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Review

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

by
Simone Agnes Efkemann
1,*,
Jakub Lickiewicz
2,
Paul Doedens
3,4,
Tella Lantta
5,6,
Panagiota Bali
7 and
Tonje Lossius Husum
8
1
Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, 44791 Bochum, Germany
2
Department of Health Psychology, Jagiellonian University Medical College, 31-501 Krakow, Poland
3
Department of Psychiatry, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
4
Urban Vitality—Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, 1105 BD Amsterdam, The Netherlands
5
Department of Nursing Science, University of Turku, 20014 Turku, Finland
6
Centre for Forensic Behavioural Sciences, Swinburne University of Technology, Melbourne 3122, Australia
7
Second Department of Psychiatry, Medical School, University General Hospital “Attikon”, National and Kapodistrian University of Athens, 12462 Chaidari, Greece
8
Faculty of Health Sciences, Oslo Metropolitan University, 0130 Oslo, Norway
*
Author to whom correspondence should be addressed.
Healthcare 2024, 12(16), 1552; https://doi.org/10.3390/healthcare12161552
Submission received: 28 June 2024 / Revised: 31 July 2024 / Accepted: 1 August 2024 / Published: 6 August 2024
(This article belongs to the Special Issue Moving Away from Coercion in Mental Health Care)
Browse Figure
Versions Notes

Abstract

:
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.

1. Introduction

Attitudes play an essential role in human behavior. They support planning and decision-making processes and allow us to obtain a sensible and orderly perception of the world. Attitudes are a framework for organizing and simplifying complex and ambivalent information from the environment and are important for a person to adequately understand information [1]. A common definition of attitudes defines it as the summary evaluation of a specific subject. Furthermore, attitudes can be summarized in the Tripartite model, meaning that attitudes have three components: affective (e.g., emotional-evaluative and emotional-motivational), cognitive (e.g., knowledge, beliefs, opinions, messages, suspicions, doubts, and thoughts), and behavioral (action, motivation, tendency to act, and tendency to behavior) [2].
Professionals’ attitudes are essential in their decision-making, especially in high-demanding situations. An example of such a situation is the use of coercive measures in mental healthcare. In terms of the above-mentioned definition of attitudes in general, attitudes toward coercion can be defined as the summary evaluation of the use of coercion. According to Ajzen and Schmidt, any action (such as the decision to use coercive measures) is the result of social influence and personal factors. Social factors are perceived as social pressures that lead to conducting or omitting a given act (subjective norms) [3]. Understanding other people’s expectations, the value of certain behaviors, and the tendency to comply with other people’s expectations (motivation to comply) are important characteristics of social influence. Subjective norms affect peoples’ intentions and lead to motivation, which is necessary to engage in certain behaviors [4,5]. This leads to intentions based on attitudes about certain behaviors, as well as norms and perceived control over those behaviors [5]. Attitudes resulting from beliefs about behavior and its potential consequences strongly influence peoples’ intentions [3,6]. Furthermore, according to the theory of planned behavior (TPB), positive attitudes and positive subjective norms lead to the increased performance of a give activity, while this effect is moderated by the perceived control of the respective behavior [6]. Subsequently, the attitudes of professionals towards patient behavior and coercive measures highly affect the subjective norms they hold and, thereby, the perceived appropriateness of a coercive measure in given circumstances.
Coercion in mental health care is associated with acting against the will of a patient and therefore is connected with several ethical and legal dilemmas. When using coercive measures, professionals deal with ethical and legal dilemmas. For example, coercive measures are, from a human rights perspective, a violation of patients’ autonomy and physical integrity, but professionals can view such measures as essential to their safety [7]. Personal perceptions and beliefs play a significant role in the decision-making process regarding the use of coercion [8], and professionals’ attitudes can influence the treatment process [9,10]. The lack of knowledge about the influence of attitudes and emotional factors may undermine the decision-making process concerning coercive measures. Because of their essential role in decision-making around coercive measures, attitudes are the subject of research with an increasing evidence base [11,12]. Several authors consider the role of attitudes as an important factor in interventions aiming to reduce the use of coercion in mental healthcare [13,14]. Subsequently, to accomplish a mindset change in mental healthcare, it is essential that staff training focuses on influencing staff attitudes towards coercion [12,15].
Validated questionnaires are available to measure staff attitudes towards coercion in mental healthcare. One of the first tools to explore this phenomenon was a questionnaire by Klinge, investigating the attitudes and opinions of the staff regarding physical restraint and seclusion of patients [16]. A more recent questionnaire is the Attitudes to Containment Measures Questionnaire (ACMQ), developed by Bowers and colleagues [17,18], which measures how staff attitudes rate whether different forms of coercive measures are justifiable. Another approach for assessing attitudes toward coercion is the Knowledge, Attitudes, and Practice (KAP) model [19,20]. Furthermore, the Implicit Association Test (IAT) or the Go/No-Go Association Task (GNAT) are available to assess attitudes and beliefs that people may be unwilling or unable to report [21,22]. IAT has lately been used to provide insights into the relationship between implicit attitudes to the use of coercion and actual behavior regarding coercion in mental healthcare, as well as between implicit and explicit attitudes to the use of coercion [23]. A recently published review has furthermore evaluated the psychometric properties of research instruments for the assessment of attitudes of mental healthcare professionals towards the use of restraint. Though the authors identified a variety of instruments, one of the two most used instrument was the Staff Attitude to Coercion Scale (SACS). In this review, the SACS was the only instrument that allowed a review of psychometric properties and, in this context, was identified as the instrument that has been most validated in previous studies [24]. Furthermore, the SACS represents the only instrument that addresses attitudes to coercion in general without focusing on a specific coercive measure. This seems relevant in terms of comparing attitudes in different settings or countries that use different coercive measures.
The SACS is a widely used and effective tool for measuring staff attitudes towards coercion in mental healthcare, developed in Norway [25]. This 15-item tool aims to assess the attitudes of psychiatric institution personnel toward the use of coercion, using a 5-point Likert scale. The questionnaire asks the subject about their view on coercion in treatment and is explicit that no answer is right or wrong. The developmental study of SACS identified three types of attitudes: (1) coercion as offending to the patient (critical attitude)—the view that coercion violates the patient’s subjectivity; (2) coercion as a care and security (pragmatic attitude)—the view that coercion is needed for care and safety purposes; and (3) coercion as a form of treatment (positive attitude)—the view that coercion may constitute a therapeutic intervention. The original version has adequate psychometric properties [25]. Several authors have translated the SACS into their own language, indicating its potential for cross-cultural applicability [26,27,28,29]. A current review considering the psychometric properties of the SACS in existing studies has summarized the internal consistency for the total score ranging between 0.58 and 0.84, with most studies reporting a score higher than 0.70. A comparable result was found for the individual subscales [30].
In comparison to other tools, the SACS is the only validated questionnaire that measures the general attitudes of mental health professionals toward the use of coercion in psychiatry, without focusing on specific forms of coercive measures. The questionnaire proved its use in various populations, including patients and caregivers. The SACS measures only explicit attitudes towards coercion and has been used in previous studies to examine associations between those attitudes and the incidence of coercive measures [30,31,32]. Additionally, some studies aimed to measure factors influencing attitudes and assess differences between wards in staff attitudes towards coercion [31,33].
Nonetheless, results from existing studies highlight the limitations of the SACS and other instruments in assessing staff attitudes towards coercion [24,31]. Therefore, the objective of our study was to systematically map these limitations of the SACS and the assessment of staff attitudes towards coercion in general. In doing so, we aimed to provide a structured overview of those aspects to facilitate the future development of instruments and research in this area. For this, we conducted a scoping review with the underlying research questions: (1) What do we know from research about staff attitudes towards coercion in mental healthcare since the SACS was developed? (2) Which challenges in the assessment of attitudes towards coercion can be identified from previous studies? (3) Which implications do they raise regarding the update of the SACS?

2. Methods

2.1. Design

We conducted a scoping review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR). In comparison to a previously conducted review [31], in the present review, we specifically addressed relevant aspects for adaptation or update of the SACS and focused on studies that did or did not use the SACS itself. We conducted the literature search according to a study protocol that has previously been registered in INPLASY (INPLASY202390007).

