Changes in psychiatric nurse attitudes towards legal representation of inpatients at District Psychiatric Board hearings in Israel: a pilot study

doi:10.4236/ojpsych.2011.13019

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Open Journal of Psychiatry, 2011, 1, 126-131

doi:10.4236/ojpsych.2011.13019 Published Online October 2011 (http://www.SciRP.org/journal/OJPsych/

OJPsych

Published Online October 2011 in SciRes. http://www.scirp.org/journal/OJPsych

Changes in psychiatric nurse attitudes towards legal

representation of inpatients at district psychiatric board

hearings in Israel: a pilot study

Alexander Grinshpoon1, Razek Khawaled2, Tamar Levy1, Paula Rosca2, Alexander M. Ponizovsky2*

1Tirat Carmel Mental Health Center, Tirat Carmel, Israel;

2Mental Health Services, Ministry of Health, Jerusalem, Israel.

Email: *[email protected]

Received 11 August 2011; revised 8 September 2011; accepted 16 September 2011.

ABSTRACT

Aims: To compare the initial attitudes of nurses and

other professional groups in a psychiatric hospital

towards the legal representation (LR) of involuntary

admitted psychiatric patients before District Psychi-

atric Boards (DPB), and to assess how these attitudes

changed after LR had become an everyday routine

practice in the hospital. Background: LR of hospital-

ized psychiatric patients before DPB has been intro-

duced into mental health system worldwide, include-

ing Israel. Attitudes of psychiatric staff towards LR

and their changes over time are a very important

–though unstudied issue. Methods: Thirty seven psy-

chiatric nurses employed in the Tirat Carmel Mental

Health Center, Israel and 30 other mental health

professionals (comparison group) completed the At-

titudes to Legal Representation Questionnaire before

LR has been instituted in the Center (November 1,

2006) and one year later. Baseline differences be-

tween the groups were tested using one-way ANOVA,

and pre-post differences in the attitude scores were

tested by paired t-tests. Results: Baseline psychiatric

nurses attitudes towards LR were significantly more

negative than those of the comparison group [F67,3 =

6.87, p < 0.0001], but they significantly improved

over the study period (t37 = 2.56, p = 0.015). Conclu-

sion: Yearlong, routine exposure to the LR of invol-

untarily admitted psychiatric patients may attenuate

negative nurse beliefs and attitudes towards LR of

such patients at DPB hearings. The more positive

attitudes may enhance the nurses’ ability to present

information about patients without jeopardizing their

human and civil rights, and help patients to attain a

greater sense of control over their illness manage-

ment and satisfaction with the services received.

Keywords: Attitudes; Changes over Time; Legal Rep-

resentation; Patient Advocacy; Psychiatric Nurses

1. INTRODUCTION

In Israel psychiatric hospitalizations, both voluntary and

compulsory, are regulated by the Mental Patients Treat-

ment Act, 1991 [1]. The District Psychiatric Board (DPB)

reviews all involuntary commitments, both in the civil

and criminal pathway. The DPB is entitled to decide

whether extending or not the involuntary hospitalization

in the civil pathway and to rule on matters of leave, hos-

pitalization extension or discharge in the criminal path-

way [2].

At present there are 3200 hospital beds for psychiatric

inpatients in Israel. Approximately 20,000 patients are

admitted to psychiatric inpatient care each year. One

fourth receives compulsory psychiatric care under either

District Psychiatrist Order, or Court Order [3]. DPBs

deal with about 8000 cases per year. Patients hospitali-

zed under District Psychiatrist Order appear before the

DPB within 14 days after involuntary hospitalization and

every three months thereafter. Patients hospitalized under

Court Order appear before the DPB every six months or

whenever the patients or the staff wish to obtain release,

short leave or vacation.

Since 2004, all patients appearing before a DPB are

entitled to receive legal representation (LR). Its purpose

is to safeguard the rights of the mentally ill facing com-

pulsory commitment and to help them express their opin-

ion on the treatment received and their wishes for dis-

charge from involuntary hospitalization [1].

