Clinician attitude and perspective on the use of coercive measures in clinical practice from tertiary care mental health establishment - A cross-sectional study

Comparing attitudes towards compulsory interventions in severe and persistent mental illness among psychiatrists in India and Switzerland

BACKGROUND

Psychiatrists face a major ethical challenge when deciding whether to make use of coercive measures in the treatment process of patients suffering from severe and persistent mental illness (SPMI). As India and Switzerland show major cultural, political and financial differences, it is hypothesized that attitudes towards coercive measures among Indian and Swiss psychiatrists will vary too. Exploring differences in attitudes between cultures strengthens the critical reflection on one's own stances and in consequence, on our way of action. Especially when it comes to situations involving power imbalances between patients and health practitioners, self-reflection is essential to prevent ethically inappropriate behavior.

METHODS

An online survey on aspects of care for patients with SPMI was sent to 3'056 members of the Indian Psychiatric Society between April and June 2020 and to 1'311 members of the Swiss Society for Psychiatry and Psychotherapy between February and March 2016. The respondents' answers were compared. This article deals with the questionnaire's items on autonomous decision making and the implementation of coercive measures in clinical practice. More precisely, participating psychiatrists were asked to rate the importance of patient's autonomy in general and their willingness to apply coercive measures regarding two specific case vignettes depicting a patient with schizophrenia and one with depression. The statistical analysis, namely descriptive data analysis and calculation of arithmetic means, Shapiro Wilks tests and Mann-Whitney U tests, was carried out using IBM SPSS Statistics version 27.

RESULTS

Answers were received from 206 psychiatrists in India and 457 psychiatrists in Switzerland. Indian participants tended to value autonomous decision making as slightly less important than Swiss participants (62.2% vs. 91%, p =.01). Regarding a case of severe and persistent depression, psychiatrists in the Indian group were on average more in favor of acting against the wishes of the patient (55% vs. 34.1%, p <.0001) as well as of accepting a temporary decrease in quality of life due to coercion (40% vs. 23%, p =.008). Answers concerning a case of schizophrenia revealed that Indian participants were more in favor of acting against the patient's wishes than Swiss participants (39% vs. 37%, p =.007), whereas the comparison whether to accept a temporary decrease in quality of life regarding this case showed no significant difference (p =.328).

CONCLUSIONS

The significant difference in attitudes towards coercive measures among Indian compared to Swiss psychiatrists found in this study might arise from a predominantly more collectivist society in India compared to Switzerland. Moreover, differences in financial resources, the organization of the health care system, and the historical background might have an influence. Continuous and critical reflection on one's own views and behavior is essential, especially if ethical principles and individual rights could be violated through a power imbalance, as in the case of coercive measures.

Psychiatrists’ occupational stigma conceptualization, measurement, and intervention: A literature review

Psychiatrists require frequent contact with and treatment of patients with mental illnesses. Due to the influence of associative stigma, psychiatrists may also be targets of stigma. Occupational stigma warrants special consideration because it significantly affects psychiatrists' career advancement, well-being, and their patients’ health. Given that there is no complete summary of this issue, this study reviewed the existing literature on psychiatrists' occupational stigma to clearly synthesize its concepts, measurement tools, and intervention strategies. Herein, we emphasize that psychiatrists’ occupational stigma is a multifaceted concept that simultaneously encompasses physically, socially, and morally tainted aspects. Currently, standardized methods to specifically measure psychiatrists’ occupational stigma are lacking. Interventions for psychiatrists’ occupational stigma may consider the use of protest, contact, education, comprehensive and systematic methods, as well as the use of psychotherapeutic approaches. This review provides a theoretical basis for the development of relevant measurement tools and intervention practices. Overall, this review seeks to raise public awareness of psychiatrists' occupational stigma, thereby promoting psychiatric professionalism and reducing its stigma.

Psychometric properties of the Italian version of the staff attitude to coercion scale: an exploratory factor analysis

Aims

The current study aimed to validate the Italian version of the Staff Attitude to Coercion Scale (SACS), which assesses mental health care staff's attitudes to the use of coercion in treatment.

Methods

The original English version of the SACS was translated into Italian, according to the back-translation procedure. Subsequently, it was empirically validated by performing an exploratory factor analysis on a sample of 217 mental health professionals (Mean = 43.40 years, SD = 11.06) recruited form Italian general hospital (acute) psychiatric wards (GHPWs), with at least 1 year of work experience (i.e., inclusion criteria).