2.2. Eligibility Criteria

We included qualitative and quantitative empirical studies that addressed the attitudes of professionals in mental healthcare towards the use of coercive measures. Based on pilot testing in the first search results, we defined our inclusion criteria as follows: (1) study population included mental health professionals and staff members; (2) intervention or study objective included attitudes towards coercion, normative attitudes, and feelings/emotions and excluded decision-making, experiences, and ethical challenges as those do not fall under the scope of the definition of attitudes as provided in the introduction; and (3) study characteristics included empirical studies, adult psychiatry setting, and outpatient setting (not online). Our exclusion criteria were as follows: (1) service users, informal carers, and students as study participants; (2) adolescent or juvenile settings, forensic or prison settings, and elderly care settings; (3) literature reviews, editorials, comments, letters, thesis, and book chapters; (4) Studies published before 2008, as the original version of the SACS was published then. Inclusion was independent of whether the respective study design or research question specifically addressed attitudes toward coercion. We used no exclusion criteria on language.

2.3. Search Strategy

A librarian at Oslo Metropolitan University conducted the literature search, which consisted of combinations of three main search terms/words and their synonyms: coercion, professional working in mental health services, and attitudes. We provide our full search history in the supplement (Supplementary File S1).

2.4. Study Selection

The authors performed the study selection using the web-based software Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). First, two authors reviewed all titles and abstracts for eligibility based on our inclusion and exclusion criteria. Afterward, we gathered full-text manuscripts of the remaining references, and two authors screened those independently. We solved any disagreement by consensus or based the decision on a third author.

2.5. Data Extraction

All authors performed data extraction using Covidence. For each reference, one author conducted the data extraction, and a second author concluded the final extraction and checked for correctness. We extracted the following information from the included studies:
(1)
General information including title, lead author, year of publication, and country.
(2)
Study characteristics, specifically study aim, study population, study design, the used definition of “attitudes”, assessment instrument, and description of assessment of attitudes.
(3)
Main results.
(4)
Limitations regarding attitudes and their assessment.
We used SPSS 29 to conduct numerical descriptive analysis for all quantitative variables (year of publication, country of origin, study aim, study population, study design, and assessment instrument used) and thematic analysis using Excel for all qualitative variables (definition of attitudes, main results, and limitations). Qualitative data were grouped and analyzed numerically. Furthermore, we identified different groups in terms of study aims and used these groups as categories in which we qualitatively summarized the respective main results from those studies. In the analysis of study limitations, we focused on the limitations that included studies reported regarding attitudes towards coercion (and the assessment of those attitudes).

3. Results

3.1. Search Results

In total, the search resulted in 4521 references. The medical information specialist identified and removed n = 2115 duplicates. Therefore, we entered n = 2406 references into Covidence, which removed one more duplicate. After the selection of title and abstract, n = 124 references remained for full-text assessment. This resulted in n = 80 studies included in this scoping review. We summarized the selection process in a PRISMA flow chart (Figure 1).

3.2. Aims and Key Findings of Studies Reviewed

Table 1 provides an overview of general information and study characteristics including the study aim. As can be seen there, most of the studies were published in the last five years, stemmed from Asia or Europe, addressed nurses as the study population, and were conducted with a quantitative study design. Furthermore, the studies were quite heterogeneous in their reported study aims. In total, 65 studies explicitly addressed staff attitudes towards coercion in the aim of the study, with differences in the specific research questions. The key findings of the different study aims will be further summarized shortly. We provide a list of all studies including extracted data in terms of general information, study characteristics, and key findings in the Supplementary Materials (Supplementary File S2).
(1)
Overall, we found substantial differences in attitudes towards coercion throughout the studies [34,35], especially between different settings, but also between specific types and indications for coercive measures [36,37,38]. The observed studies reported that staff’s perceptions of coercion (including attitudes, emotions, opinions, or general views) were associated with staff characteristics, such as professional background, work experience, age, and gender, but the direction of these associations was highly equivocal [23,27,33,39,40,41,42,43,44,45,46,47,48,49,50]. Attitudes were strongly associated with hospital traditions and policies but also connected with a lack of institutional support [33,51,52]. Studies that reported on emotions related to the use of coercion identified predominantly negative emotions, including helplessness, grief, guilt, and anxiety, but also positive emotions such as feelings of power and control [9,53,54,55]. Further results indicated the relevance of the emotional regulation of staff members in the context of using coercion [56]. In general, staff perception towards coercion seemed to reflect the dilemma of not wanting to use coercion but also perceiving it as necessary, or even beneficial, for the patient in specific situations [54,57,58,59,60,61,62,63].
(2)
The studies that addressed the relationship between staff attitudes towards coercion and other individual characteristics reported associations with emotion-focused coping strategies as well as empathy skills [43,64]. Furthermore, attitudes towards coercion were associated with therapeutic optimism, job satisfaction, and emotional exhaustion [65,66,67,68]. Some authors reported differences in attitudes towards coercion between professional groups, specifically in terms of decisional responsibility [69,70]. Critical attitudes towards coercion were especially associated with more optimistic recovery expectations and were more prevalent in staff members working in wards that used less coercive measures, had lower bed occupancy, and had fewer involuntary admissions [71]. The perception of aggression as dysfunctional or undesirable, as well as the staff’s own experience of anger, was associated with the approval of specific coercive measures [72,73].
(3)
The results from studies examining the association between staff attitudes to and the actual use of coercion suggest a bidirectional relationship. Several studies reported that a positive attitude towards coercion was associated with more personal involvement in coercive incidents [74,75,76]. More specifically, attitudes differed depending on whether mental health professionals were present during coercive measures or not. Being present during the use of coercion seems to be associated with holding the attitude of coercion representing security and care rather than being offending. Professionals who were not only present during the coercive incident but also physically involved showed even more positive attitudes [77]. Furthermore, other studies found an association between the decision to use coercion and attitudes towards coercion, with a more positive attitude towards coercion increasing the likelihood of deciding to use coercive measures [45,48,58,78]. Beyond attitudes, the decision to use coercion also depends on the knowledge and skill levels of individual staff members [76].
(4)
In the comparison of attitudes towards coercion of staff members with those of other relevant groups, differences were found with a higher acceptance of coercive measures in healthcare professionals compared to service users and relatives [51,79,80,81]. When comparing professionals working in different services, greater acceptance and a higher use of coercive measures were found in services that provided access to such measures [82]. Regarding the effect of interventions on staff attitudes, most studies reported significant improvement in attitudes after implementing specific training or interventions to reduce coercion [83,84,85,86,87,88]. Only one study reported no effect of interventions on recovery orientation on attitudes toward coercion [89].
(5)
Several studies specifically reported on the translation process of the SACS into different languages, including psychometric validation. These studies mainly confirmed the construct validity of the SACS, though some authors recommended not using the three original subscales, but a total score instead [26,28,29,90]. Two included studies reported specific results on the validation of newly developed questionnaires: one from Germany (Cologne Questionnaire on Attitudes Towards Coercive Measures, KEZ) [91] and one from Israel (“staff attitudes toward coercion use in treatment of mentally ill patients”) [92].

3.3. Challenges in the Assessment of Staff Attitudes towards Coercion

Beyond the key findings, we also extracted information on the challenges in the assessment of staff attitudes toward coercion from the studies reviewed. Despite most studies addressing staff attitudes in the aim, only 22 studies provided information on how they defined “attitudes” in their respective study, from which we synthesized different definitions. Altogether, 68 of the studies provided specific information on how they assessed the staff attitudes towards coercion, with n 20 using a self-developed questionnaire or interview guideline. The remaining 48 of the studies used at least one originally validated instrument, though most studies used instruments without explicit validation after translation or adaptation for specific study purposes. Furthermore, 33 of the studies reported limitations concerning the assessment of staff attitudes toward coercion. Table 2 provides an overview of definitions of attitudes and assessment instruments and addresses the limitations in the studies reviewed.
A general topic that arose as a limitation was the use of self-reported questionnaires, as several authors discussed that those may limit an in-depth understanding of attitudes and provide poor accuracy [39,43,65,83]. Qualitative studies were helpful in this regard, as they also included an examination of the rationale and thought process behind attitudes [66,83]. In addition, attitudes were often surveyed using a cross-sectional design and, therefore, limit any causal claims about the reported associations. The authors of those studies claimed that experimental studies and longitudinal study designs are necessary [33,37,39,93]. As staff attitudes towards coercion represent a sensitive topic, some studies addressed certain biases of acceptability that might even occur in anonymous, self-reported questionnaires [44,57,94]; there might be an a priori difference between staff members participating in studies regarding attitudes towards coercion and those not willing to participate [51,57]. Most questionnaires only address the cognitive component of attitudes, neglecting the emotional and behavioral components [45,78,89]. Several studies discussed that the existing evidence on the general stability versus the possible fluidity of staff attitudes towards coercion is insufficient. This goes along with reports of missing data on the influence of specific interventions on attitudes [37,81,89].
When adapting instruments regarding attitudes towards coercion, translation might be difficult due to existing differences in local terminology, leading to translation bias [43,95]. Difficulties in the comparison of studies might also arise when studies modify the structure or modus of assessment instruments without sufficient empirical validation, as has been discussed in several studies [9,23,26,32,70]. Furthermore, one study specifically discussed that in the development of new instruments, construct validity cannot be tested against a gold standard due to the lack of other tools so far [29], which is a universal problem for latent constructs such as attitudes. Further reported limitations were regarding generalizability, as many studies have been conducted in highly specific areas (e.g., only in one state or even one hospital) [33,52,66,96,97]. Subsequently, several studies reported difficulties regarding cultural or institutional influence on staff attitudes [59,64,69,90,94,98]. Some studies noted that the attitudes of other relevant stakeholders as well as service users and relatives need addressing, though no validated questionnaires exist in this regard [54,66,74].