Psychiatric nurses are challenged not only to provide

optimal care but also to protect the human and civil

rights of all patients under their care. They are especially

challenged to balance the interests of individual patients

within the context of the interests of other patients, staff

A. Grinshpoon et al. / Open Journal of Psychiatry 1 (2011) 126-131 127

members and different stakeholders. What they write or

say in their reports on patients’ mental state or behavior

is commonly used, at least partly, to make legal deci-

sions concerning patients’ detainment or discharge. The

ethical-legal implication is that nurses are supposed to

accurately report patients’ mental condition while pre-

serving their civil rights and dignity.

By law since 2004 mental patients in Israel started to

receive some LR service whenever appearing before a

DPB [4]. This important amendment to the law was the

result of a number of factors: 1) the growing criticism on

the functioning of the DPBs in the preceding decade by

lawyers, judges and psychiatrists; 2) the legislation of

the basic constitutional Law on Freedom and Dignity, 3)

the recommendations of the “Schnitt Committee”, a spe-

cially appointed Board whose goal was to assess the

functioning of the DPB. All these lead to the proposal

that every person appearing before Psychiatric Boards

should be legally represented.

Despite its importance, the LR of mentally ill patients

committed under a Compulsory Admission Order re-

mains an understudied issue [2]. For example, it has not

become clear yet whether the routine practice of LR in

psychiatric hospitals has any impact on nurses’ knowl-

edge of human rights in general and on their attitudes

towards an individual patient civil rights. We are not

aware of any study on psychiatric nurse attitudes dealing

with LR of psychiatric inpatients before a DPB. Nor are

we aware of any study comparing psychiatric nurse atti-

tudes towards LR of psychiatric patients with those of

other mental health professionals.

The specific aims of this pilot study were to: 1) com-

pare baseline psychiatric nurses attitudes towards LR of

involuntary inpatients before a DPB with those of other

mental health professionals, and 2) determine whether

the routine implementation of LR of psychiatric inpa-

tients led to any change in the professional groups’ atti-

tudes towards the LR of such patients.

2. BACKGROUND

2.1. Attitudes toward Mental Illness and

Psychiatric Treatment

The literature on the attitudes toward medico-legal as-

pects of psychiatry among various health professional

groups is scarce and exclusively descriptive. Neverthe-

less the literature does point to care-givers attitudes in

mental health as focusing on positive outcomes, as well

as satisfaction with mental health services. In their lit-

erature review, Creech and Pewett [5] noted a positive

association between the attitudes of carers towards pa-

tients and effective mental health care delivered. The

researchers then compared the attitudes of the different

mental health professionals (doctors, social workers,

rehabilitation staff, nurses, etc.) in psychiatric hospitals

and in community mental health centers. Participants

attitudes were assessed according to five dimensions:

authority and its impact; benevolence; ideology indicat-

ing the carer’s positive orientation towards mental ill-

ness and the mentally ill; restrictiveness (a tendency to

perceive patients as a threat to society requiring restric-

tion of their social activity), and belief that mental illness

arises from particular interpersonal experiences. Find-

ings from the research highlighted a wide range of be-

liefs and outlooks held by mental health carers with re-

gard to the causes, treatment and prognosis of mental

illness. Interestingly the authors noted that a positive and

humane orientation towards mental illness had a positive

impact on treatment outcomes. The researchers con-

cluded that positive attitudes toward mental illness and

treatment especially among nurses would facilitate better

rehabilitation outcomes than authoritative or paternalis-

tic attitudes.

Tay and associates [6] explored the factors influencing

nurses’ attitudes and involvement with psychiatric pa-

tient care. Their aim was to establish which facilitating

factors were associated with the most positive nurses’

attitudes. The authors found that 31-to-50 year-old

nurses with an M. A. diploma, mental health training,

and 10 years of psychiatric nursing experience held more

positive attitudes towards patients with mental illness

that their less educated and experienced counterparts.

They also found that senior-level nursing managers had

more positive attitudes than staff-level nurses or assistant

nurses. Moreover, nurses working in short-stay acute

ward environments revealed more positive attitudes than

nurses working in long-stay chronic ward environments.

2.2. Advocacy

Thomas [7] compared psychiatrists and psychiatric nurses’

views of mental health advocacy and found positive

support for the perceived usefulness of the approach in

both groups. Psychiatrists tended to make negative

comments about it, and believed that advocacy had no

impact on patient management, but they did not provide

any indication that advocates would promote an anti-

medical-establishment political agenda.