Results

Results confirmed the three-factor solution of the original version for the Italian version of the SACS, though three items loaded on different factors, compared to the original. The three extracted factors, explained 41% of total variance, and were labeled similarly to the original scale and according to their respective item content, i.e., Factor 1 "Coercion as offending" (items: 3, 13, 14, and 15), Factor 2 "Coercion as care and security" (items: 1, 2, 4, 5, 7, 8, and 9), and Factor 3 "Coercion as treatment" (items: 6, 10, 11, and 12). The internal consistency of the three-factor model of the Italian version of the SACS was assessed through Cronbach's α and yielded acceptable indexes, ranging from 0.64 to 0.77.

Conclusion

The present findings suggest that the Italian version of the SACS is a valid and reliable tool that can be used to assess healthcare professionals' attitudes toward coercion.

Systematic literature review of the use of Staff Attitudes to Coercion Scale (SACS)

OBJECTIVE

Staff's attitudes to the use of coercion may influence the number of coercive interventions employed and staff willingness to engage in professional development projects aimed at reducing the use of coercion itself. The Staff Attitude to Coercion Scale (SACS) was developed to assess the attitudes of mental healthcare staff to the use of coercion in 2008 and has been employed subsequently. This global study systematically reviews and summarizes the use of the scale in research.

METHODS

Seven databases were searched for studies using SACS in articles published in peer reviewed journals and gray literature. In addition, researchers who have asked for permission to use the scale since its development in 2008 were contacted and asked for their possible results. Extracting of data from the papers were performed in pairs of the authors.

RESULTS

Of the 82 identified publications, 26 papers with 5,838 respondents were selected for review. A review of the research questions used in the studies showed that the SACS questionnaire was mostly used in studies of interventions aimed at reducing coercion and further explain variation in the use of coercion.

CONCLUSION

SACS is, to our best of knowledge, the only questionnaire measuring staff's attitudes to the use of coercive interventions in mental health services. Its widespread use indicates that the questionnaire is perceived as feasible and useful as well as demonstrating the need for such a tool. However, further research is needed as the relationship between staff attitudes to coercion and the actual use of coercion remains unclear and needs to be further investigated. Staff attitudes to coercion may be a prerequisite for leaders and staff in mental healthcare to engage in service development and quality improvement projects.

Factors associated with perceived coercion in adults receiving psychiatric care: a scoping review protocol

INTRODUCTION

Coercion is inevitably linked to psychiatric and mental healthcare. Though many forms of coercion exist, perceived coercion appears to be a less studied form despite its marked prevalence and negative consequences. In the literature, several factors have been studied for their association with perceived coercion, but few literature reviews have focused on this precise subject. Gaining knowledge of the association between these factors and the degree of perceived coercion is essential to guide future research and develop informed interventions. The purpose of this review will be to identify, in the literature, factors associated with perceived coercion by adults receiving psychiatric care.

METHODS AND ANALYSIS

A scoping review will be conducted by following the Joanna Briggs Institute methodology. A search with descriptors and keywords will be performed in the following databases: CINAHL, MEDLINE, PUBMED, EMBASE and PsycINFO. Then, a search for grey literature will be conducted, psychiatric and mental health journals will be searched, and reference lists will be examined to identify further pertinent literature. All literature on factors (human, health related, organisational, etc) and their association to perceived coercion by adults (18 and older) in inpatient, outpatient and community-based psychiatry will be included. A quality assessment of the literature included will be performed. The extracted data will be analysed with a method of content analysis. An exploratory search was conducted in September 2021 and will be updated in September 2022 once the evidence selection process is planned to begin.

ETHICS AND DISSEMINATION

No ethics approval is required for this review. The results of this scoping review will be submitted to a scientific journal for publication, presented in conferences and shared with clinicians working in psychiatric and mental healthcare.

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.

Approach to Informed Consent in Telepsychiatric Service: Indian Perspective

Consent is an essential and important medico-legal prerequisite for a patient's treatment. This necessitates the service provider to participate in the informed consent process and discuss the risk-benefit of the proposed treatment, the best available treatment, engage in shared decision-making process, opportunity to convey their view and thereby limit chances of legal liability for all parties. The clinician should have ample knowledge and skill pertaining to the informed consent process and also have adequate understanding of medical ethics and law. This article provides an overview on informed consent pertaining to telepsychiatric services in India.

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.

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

Alternatives to use of restraint: A path toward humanistic care

Restraint and seclusion are measures to restrict the movement of a person. The predominant reason cited for the use of restraint in mental health settings is the safety of the staff and the patient in times of aggression and to control problem behaviors. However, there have been significant issues in terms of ethics, rights of the patient, and the harmful effects of restraint. Recently, there has been a move in Western countries to decrease its use by incorporating alternative methods and approaches. In India, the Mental Healthcare Act of 2017 advocates the use of least restrictive measures and alternatives to restraint in providing care and treatment for person with mental illness. In this context, approach to restraints is all the more relevant. This article looks to overview the types of restraints, complications of restraints, and the alternatives to restraint in diverse settings.