The biobank for the molecular classification of kidney disease: research translation and precision medicine in nephrology.

BACKGROUND: Advances in technology and the ability to interrogate disease pathogenesis using systems biology approaches are exploding. As exemplified by the substantial progress in the personalized diagnosis and treatment of cancer, the application of systems biology to enable precision medicine in other disciplines such as Nephrology is well underway. Infrastructure that permits the integration of clinical data, patient biospecimens and advanced technologies is required for institutions to contribute to, and benefit from research in molecular disease classification and to devise specific and patient-oriented treatments. METHODS AND RESULTS: We describe the establishment of the Biobank for the Molecular Classification of Kidney Disease (BMCKD) at the University of Calgary, Alberta, Canada. The BMCKD consists of a fully equipped wet laboratory, an information technology infrastructure, and a formal operational, ethical and legal framework for banking human biospecimens and storing clinical data. The BMCKD first consolidated a large retrospective cohort of kidney biopsy specimens to create a population-based renal pathology database and tissue inventory of glomerular and other kidney diseases. The BMCKD will continue to prospectively bank all kidney biopsies performed in Southern Alberta. The BMCKD is equipped to perform molecular, clinical and epidemiologic studies in renal pathology. The BMCKD also developed formal biobanking procedures for human specimens such as blood, urine and nucleic acids collected for basic and clinical research studies or for advanced diagnostic technologies in clinical care. The BMCKD is guided by standard operating procedures, an ethics framework and legal agreements with stakeholders that include researchers, data custodians and patients. The design and structure of the BMCKD permits its inclusion in a wide variety of research and clinical activities. CONCLUSION: The BMCKD is a core multidisciplinary facility that will bridge basic and clinical research and integrate precision medicine into renal pathology and nephrology.

A survey of patient perspectives on the research use of health information and biospecimens.

BACKGROUND: Personal health information and biospecimens are valuable research resources essential for the advancement of medicine and protected by national standards and provincial statutes. Research ethics and privacy standards attempt to balance individual interests with societal interests. However these standards may not reflect public opinion or preferences. The purpose of this study was to assess the opinions and preferences of patients with kidney disease about the use of their health information and biospecimens for medical research. METHODS: A 45-item survey was distributed to a convenience sample of patients at an outpatient clinic in a large urban centre. The survey briefly addressed sociodemographic and illness characteristics. Opinions were sought on the research use of health information and biospecimens including consent preferences. RESULTS: Two hundred eleven of 400 distributed surveys were completed (response rate 52.8 %). Respondents were generally supportive of medical research and trusting of researchers. Many respondents supported the use of their information and biospecimens for health research and also preferred consent be sought for use of health information and biospecimens. Some supported the use of their information and biospecimens for research without consent. There were significant differences in the opinions people offered regarding the research use of biospecimens compared to health information. Some respondent perspectives about consent were at odds with current regulatory and legal standards. CONCLUSIONS: Clinical health data and biospecimens are valuable research resources, critical to the advancement of medicine. Use of these data for research requires balancing respect for individual autonomy, privacy and the societal interest in the greater good. Incongruence between some respondent perspectives and the regulatory standards suggest both a need for public education and review of legislation to increase understanding and ensure the public's trust is maintained.

An exploratory, descriptive study of consumer opinions and behaviors regarding health products sales at 4 chiropractic practices in a large, western Canadian urban center.

OBJECTIVE: This study describes the opinions and behaviors of chiropractic patients in a large, western Canadian urban center regarding the sale of health products by doctors of chiropractic. METHODS: A brief, descriptive survey consisting of both fixed-choice and open-ended questions was distributed by clinic reception staff at 4 chiropractic offices in Calgary, Alberta, Canada. Each practice sold a range of health products, including those relating to musculoskeletal care and nutrition, and served between 275 and 320 clients per week. RESULTS: After a 10-week recruitment interval between January and March 2013, a convenience sample of 103 chiropractic patients was obtained. Most patients supported the sale of health products by doctors of chiropractic (n = 101; 98.1%), and most had made health product purchases from a doctor of chiropractic at some point (n = 73; 70.9%). Products relating to muscular care, exercise/rehabilitation products, and pillows were purchased most often (>40%). Consumers were most supportive of doctors of chiropractic selling products they perceived to be directly related to musculoskeletal care. Some participants believed that there should be limits placed on the range of products sold including the products had to be consistent with the practitioner's area of expertise and had to have some demonstrated level of effectiveness. Primary reasons for health product purchase included the doctor's recommendations, convenience, and perception that the product would improve well-being (>50%). CONCLUSIONS: This study found that chiropractic patients were supportive of health product sales by doctors of chiropractic, assuming certain conditions were met. Consumers believed that product sales should be undertaken with integrity and should be consistent with the doctor's area of expertise. Consumer beliefs appeared to impact their purchasing behaviors.