The psychiatrists also indicated that the representation

of patients’ interests by lawyers would inevitably cause

conflicts with the psychiatrists treating them. Nurses, on

the other hand, thought that advocacy empowered clients

by giving them greater control over the management of

their illness. Nurses indicated that advocates challenged

their personal opinion about patients’ management. The

nurses also described positive experiences with advo-

cates who put forward their clients’ views, particularly in

situations where the client found it difficult to express

A. Grinshpoon et al. / Open Journal of Psychiatry 1 (2011) 126-131

128

his/her own ideas.

Some nurses, however, cited negative advocacy ex-

periences, for instance, when overzealous advocates

urged a client’s point of view without actually attempt-

ing to mediate as expected by them. By mediation they

meant acting as a go-between two parties i.e. the staff

member and the patient, in a dispute, in which case ad-

vocates should be expected to represent both the profes-

sional and the patient viewpoint. Some nurses also re-

ported that they would be failing their professional duty

if they represented a patient’s view themselves.

2.3. Legal Representation

According to Oladimeji [8] the LR of psychiatric pa-

tients should not only protect patient rights but also

promote patient autonomy and welfare by spelling out

wishes, needs, and interests of the patients being repre-

sented. In this regard, legal advocates should also col-

laborate with professional carers in making decisions

about a patient treatment and then explain the deci-

sion-making process and the decisions made to the pa-

tient. Lawyers representing a patient at a DPB hearing

typically ground their arguments for or against a pa-

tient’s detention in hospital, at least partly, on the reports

on the his current mental state and behavior of nurses,

physicians, and significant others. Healthcare profes-

sionals, including nurses, thus need to be well instructed

and have thorough knowledge on patients civil and hu-

man rights especially of those who must appear at DPB

hearings. But are all nurses sufficiently informed or have

an appropriate professional attitude toward LR of the

human and civil rights of involuntary patients in psychi-

atric hospital setting? Would LR of patients in the hos-

pital setting result in some nurses feeling threatened or

relieved, or fearing for their patients perceived harm or

being optimistic about the well-being of their patients?

These issues are controversial and need to be further

assessed.

3. METHODS

3.1. Study Design

A case-control pilot survey was designed to determine

baseline beliefs and attitudes of hospital mental health

professionals towards the LR of involuntarily hospital-

ized psychiatric patients appearing before a DPB. A lon-

gitudinal study design was used to determine possible

changes in the participants’ attitudes over one year time,

following routine implementation of the practice of LR

of patients appearing before a DPB at the Tirat Carmel

Mental Health Center in Israel. The Institutional Review

Board approved the research protocol and written in-

formed consent was received from all participants. The

study was initially planned as a pilot study, and after

evaluation of the preliminary data a longitudinal study,

involving multiple mental health centers across the

country was planned.

3.2. Participants and Setting

The setting for this study was a state psychiatric hospital

which has a total of 228 beds distributed as follows: 24

adolescents’ beds, 68 chronic and 136 acute patients’

beds, and 14 ambulatory centers. The hospital serves a

catchment area with a mixed lower and middle-income

population of 600,000. During the survey period, the

professional staff of the hospital included 83 psychiatric

registered nurses, 21 certified psychiatrists, 11 psychiat-

ric residents, and 14 social workers. LR was imple-

mented in the hospital since November 1, 2007. Over the

1-year course of the study, 51 DPB sessions have been

conducted, and 50 involuntarily hospitalized patients

received routine LR.

3.3. The Questionnaire

An “Attitudes to Legal Representation Questionnaire”

(ALRQ) was especially developed for the study (see

Appendix). The questionnaire consists of 11 items

grouped into two subscales: the positive and negative

attitudes subscales. The first reflects staff member no-

tions about the various benefits bound to legal represen-

tation of all participants in the process, whereas the sec-

ond subscale defines staff members’ concerns/beliefs

about the potential harm of LR. Correspondingly, the

positive attitudes subscale consists of 7 items: “LR helps

protect patients’ rights”; “LR enables the caring staff to

explain care decisions to patients”; “LR makes DPB

hearings more careful”; “LR makes the DPB similar to

court hearings”; “LR improves the personnel-patient

partnership”; “LR improves the quality of psychiatric

examinations”; and “LR enables a more accurate evalua-

tion of patients’ dangerousness”. The negative subscale

comprises 4 items: “LR leads to premature discharge

from hospital”; “LR increases a likelihood of readmis-

sion”; “LR turns DPB hearings into a formal juridical

procedure”, and “LR distorts the DPBs’ decisions”.

