Open Journal of Psychiatry, 2011, 1, 126-131
doi:10.4236/ojpsych.2011.13019 Published Online October 2011 (
Published Online October 2011 in SciRes.
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: *
Received 11 August 2011; revised 8 September 2011; accepted 16 September 2011.
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
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.
2.1. 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
opyright © 2011 SciRes. OJPsych
A. Grinshpoon et al. / Open Journal of Psychiatry 1 (2011) 126-131
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
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-
Copyright © 2011 SciRes. OJPsych
A. Grinshpoon et al. / Open Journal of Psychiatry 1 (2011) 126-131
Copyright © 2011 SciRes.
bach’s alpha coefficients, was 0.78 for the Positive Atti-
tude subscale and 0.73 for the Negative Attitude sub-
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-
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
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
Negative attitudes 3.00 0.38 3.01 0.48 0.02
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
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
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
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 groupsover 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
Copyright © 2011 SciRes. OJPsych
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.
Dr. A.M. Ponizovsky was supported by the Ministry of Immigrant
Absorption. We thank Dr. I. Levav for his support in this study.
[1] State of Israel (1991) Mental patients treatment act. Je-
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[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.
[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
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[6] Tay, C., Pariyasami, D., Ravindran, K., Ali, M. and Row-
sudeen, M. (2004) Nurses attitudes to people with mental
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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
N Legal representation… Completely disagree
Completely agree
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-
7 … improves the personnel-patient
8 … turns DPB hearings into a formal
juridical procedure.
9 … distorts the DPB’s decisions.
10 … improves the quality of psychiatric examina-
11 … enables a more accurate evaluation of patient’s
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.
opyright © 2011 SciRes. OJPsych