Causes of death among an urban homeless population considered by the medical examiner.

Those who are homeless face illness and death, however, live in places not conducive to provision of end-of-life care. Limited information exists on causes of death among this group of people. To characterize causes of death, data were requested from the Office of the Chief Medical Examiner for Alberta Justice, Canada, for people determined to be homeless in the period 2007-2009. One hundred and thirty-two deaths were reported. Most deaths that could be classified were attributed to drug and alcohol use/abuse and to natural causes. For many, end-of-life circumstances may have been improved through provision of palliative care delivered in a hospice setting.

Chiropractic care and public health: answering difficult questions about safety, care through the lifespan, and community action.

The purpose of this collaborative summary is to document current chiropractic involvement in the public health movement, reflect on social ecological levels of influence as a profession, and summarize the relationship of chiropractic to the current public health topics of: safety, health issues through the lifespan, and effective participation in community health issues. The questions that are addressed include: Is spinal manipulative therapy for neck and low-back pain a public health problem? What is the role of chiropractic care in prevention or reduction of musculoskeletal injuries in children? What ways can doctors of chiropractic stay updated on evidence-based information about vaccines and immunization throughout the lifespan? Can smoking cessation be a prevention strategy for back pain? Does chiropractic have relevance within the VA Health Care System for chronic pain and comorbid disorders? How can chiropractic use cognitive behavioral therapy to address chronic low back pain as a public health problem? What opportunities exist for doctors of chiropractic to more effectively serve the aging population? What is the role of ethics and the contribution of the chiropractic profession to public health? What public health roles can chiropractic interns perform for underserved communities in a collaborative environment? Can the chiropractic profession contribute to community health? What opportunities do doctors of chiropractic have to be involved in health care reform in the areas of prevention and public health? What role do citizen-doctors of chiropractic have in organizing community action on health-related matters? How can our future chiropractic graduates become socially responsible agents of change?

Meaning and challenges in the practice of multiple therapeutic massage modalities: a combined methods study.

BACKGROUND: Therapeutic massage and bodywork (TMB) practitioners are predominantly trained in programs that are not uniformly standardized, and in variable combinations of therapies. To date no studies have explored this variability in training and how this affects clinical practice. METHODS: Combined methods, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, were used to explore the training and practice of TMB practitioners in Alberta, Canada. RESULTS: Of the 5242 distributed surveys, 791 were returned (15.1%). Practitioners were predominantly female (91.7%), worked in a range of environments, primarily private (44.4%) and home clinics (35.4%), and were not significantly different from other surveyed massage therapist populations. Seventy-seven distinct TMB therapies were identified. Most practitioners were trained in two or more therapies (94.4%), with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen interviews were conducted. Participants described highly variable training backgrounds, resulting in practitioners learning unique combinations of therapy techniques. All practitioners reported providing individualized patient treatment based on a responsive feedback process throughout practice that they described as being critical to appropriately address the needs of patients. They also felt that research treatment protocols were different from clinical practice because researchers do not usually sufficiently acknowledge the individualized nature of TMB care provision. CONCLUSIONS: The training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. In addition, clinical experience and continuing education may further alter or enhance treatment techniques. Practitioners individualize each patient's treatment through a highly adaptive process. Therefore, treatment provision is likely unique to each practitioner. These results may be of interest to researchers considering similar practice issues in other professions. The use of a combined-methods design effectively captured this complexity of TMB practice. TMB research needs to consider research approaches that can capture or adapt to the individualized nature of practice.

The perspectives and practices of alberta chiropractors regarding the sale of health care products in chiropractic offices.

OBJECTIVE: The purpose of this study is to describe the practices and perspectives of doctors of chiropractic in Alberta, Canada, regarding the sale of health products. This practice is considered in terms of ethical principles and professional practice standards. METHODS: Chiropractic Web sites in Alberta were identified using the publically available Web site of the Alberta College and Association of Chiropractors. A random sample of chiropractors was drawn and mailed a brief 4-page survey and return envelope. There was a follow-up mail out to nonrespondents 3 weeks later. Practitioners provided responses regarding their personal and professional characteristics and their perspectives and practices regarding health product sales. RESULTS: A total of 265 responses were received (response rate, 51.2%). Most practitioners endorsed health product sales by chiropractors (95%), and most were engaged in the practice (89%). Orthotics (77%) and pillows (69%) were sold most often, followed by nutritional supplements (68%), hot/cold packs (68%), and vitamins (52%). Some respondents identified areas of potential ethical concern, including product safety and efficacy, professional influence on consumer product purchase, and potential conflict of interest. Codes of ethics and conduct offer some guidance to practitioners, but their awareness of standards varied. CONCLUSIONS: The chiropractic profession within Alberta condones product sales, and most of its membership engages in the practice. Individual members differ in their perspectives on this practice and in their awareness of the national code of ethics and conduct.