4. Discussion

The number of studies that investigate the attitudes of mental health staff at towards coercion is varying over time but overall increasing. The relevance of human rights in healthcare has been globally discussed, especially since the publication of the Convention on the Rights of Persons with Disabilities (CRPD) in 2008 [99]. The discussion on human rights has a strong impact also on clinical practice in mental health services and challenges long-time traditions, including the belief in using coercion [100]. According to the CRPD, it must be abolished accordingly as it violates human rights. In a recent call on the need to move away from coercive approaches, they stated that coercion “is incompatible with contemporary human rights principles and standards” [101]. Furthermore, in their guideline on mental health, human rights, and legislation, the WHO also indicated that it is an essential legislative provision to eliminate coercion in mental health services, and upholding the right to free and informed consent should be created [102]. The increasing interest in measuring staff attitudes towards coercion might reflect this worldwide concern, as the use of coercion in mental health challenges the human rights of patients affected [103,104]. This is highlighted by the research and reports of patients’ experiences of the harm caused by coercive measures [105] and also reflected by a strong ethical dilemma experienced by mental health professionals [106]. Along with the discussion on human rights comes the necessity of evidence-based health services, interventions, and treatment [107,108]. A lack of research or ambiguous evidence regarding e.g., community treatment orders [109], raises new challenges for (mental) health professionals. Research on the geographical variation in health services further supports the assumption that lack of evidence for specific services results in doubt and differing beliefs regarding effective interventions in professional narratives [110]. Subsequently, the lack of evidence leaves room for local cultures and the individual beliefs of professionals to guide decision-making. However, variations in the use of coercion, as well as the initiatives to reduce coercion that show positive effects, challenge the belief that coercion is inevitable. This might lead to more extensive efforts to better understand the psychological factors associated with the decision to use coercive measures.
When considering the role of staff attitude in this regard, the association between attitudes and behavior needs further consideration. Evidence supports a bidirectional relationship between attitudes toward coercion and the actual use of coercion in clinical practice. This means that attitudes towards coercion might influence if and how often coercive measures are used, but the use of coercion in clinical practice can also influence the attitudes of mental health professionals towards its use. This is relevant in terms of existing approaches to reduce coercion, as changes in the attitudes of mental health professionals are often viewed as essential in reducing the use of coercive measures or that negative attitudes are a barrier to the reduction of coercion [111,112,113]. Furthermore, attitudes may also influence the intention to implement interventions to reduce the use of coercive measures. Especially in such an ethically controversial topic, it is likely that mental health professionals experience a high degree of moral doubt and cognitive dissonance when they have to use coercion in clinical practice [69,100,114,115]. This might result in positive attitudes towards coercion to cope with such cognitive dissonance. Furthermore, interventions aiming to reduce coercion or educating mental health professionals in this direction might also lead to cognitive resistance preventing any relevant changes in this regard [116,117,118]. Therefore, when implementing measures to reduce coercion, specific additional interventions should be conducted to address mental health professionals’ attitudes, including, specifically, the handling of arising cognitive dissonance. To do this, mental health services need specific interventions addressing staff attitudes towards coercion. The evidence reviewed in this paper provide promising insights, but several theoretical questions still need addressing before the development of specific interventions is feasible. One main question in this context is the stability of staff attitudes towards coercion. Most of the reviewed studies used a cross-sectional design and did not assess attitudes toward coercion in a longitudinal design. This might be especially relevant considering the variety of factors that are associated with staff attitudes towards coercion, e.g., age or professional experience. This might also reflect or be explained by a general change in attitudes over time [119,120]. Many of the studies reviewed discussed the influence of cultural background on staff attitudes towards coercion, which would indicate a lower stability of those attitudes than expected. This suggests opportunities to change those attitudes in a favorable direction with specific interventions, keeping in mind that those might conflict with the reality of clinical practice. Nevertheless, the included studies in this review found little evidence of the effects of such training or interventions on staff attitudes towards coercion. Furthermore, the influence of cultural background on attitudes needs consideration, which also includes organizational culture toward treatment philosophy [35,83,92,97]. As a practical implication, mental health care workers should nevertheless be encouraged to make themselves aware of existing attitudes and to critically reflect on how those might influence their clinical practice.
Considering the relevance of attitudes towards coercion for the reduction of coercive measures, studies that address attitudes need solid theoretical foundations. The evidence included in this review show a substantial variety of concepts and definitions of attitudes. In social psychology, attitude is a frequently studied concept, and results from this area should be applied more strictly to the phenomenon of coercion in mental healthcare. This is especially relevant regarding the different underlying concepts of attitudes in existing studies, raising the challenge to identify the most suitable concept and explain how attitudes towards coercion might influence the actual use of coercive measures. Depending on the research question, attitudes might be defined in terms of (moral) values and normative beliefs [121] or in terms of the three components (cognitive, emotional, and behavioral) [2]. The choice of the definition used needs a clear explanation in such studies. As stated, the use of coercive measures is ethically a highly controversial practice. Therefore, it does not seem reasonable to omit the emotional aspects of attitudes when trying to examine the relationship between attitudes toward coercion and the use of coercive measures. Those aspects are critical for developing new or adapting existing assessment instruments. However, our results revealed several challenges in this regard. When developing new instruments, construct validity cannot be tested against a gold standard due to the lack of other tools. The described variety of differing concepts further challenges this, because, in terms of attitudes toward coercion, we face a latent construct, of which the formal definition is not universally used in all studies. In the adaptation of existing instruments to different languages or settings, the authors identified several biases due to cultural or organizational differences, specifically complicating the translation of respective items.
We based this scoping review on a thorough database search that was not limited by the language of publications. However, unclear terminology could have resulted in the exclusion of relevant studies. In the analysis of study limitations, we did not perform a formal assessment of methodological rigor. Furthermore, our research team was multidisciplinary, providing different perspectives on the examined subject. Nonetheless, the developer of the SACS was part of the review team, and, in addition, further authors of the papers included were involved in the review. We aimed to address this by specifically discussing and following set criteria in cases of conflicts. Furthermore, our general aim was to critically reflect on the SACS instrument and its limitations.
The considerations from the results raise several implications of concern about updating the SACS, and we suggest an adaptation of it according to the following points: It seems necessary to add items assessing the emotional (and behavioral) component in the questionnaire, as several studies addressed this as a limitation in the current assessment. The German KEZ questionnaire is a good starting point, as the authors did include those components [91]. Furthermore, new versions of the SACS require development and validation to allow the assessment of attitudes towards coercion from other relevant stakeholders, such as service users, relatives, and professionals outside mental healthcare, to enable a valid comparison of the attitudes of those stakeholders. As the cultural background highly influences the attitudes assessed with the SACS, several difficulties arise when translating and adapting the SACS to other countries. To facilitate this process and enable international comparison of attitudes, there is a need for a standard procedure for cultural adaption of the SACS into different countries and settings to ensure content is not lost during the translation process and minimize cross-cultural differences. Additionally, a complementary qualitative part of the SACS might be needed for specific research questions that call for a more in-depth examination. Nevertheless, this instrument should follow a standardized concept of attitudes and specifically developed questions in this regard to prevent further blurring of the underlying definition.

