Measurement Properties of the Staff Attitude to Coercion Scale: A Systematic Review

Staff Attitude Towards Coercive Measures in Hospital and Community Psychiatric Settings

Background/Objectives: The use of coercive measures in psychiatry is an ethically controversial issue. Staff attitude towards coercive measures could explain the different application frequencies of coercive measures across psychiatric services. Methods: We analyzed the attitude towards coercion held by professionals working in a psychiatric department using the Staff Attitude to Coercion Scale (SACS). We statistically evaluated the correlation between the SACS score and the demographic and work characteristics of professionals. Results: The most represented category of participants was nurses (73.03%). Most professionals worked in a Mental Health Community Service (MHCS) (72.09%). We reported a score of 41.9 ± 8.8 SD in total SACS and high scores in two SACS factors: "Coercion as offending" and "Coercion as care and security". Professionals working in Service for Psychiatric Diagnosis and Care (SPDC) showed reduced scores in total SACS and the SACS dimension "Coercion as offending" score. Place of work, particularly "working in SPDC", was statistically significantly associated with total SACS in a positive way and with the "Coercion as offending" score in a negative way in our regression multivariate test. Conclusions: Our professionals showed a predominantly critical and pragmatic attitude towards coercive measures. The professionals who are more frequently exposed to violent and aggressive behavior, such as those who work in SPDC, showed a reduced critical attitude towards coercion in comparison with those working in MHCS, suggesting that exposure to violence can shape the response of professionals.

Psychometric properties of the Turkish version of Staff Attitude to Coercion Scale

BACKGROUND

The aim of this study was to provide the Turkish version of the Staff Attitude to Coercion Scale (SACS) and to determine its psychometric properties.

METHODS

This is a descriptive and correlation design. The sample of this study consisted of 100 psychiatric staff members. The validity and reliability of the scale were assessed through translation procedures, content validity analysis, and confirmatory factor analysis (CFA). Reliability was further evaluated using Cronbach's alpha and item-total score correlations.

RESULTS

The content validity index was found to be 0.93. The scale has a three-factor structure and the Cronbach's alpha values of the subscales are 0.70 for offence, 0.87 for safety and 0.74 for treatment, respectively. The Cronbach alpha reliability coefficient of the total scale was found to be 0.86.

CONCLUSION

The Turkish version of the SACS showed good reliability and validity, and confirmatory factor analysis revealed the same factor structure with three factors as in the original SACS.

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.

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

AIM

This systematic review aimed to identify, describe and evaluate questionnaires measuring health professionals' attitudes towards restraints in mental healthcare.

DESIGN

A systematic review was undertaken in accordance with the COSMIN protocol for systematic review and the relevant sections of the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

OVID Medline, OVID nursing, Psychinfo, Embase and Cinahl were systematically searched from databases inception, with an initial search in December 2021 and updated in April 2022.

REVIEW METHODS

The inclusion criteria compromised articles reporting on self-reported instruments of attitudes or perceptions, development or validation of instruments and the evaluation of one or more measurement properties. Articles using multiple instruments in one study or not published in English were excluded. Two researchers independently extracted the data and appraised the methodological quality using the COSMIN guidelines and standards (consensus-based standards for the selection of health measurement instrument). A narrative synthesis without meta-analysis was performed. The systematic review was registered in PROSPERO Protocol ID CRD42022308818.

RESULTS

A total of 23 studies reporting ten instruments were included. The findings revealed a broad variation in the content of the questionnaires, the use of terms/constructs and the context in which the various instruments measure attitudes towards coercive measures. Many studies lacked sufficient details on report of psychometric properties. Finally, the results were not summarized and the evidence not GRADED.

CONCLUSIONS

There is a need for updated and adapted instruments with origins in theory and clear joint definitions such that attitudes towards coercive measures can be reliably assessed regarding the validity and reliability of instruments, which will be of importance to facilitate the use of instruments in research and clinical settings.

IMPACT

Reviews addressing surveys, self-reported attitudes towards restraints in mental healthcare and examination of psychometric properties seem limited. We highlight distinct complexity, psychometric limitations and broad variation in the context and content measuring attitudes towards coercive measures, and their various use of terms/constructs in the existing questionnaires. These findings contribute to further research regarding the development of questionnaires and the need of representing the concept well - carefully denoted by the indicators, likewise the importance of applying questionnaires with properly reported measurement properties in terms of validity and reliability to ensure the use in research and clinical settings.

A systematic review of the measurement properties of self-care scales in nurses

BACKGROUND

Self-care is a necessary measure against occupational injuries of nurses and improves nursing performance at the bedside. Nurses have different scales to measure self-care, and researchers are confused about choosing valid and reliable scales. This systematic review aimed to evaluate the measurement properties of self-care scales in nurses to identify the best available scales.

METHODS

Four databases (PubMed, Web of Science, SCOPUS, and ProQuest) were systematically searched, with no date limiters, until 9 Jun 2023. A manual search was performed with Google Scholar and the reference list of articles to complete the search. Studies aiming to develop or determine the measurement properties of self-care in nurses were included. Based on Consensus-Based Standards for the Selection of Health Measurement Instruments, the methodological quality of the studies was determined, and the result of each study on a measurement property was rated (sufficient, insufficient, or indeterminate). The quality of the evidence was graded using a modified Grading of Recommendations Assessment, Development, and Evaluation approach (high, moderate, low, or very low). These processes were used to make recommendations and identify the best scale to assess self-care in nurses.

RESULTS

Out of 8601 articles, six articles with five different scales were included. Only internal consistency was reported across all scales. Criterion validity, measurement error, responsiveness, feasibility, and interpretability, were not reported in any of them. Content validity was reported only in two studies with inconsistent results and low-quality evidence. None of the scales had methodological quality with a rating of very good and sufficient high-quality evidence for all measurement properties.

CONCLUSIONS

None of the scales is strongly recommended to measure self-care in nurses. Only the Professional self-care scale is temporarily recommended until their quality is assessed in future studies. Considering that the content of the examined scales does not meet all the professional self-care needs of nurses, designing a valid, reliable, and specialized scale for nurses is needed.

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.

A two-center pilot study on the effects of clinical ethics support on coercive measures in psychiatry

BACKGROUND

The use of formal coercion such as seclusion, mechanical restraint, and forced medication is one of the most challenging and complex issues in mental health care, on the clinical, the legal, and the ethical level. Clinical ethics support aims at assisting healthcare practitioners in determining the morally most justifiable course of action in these situations. However, the effectiveness of clinical ethics support has hardly been studied so far.

METHODS

Monthly moral case deliberation (MCD) was implemented in two acute wards of two different psychiatric hospitals in Switzerland. Frequency and intensity of coercion was measured on ward level (npatients = 405), and the Moral Attentiveness Scale, Knowledge on Coercion Scale, and Staff Attitudes towards Coercion Scale were applied on healthcare practitioner level (nHP = 46). Pre-post-comparisons were conducted using multi-level modeling where appropriate.

RESULTS

After implementation of MCD, formal coercion was less frequent (particularly seclusion, small effect size; 9.6 vs. 16.7%, p = .034, Cramér's V = .105) and less intense (particularly mechanical restraint, large effect size; 86.8 ± 45.3 vs. 14.5 ± 12.1 h, exact p = .019, r = -.74), and approval for coercive measures among healthcare practitioners was lower when controlling for the number of MCD sessions attended.

CONCLUSIONS

Clinical ethics support such as MCD may be a hitherto underutilized service for the reduction of coercion, complementing existing strategies and programs. Implementing clinical ethics support may help improve quality of care for persons suffering from severe mental illness.

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.