In the questionnaire, a respondent is asked to assess

his/her degree of agreement with each item. The re-

sponses are scored on a 4-point Likert scale: ‘Com-

pletely disagree’ (score 1), ‘Disagree’ (score 2), ‘Agree’

(score 3), and ‘Completely agree’ (score 4). Mean scores

for each subscale are calculated by summing item scores

divided by number of completed items. The cut off point

for the operational definition of positive and negative

attitude subscale score was established as 2.5. Thus, a

mean score lower than 2.5 indicates participant agree-

ment with the subscale items, whereas a mean score of

2.5 and over displays his/her disagreement. The internal

consistency of the ALRQ items, as measured by Cron-

A. Grinshpoon et al. / Open Journal of Psychiatry 1 (2011) 126-131

129

OJPsych

bach’s alpha coefficients, was 0.78 for the Positive Atti-

tude subscale and 0.73 for the Negative Attitude sub-

scale.

3.4. Procedure

All professional staff members employed at the research

site were personally approached by the social worker

(TL) who explained the study goals and dispensed the

questionnaire among those who gave written informed

consent to participate in the study (n = 90). All respon-

dents completed the study questionnaire anonymously,

30 days before implementation of the routine practice of

legal representation for mental patients (November 1,

2007), and one year later. Respondents remained anony-

mous, stating only their profession and whether they

personally knew any lawyer that represented patients at

DPB hearings. Note here, no one reported familiarity

with the lawyers.

3.5. Data Analysis

Statistical analysis was performed using SPSS, version

15.0 (SPSS Inc, Chicago, IL). Descriptive statistics were

used to examine item and subscale scores on the “Atti-

tudes to Legal Representation Questionnaire.” One-way

analysis of variance (ANOVA) with Tukey HSD

post-hoc single comparisons was used to determine sta-

tistical significance of baseline differences in the attitude

scores of psychiatric nurses and other professionals.

Two-tailed, paired t-tests were used to assess changes in

the attitude scores of the groups over the study time. An

alpha of 0.05 was used to determine statistical signifi-

cance.

4. RESULTS

A total of 67 respondents completed the study question-

naire twice: one month before and one year after the LR

was implemented. The participants consisted of 37 psy-

chiatric registered nurses and 30 other mental health

professionals (18 psychiatrists and 12 social workers).

Response rate was 74% for the entire sample, 98% for

nurses, and 65% for other professionals. At baseline,

64% of all respondents (43 out of 67) endorsed the posi-

tive attitudes items on the ALRQ and 55% (37 of 67)

endorsed negative attitudes items on the scale.

To test the hypothesis that psychiatric nurses do not

differ from other professionals by their attitudes about

the LR of hospitalized psychiatric patients at DPB hear-

ings, we compared baseline attitudes’ scores between the

two groups (Ta bl e 1 , the baseline column comparison).

One way ANOVA, with Tukey post-hoc single compari-

sons, indicated that initially psychiatric nurses endorsed

less positive attitudes [F67,3 = 5.28, p = 0.03] and more

negative attitudes [F67,3 = 6.87, p < 0.001] compared to

other professionals.

To test the hypothesis that the routine practice of LR

of patients before DPB hearings has an effect on nurses’

attitudes, we compared their baseline and 1-year fol-

low-up scores (Table 1, line comparisons). Paired t-tests

indicated a significant reduction in negative attitudes’

scores for the entire sample (t67 = 2.51, p < 0.015). This

change was due to a significant decrease in the negative

attitudes’ scores of the psychiatric nurses (t37 = 2.56, p <

0.015). No significant changes were found in scores of

the negative and positive attitudes in the comparison

group.

Table 1. Initial scores on the attitudes to legal representation questionnaire and their changes over a 1-year study period: Psychiatric

nurses vs. other professionals.