How Semantics Connotations May Influence Concerns About Donation of Biospecimens.

Introduction: Human biological specimen (biospecimen) donation is routinely requested for clinical care and research purposes. Successfully engaging patients and research participants in biospecimen donation depends on what they understand these initiatives entail, including their perceptions of risk. Human biospecimens are stored in facilities routinely referenced as biobanks or biorepositories, both of which labels are known to embody a variety of connotations. The words chosen to describe biospecimen facilities may influence decisions about donation. Objective: To explore differences in likelihood of donation as a function of the words chosen to represent human biospecimen storage facilities and the commensurate concerns each label evokes. Materials and Methods: Two-group experimental design. Participants completed a survey about a fictitious undertaking requesting that they consider biospecimen donation. The term used to describe the facility housing the biospecimens differed; one half of the surveys referenced a biobank, and one half referenced a biorepository. Results: Two thousand five hundred ninety-six surveys were distributed; 586 completed surveys were received (response rate: 22.6%). Sixty-three percent of respondents, regardless of whether the label referenced a biobank or biorespository, reported being extremely likely to donate. There were no significant differences between the 2 groups on the 11 concerns sampled. Factor analyses revealed that concerns could be classified in two groups: use-related concerns and person-related concerns. The label biobank evoked significantly lower perception of importance of the person-related concerns sampled (e.g., personal or other benefit, discomfort or inconvenience). Conclusions: Our results suggest that researchers may consider using the word biobank to describe the facility housing the biospecimen, as this term appears less subject to concern biases. These outcomes confirm that misunderstandings or misattributions of words used to refer to biospecimen facilities could deter participation in clinical care or research. Participation may be enhanced through ensuring clear understanding of what biospecimen donation entails and by directly addressing common semantic misunderstandings and associations.

An audit of health products advertised for sale on chiropractic Web sites in Canada and consideration of these practices in the context of Canadian chiropractic codes of ethics and conduct.

OBJECTIVE: This study describes the extent to which chiropractors with Web sites practicing in Canada advertise health products for sale and considers this practice in the context of chiropractic codes of ethics and conduct. METHODS: Chiropractic Web sites in Canada were identified using a public online business directory (Canada 411). The Web sites were searched, and an inventory of the health products for sale was taken. The influences of type of practice and province of practice on the sale of health product were assessed. Textual comments about health product marketing were summarized. National and provincial codes of ethics were reviewed, and the content on health product advertising was summarized. RESULTS: Two hundred eighty-seven Web sites were reviewed. Just more than half of the Web sites contained information on health products for sale (n = 158, 54%). Orthotics were advertised most often (n = 136 practices, 47%), followed by vitamins/nutritional supplements (n = 53, 18%), pillows and supports (n = 40, 14%), and exercise/rehabilitation products (n = 20, 7%). Chiropractors in solo or group chiropractic practices were less likely to advertise health products than those in multidisciplinary practice (P < .001), whereas chiropractors in BC were less likely to advertise nutritional supplements (P < .01). Provincial codes of ethics and conduct varied in their guidelines regarding health product sales. CONCLUSIONS: Variations in codes of ethics and in the proportions of practitioners advertising health products for sales across the country suggest that opinions may be divided on the acceptability of health product sales. Such practices raise questions and considerations for the chiropractic profession.

Canadian policy on reporting breaches of research integrity: When should Research Ethics Boards be informed?

In Canada, institutions that receive research funding from the three federal granting agencies must establish research ethics boards (REBs) to review the ethical acceptability of research involving humans. Institutions are also expected to promote the responsible conduct of research, fostering researchers' abilities to act with integrity in the conduct of their research. Where a researcher fails to act with integrity in research with humans, institutional policies and procedures of the U15, Canada's most research-intensive universities, vary in the extent to which they involve their REBs in response to such breaches. Some make no mention of the REB, whereas others state that their REB should be provided with information relating to upheld allegations. In this paper, we argue that when allegations of research integrity breaches are corroborated, the institution's REB should be identified as a party required to receive that information. Only then can REBs ensure compliance with research ethics standards, which is essential to maintain the public's trust.