5. Conclusions

This scoping review aimed to provide an overview of the evidence of staff attitudes towards coercion, specifically since the development of the SACS, one of the most used and adapted instruments. Results from the included studies indicate that the relevance of staff attitudes in the use of coercion in mental healthcare is increasing, which raises urgent demands to be based on solid theoretical foundations. In the assessment of staff attitudes toward coercion, we found a broad variety of underlying concepts and a lack of those being reflected in the instruments used. After 15 years of using the SACS, we identified several implications to update the SACS based on existing evidence. Those include the inclusion of items addressing the emotional aspect of attitudes, as well as developing different versions of the SACS for other relevant stakeholders. Furthermore, the review highlights the need for developing a standardized procedure when adapting the SACS or other assessment instruments to different languages and settings. Those efforts in terms of methodological approach could contribute to further improvement of the research of staff attitudes towards coercion and pave the way for a considerable gain in knowledge in this area.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/healthcare12161552/s1, File S1: Search history including all search terms and number of results for each database. File S2: Overview of data extracted from studies reviewed.

Author Contributions

Initial conceptualization, S.A.E., T.L.H. and J.L., methodology and data assessment, S.A.E., J.L., P.D., T.L., P.B. and T.L.H., formal analysis, S.A.E., writing – original draft preparation, S.A.E., J.L. and P.D., writing – review and editing, S.A.E., J.L., P.D., T.L., P.B. and T.L.H. All authors have read and agreed to the published version of the manuscript.

Funding

The APC for this article was funded by COST Action “Fostering and Strengthening Approaches to Reducing Coercion in European Mental Health Services” (FOSTREN), supported by COST (European Cooperation in Science and Technology) (www.cost.eu) (accessed on 14 July 2023).

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data presented in this study that are not published in the Supplementary Materials are available on request from the corresponding author.