Before legal representation

introduced (N = 67)

One year after legal representation

introduced (N = 67) Paired t-test

Hospital staff group

Mean SD Mean SD t-value p

Psychiatric nurses (n = 37)

Positive attitudes 2.44 0.38 2.35 0.47 0.87 0.38

Negative attitudes 2.71 0.54 2.40 0.57 2.56 0.015

Other professionals (n = 30)

Positive attitudes 2.46 0.50 2.15 0.48 0.45

0.65

Negative attitudes 3.00 0.38 3.01 0.48 0.02

0.98

Total sample (n = 67)

Positive attitudes 2.41 0.45 2.33 0.48 0.88 0.38

Negative attitudes 2.86 0.55 2.66 0.57 2.51 0.015

ANOVA with Tukey post-hoc single comparisons

Positive attitudes F3 = 6.87, p < 0.001 -- -- -- --

Negative attitudes F3 = 5.28, p = 0.03 -- -- -- --

A. Grinshpoon et al. / Open Journal of Psychiatry 1 (2011) 126-131

130

5. DISCUSSION

In this study we compared the attitudes of four psychiat-

ric hospital staff groups regarding the LR of patients at

DPB hearings before and after its introduction as a rou-

tine hospital policy. Our findings indicate that psychiat-

ric nurses held significantly more negative baseline atti-

tudes than other professional groups. The findings indi-

cate that the nurses also demonstrated a significant

change in their negative attitudes one year after the im-

plementation of the policy. It thus appears that the im-

plementation of the LR at the hospital and the nurses’

everyday exposure to the practice had attenuated the

nurses’ initial apprehension about the policy one year

later.

One explanation for the study findings suggests that

routine exposure to the LR of patients at DPB hearings

convinced nurses that their initial attitudes were not jus-

tified. The innovative introduction of LR may have

caused initial anxiety among nurses with a negative atti-

tude, partly due to their ignorance about the impact of

this procedure on the ward atmosphere and on their

every day practice. Moreover, the contact with lawyers

was something new and unknown to them thus arising

initial antagonism. Nurses typically have significantly

more time for and closer contact with patients than other

staff professionals. Their more close day-to-day in-

volvement or more detailed knowledge of the practical

needs of patients being represented at DPB hearings may

have influenced changes in their attitude towards LR of

the patients. Their greater response rate in this pilot

study relatively to other professional groups indirectly

supports this explanation.

In this pilot study, psychiatric nurses held significantly

more negative attitudes about LR of patients than psy-

chiatrists and social workers. It is possible that the

nurses were initially more apprehensive than other staff

groups regarding the perceived potential of LR to result

in harm. Daily exposure to LR and the experience with

the practice acquired during one year may all have de-

sensitized the nurses resulting in increased positive atti-

tudes. The attitudes of other professional groups may not

have changed because they were already more positive

at the beginning or less likely to need enhancement be-

cause of ceiling effects.

Noteworthy, nurses’ negative attitudes changed over

the course of one year while their initial positive atti-

tudes remained unchanged. This finding points to the

possibility that negative nurses’ attitudes about LR of

psychiatric inpatients are not as stable as positive ones,

and are therefore amenable to change with exposure to

the practice over a relatively short period of time. This

finding is inconsistent with Tay et al. [6], who found that

enhanced positive nurse attitudes towards caring for

people with mental illness was associated with ten or

more years of psychiatric nursing experience.

Several limitations of the study should be addressed.

The relatively small size of the groups could diminish

the statistical power of our analysis. It is possible that

pre-post differences would be statistically significant if

the sample size of each group had been larger. Another

limitation is that no data on background characteristics

of the sample were collected because of the anonymity

of the survey. Likewise, it was impossible to prevent

exposure of participants to other participants within

group and between groups, a fact which might have af-

fected the findings. Unfortunately, we were not able to

assess the opinions of the lawyers, both members of the

DPBs and those who represented mental patients before

DPBs, and hence we cannot present their side. This im-

portant side of the medicolegal dilemma warrants further

investigation.

6. CONCLUSION AND IMPLICATIONS

According to the results of our pilot study, routine ex-

posure to the LR of involuntarily admitted psychiatric

patients may attenuate negative nurse beliefs and atti-

tudes towards LR at DPBs hearings. Their more positive

attitudes may enhance their ability to present adequate

information about patients without jeopardizing their

human and civil rights.

