards containment can significantly impact the extent to which these methods are applied. The aim of this integrative review was to identify, analyse, and synthesize the available research on psychiatric nursing staffs' attitudes towards containment methods in inpatient psychiatric care. An electronic search was conducted using the CINAHL, Scopus, and PsycINFO databases. In addition, the citations of identified studies were screened for relevant research. A total of 24 relevant papers published between 2002 and 2017 were selected for further analysis. These studies revealed variation in nursing staffs' attitudes towards the use of containment methods. The use of containment methods seems to be widely accepted and nurses reported rarely considering alternative measures. It appears that attitudes towards containment have continuously become more negative, although the change has not been very pronounced. The concept of attitude was only defined in two studies. Thus, future research should strive to clarify this concept, as a generally accepted definition for attitude within nursing research and the utilization of all dimensions of this concept are both essential to the nursing field. Currently, it would be important to focus on changing attitudes among psychiatric nursing staff to reduce the use of containment methods; this calls for more research on nursing staffs' attitudes.