Acknowledgments

The systematic and peer-reviewed literature search was conducted by The Literature Search Expert Group at OsloMet—Oslo Metropolitan University, Norway.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Albarracin, D.; Johnson, B.T.; Zanna, M.P. (Eds.) The Handbook of Attitudes, 1st ed.; Psychology Press: London, UK, 2014. [Google Scholar]
  2. Vogel, T.; Wanke, M. Attitudes and Attitude Change, 2nd ed.; Psychology Press: London, UK, 2016. [Google Scholar]
  3. Ajzen, I.; Schmidt, P. Changing behavior using the theory of planned behavior. In The Handbook of Behavior Change; Cambridge handbooks in psychology; Cambridge University Press: New York, NY, USA, 2020; pp. 17–31. [Google Scholar]
  4. Bosnjak, M.; Ajzen, I.; Schmidt, P. The Theory of Planned Behavior: Selected Recent Advances and Applications. Eur. J. Psychol. 2020, 16, 352–356. [Google Scholar] [CrossRef] [PubMed]
  5. Conner, M. Theory of Planned Behavior. In Handbook of Sport Psychology; John Wiley & Sons, Inc.: Hoboken, NJ, USA, 2020; pp. 1–18. [Google Scholar]
  6. La Barbera, F.; Ajzen, I. Control Interactions in the Theory of Planned Behavior: Rethinking the Role of Subjective Norm. Europe’s J. Psychol. 2020, 16, 401–417. [Google Scholar] [CrossRef] [PubMed]
  7. Doedens, P.; Vermeulen, J.; Boyette, L.L.; Latour, C.; de Haan, L. Influence of nursing staff attitudes and characteristics on the use of coercive measures in acute mental health services-A systematic review. J. Psychiatr. Ment. Health Nurs. 2019, 27, 446–459. [Google Scholar] [CrossRef] [PubMed]
  8. Riahi, S.; Thomson, G.; Duxbury, J. An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint. J. Psychiatr. Ment. Health Nurs. 2016, 23, 116–128. [Google Scholar] [CrossRef]
  9. Krieger, E.; Moritz, S.; Lincoln, T.M.; Fischer, R.; Nagel, M. Coercion in psychiatry: A cross-sectional study on staff views and emotions. J. Psychiatr. Ment. Health Nurs. 2021, 28, 149–162. [Google Scholar] [CrossRef] [PubMed]
  10. Aluh, D.O.; Santos-Dias, M.; Silva, M.; Pedrosa, B.; Grigaitė, U.; Silva, R.C.; de Almeida Mousinho, M.; Ferreira; Antunes, J.P.; Remelhe, M.; et al. Contextual factors influencing the use of coercive measures in Portuguese mental health care. Int. J. Law Psychiatry 2023, 90, 101918. [Google Scholar] [CrossRef] [PubMed]
  11. Laukkanen, E.; Vehviläinen-Julkunen, K.; Louheranta, O.; Kuosmanen, L. Psychiatric nursing staffs’ attitudes towards the use of containment methods in psychiatric inpatient care: An integrative review. Int. J. Ment. Health Nurs. 2019, 28, 390–406. [Google Scholar] [CrossRef] [PubMed]
  12. Whittington, R.; Aluh, D.O.; Caldas-de-Almeida, J.M. Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World. Healthcare 2023, 11, 2834. [Google Scholar] [CrossRef] [PubMed]
  13. Barbui, C.; Purgato, M.; Abdulmalik, J.; Caldas-de-Almeida, J.M.; Eaton, J.; Gureje, O.; Hanlon, C.; Nosè, M.; Ostuzzi, G.; Saraceno, B.; et al. Efficacy of interventions to reduce coercive treatment in mental health services: Umbrella review of randomised evidence. Br. J. Psychiatry 2020, 218, 185–195. [Google Scholar] [CrossRef] [PubMed]
  14. Wild, B.; Paul, C.; Friederich, H.C. Reduction of coercion in psychiatric hospitals: How can this be achieved? Lancet Reg. Health Eur. 2023, 35, 100795. [Google Scholar] [CrossRef]
  15. Gill, N.; Drew, N.; Rodrigues, M.; Muhsen, H.; Morales Cano, G.; Savage, M.; Pathare, S.; Allan, J.; Galderisi, S.; Javed, A.; et al. Bringing together the World Health Organization’s QualityRights initiative and the World Psychiatric Association’s programme on implementing alternatives to coercion in mental healthcare: A common goal for action. BJPsych Open 2024, 10, e23. [Google Scholar] [CrossRef] [PubMed]
  16. Klinge, V. Staff opinions about seclusion and restraint at a state forensic hospital. Hosp. Community Psychiatry 1994, 45, 138–141. [Google Scholar] [CrossRef] [PubMed]
  17. Bowers, L.; Alexander, J.; Simpson, A.; Ryan, C.; Carr-Walker, P. Cultures of psychiatry and the professional socialization process: The case of containment methods for disturbed patients. Nurse Educ. Today 2004, 24, 435–442. [Google Scholar] [CrossRef] [PubMed]
  18. Bowers, L.; Alexander, J.; Simpson, A.; Ryan, C.; Carr-Walker, P. Student psychiatric nurses’ approval of containment measures: Relationship to perception of aggression and attitudes to personality disorder. Int. J. Nurs. Stud. 2007, 44, 349–356. [Google Scholar] [CrossRef] [PubMed]
  19. Janelli, L.M.; Scherer, Y.K.; Kanski, G.W.; Neary, M.A. What Nursing Staff Members Really Know About Physical Restraints. Rehabil. Nurs. 1991, 16, 345–348. [Google Scholar] [CrossRef] [PubMed]
  20. Khalil, A.I.; Al Ghamdi, M.A.M.; Al Malki, S. Nurses’ knowledge, attitudes, and practices toward physical restraint and seclusion in an inpatients’ psychiatric ward. Int. J. Cult. Ment. Health 2017, 10, 447–467. [Google Scholar] [CrossRef]
  21. Greenwald, A.G.; McGhee, D.E.; Schwartz, J.L. Measuring individual differences in implicit cognition: The implicit association test. J. Pers. Soc. Psychol. 1998, 74, 1464–1480. [Google Scholar] [CrossRef] [PubMed]
  22. Nosek, B.A.; Banaji, M.R. The Go/No-Go Association Task. Soc. Cogn. 2001, 19, 625–666. [Google Scholar] [CrossRef]
  23. Vandamme, A.; Wullschleger, A.; Garbe, A.; Cole, C.; Heinz, A.; Bermpohl, F.; Mielau, J.; Mahler, L.; Montag, C. The Role of Implicit and Explicit Staff Attitudes in the Use of Coercive Measures in Psychiatry. Front. Psychiatry 2021, 12, 699446. [Google Scholar] [CrossRef]
  24. Bachmann, L.; Ødegård, A.; Mundal, I.P. A comprehensive examination of research instruments utilized for assessing the attitudes of healthcare professionals towards the use of restraints in mental healthcare: A systematic review. J. Adv. Nurs. 2023, 80, 2728–2745. [Google Scholar] [CrossRef]
  25. Husum, T.L.; Finset, A.; Ruud, T. The Staff Attitude to Coercion Scale (SACS): Reliability, validity and feasibility. Int. J. Law Psychiatry 2008, 31, 417–422. [Google Scholar] [CrossRef] [PubMed]
  26. Efkemann, S.A.; Scholten, M.; Bottlender, R.; Juckel, G.; Gather, J. A German Version of the Staff Attitude to Coercion Scale. Development and Empirical Validation. Front. Psychiatry 2021, 11, 573240. [Google Scholar] [CrossRef] [PubMed]
  27. Al-Maraira, O.A.; Hayajneh, F.A. Correlates of psychiatric staff’s attitude toward coercion and their sociodemographic characteristics. Nurs. Forum 2020, 55, 603–610. [Google Scholar] [CrossRef] [PubMed]
  28. Kiejna, A.; Jakubczyk, M.H.; Gondek, T.M.; Rajba, B. The Staff Attitude to Coercion Scale (SACS)—Polish adaptation. Psychiatr. Pol. 2020, 54, 113–124. [Google Scholar] [CrossRef] [PubMed]
  29. Venturini, P.; Bassi, G.; Salcuni, S.; Kotzalidis, G.D.; Telesforo, C.L.; Salustri, E.; Trevisi, M.; Roselli, V.; Tarsitani, L.; Infante, V.; et al. Psychometric properties of the Italian version of the staff attitude to coercion scale: An exploratory factor analysis. Front. Psychiatry 2023, 14, 1172803. [Google Scholar] [CrossRef]
  30. Husum, T.L.; Ruud, T.; Lickiewicz, J.; Siqveland, J. Measurement Properties of the Staff Attitude to Coercion Scale: A Systematic Review. Front. Psychiatry 2022, 13, 744661. [Google Scholar] [CrossRef]
  31. Husum, T.L.; Siqveland, J.; Ruud, T.; Lickiewicz, J. Systematic literature review of the use of Staff Attitudes to Coercion Scale (SACS). Front. Psychiatry 2023, 14, 1063276. [Google Scholar] [CrossRef] [PubMed]
  32. Lickiewicz, J.; Husum, T.L.; Ruud, T.; Siqveland, J.; Musiał, Z.; Makara-Studzińska, M. Measuring Staff Attitudes to Coercion in Poland. Front. Psychiatry 2021, 12, 745215. [Google Scholar] [CrossRef] [PubMed]
  33. Galbert, I.; Azab, A.N.; Kaplan, Z.; Nusbaum, L. Staff attitudes and perceptions towards the use of coercive measures in psychiatric patients. Int. J. Ment. Health Nurs. 2023, 32, 106–116. [Google Scholar] [CrossRef]
  34. Ucun, Y.; GÜRhan, N.; Kaya, B. Psikiyatri Kliniğinde Çalışan Hemşirelerin ve Hekimlerin Hasta Kısıtlama Yöntemleri ile İlgili Görüşleri. Turk. J. Res. Dev. Nurs./Hemşirelikte Araştırma Geliştirme Derg. 2015, 17, 10–20. [Google Scholar]
  35. Aasland, O.G.; Husum, T.L.; Førde, R.; Pedersen, R. Between authoritarian and dialogical approaches: Attitudes and opinions on coercion among professionals in mental health and addiction care in Norway. Int. J. Law Psychiatry 2018, 57, 106–112. [Google Scholar] [CrossRef] [PubMed]