Our study findings are consistent with qualitative re-

search describing the positive experiences of psychiatric

nurses with individuals who advocate on behalf of psy-

chiatric patients [7]. In that research, the nurses stressed

the usefulness of advocacy for empowering their clients,

giving them greater control over the management of

their illness, and stimulating the nurses own thinking

about patient management. Thus, it is possible that en-

hanced positive nurses’ attitudes about the LR of mental

patients before a DPB may affect their patients’ symp-

tom-management and create more satisfaction with the

services received.

Further research is needed in order to assess how such

attitudes may be influenced and changeable for all pro-

fessional groups―over a longer time-period. In order to

diminish the negative attitudes of the staff a preliminary

seminar addressing the initial fears and prejudices to-

wards LR, illustrating the law amendment, its rationale

and the procedure of its implementation is recommended.

The seminar should also include a discussion group with

some lawyers from the Public Defender Office or from

the Legal Aid such allowing some desensitization and a

better cooperation between the two professions. Illustra-

tions of some case vignettes showing the positive impact

of the LR on the patients health should also be recom-

mended. We do believe that in order to better safeguard

A. Grinshpoon et al. / Open Journal of Psychiatry 1 (2011) 126-131 131

mental patients rights ongoing and periodical meetings

should be organized including both hospital staff and

representing lawyers, thus promoting improved clinical

and legal practice.

7. ACKNOWLEDGEMENTS

Dr. A.M. Ponizovsky was supported by the Ministry of Immigrant

Absorption. We thank Dr. I. Levav for his support in this study.

REFERENCES

[1] State of Israel (1991) Mental patients treatment act. Je-

rusalem.

[2] Bauer, A., Rosca, P., Grinshpoon, A., Khawalled, R. and

Mester, R. (2005) District psychiatric boards in Israel:

Expectations and realities. The Journal of Forensic Psy-

chiatry, 28, 661-669.

[3] Ministry of Health. (2009) Mental health in Israel, Statis-

tical Annual 2008. Ministry of Health, Jerusalem.

[4] Bauer, A., Khawaled, R., Rosca, P. and Ponizovsky, A.

(2008) Legal representation is associated with psychiatric

readmissions. Open Law Journal, 1, 6-10.

doi:10.2174/1874950X00801010006

[5] Creech, S.K. and Prewett, R.C. (1976) Opinions about

mental illness held by personnel of a state psychiatric

hospital and community mental health centers. Journal of

Community Psychology, 4, 347-356.

doi:10.1002/1520-6629(197610)4:4<347::AID-JCOP229

0040405>3.0.CO;2-E

[6] Tay, C., Pariyasami, D., Ravindran, K., Ali, M. and Row-

sudeen, M. (2004) Nurses attitudes to people with mental

illness in a psychiatric hospital in Singapore. Journal of

Psychosocial Nursing and Mental Health Services, 42,

40-47.

[7] Thomas, Ph. (2001) A survey of psychiatrists and nurses

views of mental health advocacy. Psychiatric Bulletin, 25,

477-448.

[8] Oladimeji, K. (1999) The value of advocacy: Putting

ethics into practice. Psychiatric Bulletin, 23, 569-571.

APPENDIX

The Attitudes to Legal Representation Questionnaire

The new Article 29(a) of the Mental Patients Treatment Act, 1991, requires to provide legal representation of involun-

tarily hospitalized mentally ill persons before a District Psychiatric Board. In order to understand the attitude of mental

health professions to legal representation, we ask you to note to which extent you agree or disagree with the following

statements.

N Legal representation… Completely disagree

(1)

Disagree

(2)

Agree

(3)

Completely agree

(4)

1 … leads to premature discharge from hospital.

2 … increases a likelihood of readmission.

3 … helps to protect patients’ rights.

4 … enables the caring staff to explain care decisions

to patients.

5 … makes DPB hearings more careful.

6 … makes the DPB hearings similar to court hear-

ings.

7 … improves the personnel-patient

partnership.

8 … turns DPB hearings into a formal

juridical procedure.

9 … distorts the DPB’s decisions.

10 … improves the quality of psychiatric examina-

tions.

11 … enables a more accurate evaluation of patient’s

dangerousness.

coring: The Negative attitudes index is the sum of scores for items 1, 2, 8, and 9; The Positive attitudes index is the sum of scores for items 3, 4, 5, 6, 7, 10 and 11.