  36. Hotzy, F.; Hengartner, M.P.; Hoff, P.; Jaeger, M.; Theodoridou, A. Clinical and socio-demographic characteristics associated with involuntary admissions in Switzerland between 2008 and 2016: An observational cohort study before and after implementation of the new legislation. Eur. Psychiatry 2019, 59, 70–76. [Google Scholar] [CrossRef] [PubMed]
  37. Dickens, G.L.; Hosie, L. Coercive containment measures for the management of self-cutting versus general disturbed behaviour: Differences in use and attitudes among mental health nursing staff. Int. J. Ment. Health Nurs. 2022, 31, 962–973. [Google Scholar] [CrossRef] [PubMed]
  38. Tateno, M. Initial treatment and behavior restriction in the treatment of schizophrenia in the acute stage--a survey on the attitude of young psychiatrists. Seishin Shinkeigaku Zasshi 2010, 112, 49–53. [Google Scholar] [PubMed]
  39. Gelkopf, M.; Roffe, Z.; Behrbalk, P.; Melamed, Y.; Werbloff, N.; Bleich, A. Attitudes, opinions, behaviors, and emotions of the nursing staff toward patient restraint. Issues Ment. Health Nurs. 2009, 30, 758–763. [Google Scholar] [CrossRef] [PubMed]
  40. Wu, H.-C.; Tang, I.-C.; Lin, W.-I.; Chang, L.-H. Professional values and attitude of psychiatric social workers toward involuntary hospitalization of psychiatric patients. J. Soc. Work 2013, 13, 419–434. [Google Scholar] [CrossRef]
  41. Goktas, A.; Buldukoglu, K. Determination of psychiatric clinic nurses’ knowledge, attitudes, and practices regarding the use of physical restraints. J. Psychiatr. Nurs. 2018, 9, 1–10. [Google Scholar] [CrossRef]
  42. Hsieh, M.-H.; Wu, H.-C.; Chou, F.H.-C.; Molodynski, A. A cross cultural comparison of attitude of mental healthcare professionals towards involuntary treatment orders. Psychiatr. Q. 2017, 88, 611–621. [Google Scholar] [CrossRef]
  43. Bregar, B.; Skela-Savič, B.; Kores Plesničar, B. Cross-sectional study on nurses’ attitudes regarding coercive measures: The importance of socio-demographic characteristics, job satisfaction, and strategies for coping with stress. BMC Psychiatry 2018, 18, 171. [Google Scholar] [CrossRef] [PubMed]
  44. Shao, Y.; Xie, B.; Wu, Z. Psychiatrists’ attitudes towards the procedure of involuntary admission to mental hospitals in China. Int. J. Soc. Psychiatry 2012, 58, 440–447. [Google Scholar] [CrossRef]
  45. Laukkanen, E.; Kuosmanen, L.; Louheranta, O.; Vehviläinen-Julkunen, K. Psychiatric nursing managers’ attitudes towards containment methods in psychiatric inpatient care. J. Nurs. Manag. 2020, 28, 699–709. [Google Scholar] [CrossRef]
  46. Wynn, R.; Kvalvik, A.-M.; Hynnekleiv, T. Attitudes to coercion at two Norwegian psychiatric units. Nord. J. Psychiatry 2011, 65, 133–137. [Google Scholar] [CrossRef]
  47. Lee, T.K.; Välimäki, M.; Lantta, T. The Knowledge, Practice and Attitudes of Nurses Regarding Physical Restraint: Survey Results from Psychiatric Inpatient Settings. Int. J. Environ. Res. Public Health 2021, 18, 6747. [Google Scholar] [CrossRef]
  48. Ye, J.-R.; Zeng, J.-F.; Xiao, A.-X.; Xia, Z.-C.; Dai, L.-D.; Wang, C. Attitude and practice toward physical restraint among psychiatric nurses in Guangdong, China: A cross-sectional survey. Front. Nurs. 2021, 8, 59–68. [Google Scholar] [CrossRef]
  49. Bregar, B.; Skela-Savič, B.; Kajdiž, K.; Kores Plesnicar, B. The Heyman Survey of nursing employees’ attitudes towards mechanical restraints in Slovenia. Obz. Zdr. Nege 2019, 53, 18–30. [Google Scholar] [CrossRef]
  50. Gandhi, S.; Poreddi, V.; Nagarajaiah; Palaniappan, M.; Reddy, S.S.N.; BadaMath, S. Indian nurses’ Knowledge, Attitude and Practice towards use of physical restraints in psychiatric patients. Investig. Educ. Enferm. 2018, 36, e10. [Google Scholar] [CrossRef]
  51. Hotzy, F.; Jaeger, M.; Buehler, E.; Moetteli, S.; Klein, G.; Beeri, S.; Reisch, T. Attitudinal variance among patients, next of kin and health care professionals towards the use of containment measures in three psychiatric hospitals in Switzerland. BMC Psychiatry 2019, 19, 128. [Google Scholar] [CrossRef] [PubMed]
  52. Happell, B.; Koehn, S. Attitudes to the use of seclusion: Has contemporary mental health policy made a difference? J. Clin. Nurs. 2010, 19, 3208–3217. [Google Scholar] [CrossRef] [PubMed]
  53. Okanli, A.; Yilmaz, E.; Kavak, F. Patients’ Perspectives on and Nurses’ Attitudes toward the Use of Restraint/Seclusion in a Turkish Population. Int. J. Caring Sci. 2016, 9, 932–938. [Google Scholar]
  54. Guivarch, J.; Cano, N. Use of restraint in psychiatry: Feelings of caregivers and ethical perspectives. Encephale 2013, 39, 237–243. [Google Scholar] [CrossRef]
  55. El-Badri, S.; Mellsop, G. Patient and staff perspectives on the use of seclusion. Australas 2008, 16, 248–252. [Google Scholar] [CrossRef] [PubMed]
  56. Moran, A.; Cocoman, A.; Scott, P.A.; Matthews, A.; Staniuliene, V.; Valimaki, M. Restraint and seclusion: A distressing treatment option? J. Psychiatr. Ment. Health Nurs. 2009, 16, 599–605. [Google Scholar] [CrossRef] [PubMed]
  57. Gerace, A.; Muir-Cochrane, E. Perceptions of nurses working with psychiatric consumers regarding the elimination of seclusion and restraint in psychiatric inpatient settings and emergency departments: An Australian survey. Int. J. Ment. Health Nurs. 2019, 28, 209–225. [Google Scholar] [CrossRef] [PubMed]
  58. Aluh, D.O.; Ayilara, O.; Onu, J.U.; Pedrosa, B.; Silva, M.; Grigaite, U.; Santos-Dias, M.; Cardoso, G.; Caldas-de-Almeida, J.M. Use of coercion in mental healthcare services in Nigeria: Service providers’ perspective. J. Ment. Health 2023, 33, 75–83. [Google Scholar] [CrossRef] [PubMed]
  59. Stoll, J.; Hodel, M.A.; Riese, F.; Irwin, S.A.; Hoff, P.; Biller-Andorno, N.; Trachsel, M. Compulsory Interventions in Severe and Persistent Mental Illness: A Survey on Attitudes Among Psychiatrists in Switzerland. Front. Psychiatry 2021, 12, 537379. [Google Scholar] [CrossRef] [PubMed]
  60. Mann-Poll, P.S.; Smit, A.; Koekkoek, B.; Hutschemaekers, G. Seclusion as a necessary vs. an appropriate intervention: A vignette study among mental health nurses. J. Psychiatr. Ment. Health Nurs. 2015, 22, 226–233. [Google Scholar] [CrossRef] [PubMed]
  61. Vedana, K.G.G.; da Silva, D.M.; Ventura, C.A.A.; Giacon, B.C.C.; Zanetti, A.C.G.; Miasso, A.I.; Borges, T.L. Physical and mechanical restraint in psychiatric units: Perceptions and experiences of nursing staff. Arch. Psychiatr. Nurs. 2018, 32, 367–372. [Google Scholar] [CrossRef] [PubMed]
  62. Daou, M.; El-Hachem, C.; Nehme, K.; Dagher, R.; Richa, S. Attitude of psychiatrists and psychiatry residents in Lebanon towards restraint and informed consent. Encephale 2021, 47, 21–25. [Google Scholar] [CrossRef] [PubMed]
  63. Fereidooni Moghadam, M.; Fallahi Khoshknab, M.; Pazargadi, M. Psychiatric Nurses’ Perceptions about Physical Restraint; A Qualitative Study. Int. J. Community Based Nurs. Midwifery 2014, 2, 20–30. [Google Scholar]
  64. Yildirim Usenmez, T.; Gumus, F. The effect of empathy skills of psychiatric nurses on their attitudes and practices towards the use of physical restraint. Perspect. Psychiatr. Care 2021, 57, 1595–1603. [Google Scholar] [CrossRef]
  65. Happell, B.; Dares, G.; Russell, A.; Cokell, S.; Platania-Phung, C.; Gaskin, C.J. The Relationships between Attitudes toward Seclusion and Levels of Burnout, Staff Satisfaction, and Therapeutic Optimism in a District Health Service. Issues Ment. Health Nurs. 2012, 33, 329–336. [Google Scholar] [CrossRef] [PubMed]
  66. Happell, B.; Koehn, S. Scratching Beneath the Surface: Influencing Factors on Nurses’ Attitudes toward the Use of Seclusion. Issues Ment. Health Nurs. 2011, 32, 449–456. [Google Scholar] [CrossRef] [PubMed]
  67. Happell, B.; Koehn, S. Seclusion as a necessary intervention: The relationship between burnout, job satisfaction and therapeutic optimism and justification for the use of seclusion. J. Adv. Nurs. 2011, 67, 1222–1231. [Google Scholar] [CrossRef] [PubMed]
  68. Happell, B.; Koehn, S. Impacts of seclusion and the seclusion room: Exploring the perceptions of mental health nurses in Australia. Arch. Psychiatr. Nurs. 2011, 25, 109–119. [Google Scholar] [CrossRef] [PubMed]
  69. Molewijk, B.; Kok, A.; Husum, T.; Pedersen, R.; Aasland, O. Staff’s normative attitudes towards coercion: The role of moral doubt and professional context—A cross-sectional survey study. BMC Med. Ethics 2017, 18, 37. [Google Scholar] [CrossRef] [PubMed]
  70. Raveesh, B.N.; Pathare, S.; Noorthoorn, E.O.; Gowda, G.S.; Lepping, P.; Bunders-Aelen, J.G. Staff and caregiver attitude to coercion in India. Indian J. Psychiatry 2016, 58, S221–S229. [Google Scholar] [CrossRef] [PubMed]
  71. Mötteli, S.; Hotzy, F.; Lamster, F.; Horisberger, R.; Theodoridou, A.; Vetter, S.; Seifritz, E.; Jäger, M. Optimistic recovery expectations are associated with critical attitudes toward coercion among mental health professionals. Int. J. Ment. Health 2019, 49, 157–169. [Google Scholar] [CrossRef]
  72. Ozcan, N.K.; Bilgin, H.; Akin, M.; Badirgali Boyacioglu, N.E. Nurses’ attitudes towards professional containment methods used in psychiatric wards and perceptions of aggression in Turkey. J. Clin. Nurs. 2015, 24, 2881–2889. [Google Scholar] [CrossRef]
  73. Jalil, R.; Huber, J.W.; Sixsmith, J.; Dickens, G.L. Mental health nurses’ emotions, exposure to patient aggression, attitudes to and use of coercive measures: Cross sectional questionnaire survey. Int. J. Nurs. Stud. 2017, 75, 130–138. [Google Scholar] [CrossRef] [PubMed]
  74. van Doeselaar, M.; Sleegers, P.; Hutschemaekers, G. Professionals’ attitudes toward reducing restraint: The case of seclusion in the Netherlands. Psychiatr. Q. 2008, 79, 97–109. [Google Scholar] [CrossRef]
  75. Mahmoud, A.S. Psychiatric Nurses’ Attitude and Practice toward Physical Restraint. Arch. Psychiatr. Nurs. 2017, 31, 2–7. [Google Scholar] [CrossRef]
  76. Barr, L.; Wynaden, D.; Heslop, K. Nurses’ attitudes towards the use of PRN psychotropic medications in acute and forensic mental health settings. Int. J. Ment. Health Nurs. 2018, 27, 168–177. [Google Scholar] [CrossRef]
  77. Dahan, S.; Levi, G.; Behrbalk, P.; Bronstein, I.; Hirschmann, S.; Lev-Ran, S. The Impact of ‘Being There’: Psychiatric Staff Attitudes on the Use of Restraint. Psychiatr. Q. 2018, 89, 191–199. [Google Scholar] [CrossRef]
  78. Efkemann, S.A.; Scholten, M.; Bottlender, R.; Juckel, G.; Gather, J. Influence of mental health professionals’ attitudes and personality traits on decision-making around coercion: Results from an experimental quantitative survey using case vignettes. Acta Psychiatr. Scand. 2022, 146, 151–164. [Google Scholar] [CrossRef]
  79. Reisch, T.; Beeri, S.; Klein, G.; Meier, P.; Pfeifer, P.; Buehler, E.; Hotzy, F.; Jaeger, M. Comparing Attitudes to Containment Measures of Patients, Health Care Professionals and Next of Kin. Front. Psychiatry 2018, 9, 529. [Google Scholar] [CrossRef]
  80. Kinner, S.A.; Harvey, C.; Hamilton, B.; Brophy, L.; Roper, C.; McSherry, B.; Young, J.T. Attitudes towards seclusion and restraint in mental health settings: Findings from a large, community-based survey of consumers, carers and mental health professionals. Epidemiol. Psychiatr. Sci. 2017, 26, 535–544. [Google Scholar] [CrossRef]
  81. Whittington, R.; Bowers, L.; Nolan, P.; Simpson, A.; Neil, L. Approval ratings of inpatient coercive interventions in a national sample of mental health service users and staff in England. Psychiatr. Serv. 2009, 60, 792–798. [Google Scholar] [CrossRef]
  82. Pettit, S.A.; Bowers, L.; Tulloch, A.; Cullen, A.E.; Moylan, L.B.; Sethi, F.; McCrone, P.; Baker, J.; Quirk, A.; Stewart, D. Acceptability and use of coercive methods across differing service configurations with and without seclusion and/or psychiatric intensive care units. J. Adv. Nurs. 2017, 73, 966–976. [Google Scholar] [CrossRef]
  83. Al-Maraira, O.A.; Hayajneh, F.A.; Shehadeh, J.H. Psychiatric staff attitudes toward coercive measures: An experimental design. Perspect. Psychiatr. Care 2019, 55, 734–742. [Google Scholar] [CrossRef]
  84. Kavak, F.; Yilmaz, E.; Okanli, A.; Aslanoglu, E. The effect of psychoeducation given to psychiatry nurses on level of knowledge, attitudes, and practices regarding physical restraint: A randomized controlled study. Perspect. Psychiatr. Care 2019, 55, 743–751. [Google Scholar] [CrossRef]
  85. Stoll, J.; Westermair, A.L.; Kübler, U.; Reisch, T.; Cattapan, K.; Bridler, R.; Maier, R.; Trachsel, M. A two-center pilot study on the effects of clinical ethics support on coercive measures in psychiatry. BMC Psychiatry 2022, 22, 370. [Google Scholar] [CrossRef] [PubMed]
  86. Mann-Poll, P.S.; Smit, A.; van Doeselaar, M.; Hutschemaekers, G.J. Professionals’ attitudes after a seclusion reduction program: Anything changed? Psychiatr. Q. 2013, 84, 1–10. [Google Scholar] [CrossRef] [PubMed]
  87. Rentala, S.; Thimmajja, S.G.; Bevoor, P.; Nanjegowda, R.B. Nurses’ knowledge, attitude and practices on use of restraints at State Mental health care setting: An impact of in-service education programme. Investig. Educ. Enferm. 2021, 39. [Google Scholar] [CrossRef] [PubMed]
  88. Boumans, C.E.; Egger, J.I.; Bouts, R.A.; Hutschemaekers, G.J. Seclusion and the importance of contextual factors: An innovation project revisited. Int. J. Law Psychiatry 2015, 41, 1–11. [Google Scholar] [CrossRef]
  89. Rabenschlag, F.; Konrad, A.; Rueegg, S.; Jaeger, M. A Recovery-Oriented Approach for an Acute Psychiatric Ward: Is It Feasible and How Does It Affect Staff Satisfaction? Psychiatr. Q. 2014, 85, 225–239. [Google Scholar] [CrossRef] [PubMed]
  90. Fukasawa, M.; Miyake, M.; Kikkawa, T.; Sueyasu, T. Development of the Japanese version of Staff Attitude to Coercion Scale. Front. Psychiatry 2022, 13, 1026676. [Google Scholar] [CrossRef] [PubMed]
  91. Baar, I.; Schmitz-Buhl, M.; Gouzoulis-Mayfrank, E. Cologne Questionnaire on Attitudes Towards Coercive Measures (KEZ). Psychiatr. Prax. 2022, 49, 322–328. [Google Scholar] [CrossRef] [PubMed]
  92. Arab, M.; Gray, S.; Hamouzadeh, P. Validation of the “staff attitude toward coercion use in treatment of mentally ill patients” questionnaire in selected public psychiatric hospitals of Tehran in 2015. J. Hosp. 2017, 16, 31–42. [Google Scholar]
  93. Husum, T.L.; Bjørngaard, J.H.; Finset, A.; Ruud, T. A cross-sectional prospective study of seclusion, restraint and involuntary medication in acute psychiatric wards: Patient, staff and ward characteristics. BMC Health Serv. Res. 2010, 10, 89. [Google Scholar] [CrossRef]
  94. Chong, Y.; Wang, C.; Zhi, T.; Fang, S.; Min, H.; Zhang, L.; Wu, X.; Wang, Y. Psychiatric Nurses’ Knowledge, Attitudes, and Practice Regarding Physical Restraint in China: A Multicentre Cross-Sectional Study. J. Multidiscip. Healthc. 2023, 16, 1475–1489. [Google Scholar] [CrossRef]
  95. Larsen, I.B.; Terkelsen, T.B. Coercion in a locked psychiatric ward:Perspectives of patients and staff. Nurs. Ethics 2014, 21, 426–436. [Google Scholar] [CrossRef]
  96. Hasan, A.A.; Abulattifah, A. Psychiatric nurses’ knowledge, attitudes, and practice towards the use of physical restraints. Perspect. Psychiatr. Care 2019, 55, 218–224. [Google Scholar] [CrossRef]
  97. Gowda, G.S.; Kumar, C.N.; Ray, S.; Das, S.; Nanjegowda, R.B.; Math, S.B. Caregivers’ attitude and perspective on coercion and restraint practices on psychiatric inpatients from South India. J. Neurosci. Rural Pract. 2019, 10, 261–266. [Google Scholar] [CrossRef]
  98. Aragones-Calleja, M.; Sanchez-Martinez, V. Experience of coercion among nursing professionals in a medium-stay mental health unit: A qualitative study in Spain. J. Psychiatr. Ment. Health Nurs. 2023, 27, 27. [Google Scholar] [CrossRef]
  99. UN. Convention on the Rights of Persons wit Disabilities (CRPD): Resolution/Adopted by the General Assembly; UN: New York, NY, USA, 2008. [Google Scholar]
  100. Hem, M.H.; Gjerberg, E.; Husum, T.L.; Pedersen, R. Ethical challenges when using coercion in mental healthcare: A systematic literature review. Nurs. Ethics 2018, 25, 92–110. [Google Scholar] [CrossRef]
  101. CRPD. Open Letter to the Secretary-General of the Council of Europe, the Committee of Ministries of the Council of Europe, the Committee on Bioethics of the Council of Europe, the Steering Committee for Human Rights, the Commissioner of Human Rights, the Parliamentary Assembly of the Council of Europe and Other Organizations and Entities of the Council of Europe; CRPD: New York, NY, USA, 2021. [Google Scholar]
  102. WHO. Mental Health, Human Rights and Legislation: Guidance and Practice; WHO: Geneva, Switzerland, 2023. [Google Scholar]
  103. Molodynski, A.; O’Brien, A.; Burns, J. Key international themes in coercion. BJPsych Int. 2017, 14, 61–63. [Google Scholar] [CrossRef]
  104. Gooding, P.; McSherry, B.; Roper, C. Preventing and reducing ‘coercion’ in mental health services: An international scoping review of English-language studies. Acta Psychiatr. Scand. 2020, 142, 27–39. [Google Scholar] [CrossRef]
  105. Nyttingnes, O.; Ruud, T.; Rugkåsa, J. ‘It’s unbelievably humiliating’—Patients’ expressions of negative effects of coercion in mental health care. Int. J. Law Psychiatry 2016, 49, 147–153. [Google Scholar] [CrossRef]
  106. Pariseau-Legault, P.; Vallée-Ouimet, S.; Goulet, M.-H.; Jacob, J.-D. Nurses’ perspectives on human rights when coercion is used in psychiatry: A systematic review protocol of qualitative evidence. Syst. Rev. 2019, 8, 318. [Google Scholar] [CrossRef] [PubMed]
  107. Barbui, C.; Purgato, M.; Churchill, R.; Adams, C.E.; Amato, L.; Macdonald, G.; McCleery, J.; Minozzi, S.; Sheriff, R.S. Evidence-based interventions for global mental health: Role and mission of a new Cochrane initiative. Cochrane Database Syst. Rev. 2017, 4, Ed000120. [Google Scholar] [CrossRef] [PubMed]
  108. Escoffery, C.; Lebow-Skelley, E.; Haardoerfer, R.; Boing, E.; Udelson, H.; Wood, R.; Hartman, M.; Fernandez, M.E.; Mullen, P.D. A systematic review of adaptations of evidence-based public health interventions globally. Implement. Sci. 2018, 13, 125. [Google Scholar] [CrossRef]
  109. Rugkåsa, J.; Canvin, K.; Sinclair, J.; Sulman, A.; Burns, T. Trust, Deals and Authority: Community Mental Health Professionals’ Experiences of Influencing Reluctant Patients. Community Ment. Health J. 2014, 50, 886–895. [Google Scholar] [CrossRef]
  110. Hofstad, T.; Husum, T.L.; Rugkåsa, J.; Hofmann, B.M. Geographical variation in compulsory hospitalisation—Ethical challenges. BMC Health Serv. Res. 2022, 22, 1507. [Google Scholar] [CrossRef]
  111. Mahler, L.; Heinz, A.; Jarchov-Jàdi, I.; Bermpohl, F.; Montag, C.; Wullschleger, A. Therapeutic attitudes and structures in (open) acute psychiatry: The Wedding model. Nervenarzt 2019, 90, 700–704. [Google Scholar] [CrossRef]
  112. Knauf, S.A.; O’Brien, A.J.; Kirkman, A.M. An analysis of the barriers and enablers to implementing the Safewards model within inpatient mental health services. Int. J. Ment. Health Nurs. 2023, 32, 1525–1543. [Google Scholar] [CrossRef]
  113. Norvoll, R.; Hem, M.H.; Pedersen, R. The Role of Ethics in Reducing and Improving the Quality of Coercion in Mental Health Care. HEC Forum 2017, 29, 59–74. [Google Scholar] [CrossRef]
  114. Morandi, S.; Silva, B.; Mendez Rubio, M.; Bonsack, C.; Golay, P. Mental health professionals’ feelings and attitudes towards coercion. Int. J. Law Psychiatry 2021, 74, 101665. [Google Scholar] [CrossRef]
  115. Chambers, M.; Kantaris, X.; Guise, V.; Välimäki, M. Managing and caring for distressed and disturbed service users: The thoughts and feelings experienced by a sample of English mental health nurses. J. Psychiatr. Ment. Health Nurs. 2015, 22, 289–297. [Google Scholar] [CrossRef]
  116. McGrath, A. Dealing with dissonance: A review of cognitive dissonance reduction. Soc. Personal. Psychol. Compass 2017, 11, e12362. [Google Scholar] [CrossRef]
  117. Howe, L.C.; Krosnick, J.A. Attitude Strength. Annu. Rev. Psychol. 2017, 68, 327–351. [Google Scholar] [CrossRef]
  118. Cancino-Montecinos, S.; Björklund, F.; Lindholm, T. Dissonance reduction as emotion regulation: Attitude change is related to positive emotions in the induced compliance paradigm. PLoS ONE 2018, 13, e0209012. [Google Scholar] [CrossRef] [PubMed]
  119. Conner, M.; van Harreveld, F.; Norman, P. Attitude stability as a moderator of the relationships between cognitive and affective attitudes and behaviour. Br. J. Soc. Psychol. 2022, 61, 121–142. [Google Scholar] [CrossRef] [PubMed]
  120. Luttrell, A.; Togans, L.J. The Stability of Moralized Attitudes Over Time. Pers. Soc. Psychol. Bull. 2021, 47, 551–564. [Google Scholar] [CrossRef] [PubMed]
  121. Sjöberg, L. Beliefs and Values as Attitude Values Components. In Social Attitudes and Psychophysical Measurement; Wegener, B., Ed.; Psychology Press: New York, NY, USA, 1982; pp. 199–217. [Google Scholar]
Healthcare 12 01552 g001
Figure 1. Flow chart of the article selection process according to PRISMA ScR (created by Covidence).
Figure 1. Flow chart of the article selection process according to PRISMA ScR (created by Covidence).
Healthcare 12 01552 g001
Table 1. Overview of general information and study characteristics of all studies reviewed (n = 80).
Table 1. Overview of general information and study characteristics of all studies reviewed (n = 80).
n (%)
Year of publication
20083 (3.8)
2009–201316 (20.8)
2014–201827 (33.75)
2019–202334 (42.5)
Regions of origin
Africa2 (2.5)
Asia28 (35.0)
Australia9 (11.3)
Europe40 (50.0)
South America1 (1.3)
Study population
Nurses65 (81.3)
Physicians37 (29.6)
Other professional groups32 (40.0)
Study design
Quantitative67 (83.8)
Qualitative10 (12.5)
Mixed method3 (3.8)
Study aim
Examination of staff’s general perception of coercion23 (28.8)
Examination of staff attitudes towards coercion16 (20.0)
Examination of the association between staff attitudes and other traits or possible influencing factors13 (16.3)
Examination of the association between staff attitudes and the actual use of coercive measures8 (10.0)
Comparison of attitudes towards coercion in staff and other groups including relatives and service users5 (6.3)
Examination of the influence of certain interventions on staff attitudes toward coercion7 (8.8)
Development and validation of instruments to assess staff attitudes towards coercion8 (10.0)
Table 2. Overview of identified challenges in the assessment of staff attitudes.
Table 2. Overview of identified challenges in the assessment of staff attitudes.
n (%)
Attitudes defined as (n = 22)
(political) opinions, beliefs, and values2 (9.1)
normative attitudes2 (9.1)
approval to use coercion2 (9.1)
learned predisposition (theory of reasoned action) 8 (36.4)
feelings about coercion2 (9.1)
preferences towards specific coercive measures1 (4.5)
(part of) ethical consideration3 (13.6)
the perception of coercion (necessity and appropriateness)2 (9.1)
Assessment instrument (n = 48)
SACS (Staff Attitude to Coercion Scale), [25]21 (43.8)
ACMQ (Attitudes to Containment Measures Questionnaire), [17,18] 10 (20.8)
KAPS (Knowledge, Attitude, and Practice on Seclusion), [19]10 (20.8)
SNASS (Survey of nurses’ attitudes towards seclusion), [34]6 (12.5)
PATS-Q (Professional Attitudes Toward Seclusion Questionnaire), [35]2 (4.2)
SREQ (Seclusion and Restraint Experience Questionnaire) [36]1 (2.1)
Limitations addressed in studies reviewed
(n = 33, multiple answers possible)
Use of self-reported questionnaires3 (9.1)
Cross-sectional design8 (24.2)
Bias of acceptability/social desiredness7 (21.2)
Neglection of emotional and behavioral components of attitudes4 (12.1)
Missing evidence on general stability or possible fluidity3 (9.1)
Translation bias5 (15.2)
Change in structure, mode of assessment2 (6.1)
Lack of a gold standard for validation1 (3.0)
Lack of generalizability of results6 (18.2)
Difficulties of cultural and institutional influence10 (30.3)
Missing assessment of attitudes of other stakeholders2 (6.1)
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MDPI and ACS Style

Efkemann, S.A.; Lickiewicz, J.; Doedens, P.; Lantta, T.; Bali, P.; Husum, T.L. A Scoping Review on Staff Attitudes towards the Use of Coercion in Mental Healthcare. Healthcare 2024, 12, 1552. https://doi.org/10.3390/healthcare12161552

AMA Style

Efkemann SA, Lickiewicz J, Doedens P, Lantta T, Bali P, Husum TL. A Scoping Review on Staff Attitudes towards the Use of Coercion in Mental Healthcare. Healthcare. 2024; 12(16):1552. https://doi.org/10.3390/healthcare12161552

Chicago/Turabian Style

Efkemann, Simone Agnes, Jakub Lickiewicz, Paul Doedens, Tella Lantta, Panagiota Bali, and Tonje Lossius Husum. 2024. "A Scoping Review on Staff Attitudes towards the Use of Coercion in Mental Healthcare" Healthcare 12, no. 16: 1552. https://doi.org/10.3390/healthcare12161552

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