Correction to: Ethical considerations in conducting surgical research in severe complicated intra-abdominal sepsis.

[This corrects the article DOI: 10.1186/s13017-019-0259-9.].

Ethical considerations in conducting surgical research in severe complicated intra-abdominal sepsis.

Background: Severe complicated intra-abdominal sepsis (SCIAS) has high mortality, thought due in part to progressive bio-mediator generation, systemic inflammation, and multiple organ failure. Treatment includes early antibiotics and operative source control. At surgery, open abdomen management with negative-peritoneal-pressure therapy (NPPT) has been hypothesized to mitigate MOF and death, although clinical equipoise for this operative approach exists. The Closed or Open after Laparotomy (COOL) study (https://clinicaltrials.gov/ct2/show/NCT03163095) will prospectively randomize eligible patients intra-operatively to formal abdominal closure or OA with NPTT. We review the ethical basis for conducting research in SCIAS. Main body: Research in critically ill incapacitated patients is important to advance care. Conducting research among SCIAS is complicated due to the severity of illness including delirium, need for emergent interventions, diagnostic criteria confirmed only at laparotomy, and obtundation from anaesthesia. In other circumstances involving critically ill patients, clinical experts have worked closely with ethicists to apply principles that balance the rights of patients whilst simultaneously permitting inclusion in research. In Canada, the Tri-Council Policy Statement-2 (TCPS-2) describes six criteria that permit study enrollment and randomization in such situations: (a) serious threat to the prospective participant requires immediate intervention; (b) either no standard efficacious care exists or the research offers realistic possibility of direct benefit; (c) risks are not greater than that involved in standard care or are clearly justified by prospect for direct benefits; (d) prospective participant is unconscious or lacks capacity to understand the complexities of the research; (e) third-party authorization cannot be secured in sufficient time; and (f) no relevant prior directives are known to exist that preclude participation. TCPS-2 criteria are in principle not dissimilar to other (inter)national criteria. The COOL study will use waiver of consent to initiate enrollment and randomization, followed by surrogate or proxy consent, and finally delayed informed consent in subjects that survive and regain capacity. Conclusions: A delayed consent mechanism is a practical and ethical solution to challenges in research in SCIAS. The ultimate goal of consent is to balance respect for patient participants and to permit participation in new trials with a reasonable opportunity for improved outcome and minimal risk of harm.

Improving the process of research ethics review.

BACKGROUND: Research Ethics Boards, or Institutional Review Boards, protect the safety and welfare of human research participants. These bodies are responsible for providing an independent evaluation of proposed research studies, ultimately ensuring that the research does not proceed unless standards and regulations are met. MAIN BODY: Concurrent with the growing volume of human participant research, the workload and responsibilities of Research Ethics Boards (REBs) have continued to increase. Dissatisfaction with the review process, particularly the time interval from submission to decision, is common within the research community, but there has been little systematic effort to examine REB processes that may contribute to inefficiencies. We offer a model illustrating REB workflow, stakeholders, and accountabilities. CONCLUSION: Better understanding of the components of the research ethics review will allow performance targets to be set, problems identified, and solutions developed, ultimately improving the process.

Immunization and the chiropractor-patient interaction: a Western canadian study.

OBJECTIVE: To explore how the topic of vaccination arises during interactions between chiropractors and their patients, the advice that is given to patients, and the factors that influence the opinions of the chiropractors. METHODS: Data were collected in semistructured interviews with a purposeful sample of chiropractors in Calgary, Canada. Data were analyzed using qualitative content analysis and constant comparison. Participants were chiropractors who had participated in a postal survey of immunization-related beliefs and behaviors and who consented to contact for further study. RESULTS: Data redundancy was attained after 14 interviews were complete. Immunization arose in clinical encounters by both indirect (provision of reference materials and/or posting of media stories in clinic waiting rooms) and direct communication. Direct communications were most commonly patient initiated and were prompted by media reports, clinic waiting room material, or patient perceived adverse reactions; however, they were also initiated by the chiropractors, particularly if they were seeing young children with their parents. For some chiropractors, the emphasis was on providing information of a negative, antivaccination nature; others referred clients to physicians and nurses. Factors that influenced their opinions included their chiropractic training, philosophy of health and illness, and self or important others having experienced negative reactions that were perceived to result from immunization. CONCLUSIONS: Both patients and chiropractors initiate discussions on immunization in practice, with many chiropractors using indirect stimuli to open the topic. Doctors of chiropractic in this particular sample were heterogeneous with respect to the information provided to patients. However, study findings may not be generalizable outside Canada.

Treatment refusal: the beliefs and experiences of Alberta nurses.

This study explored the beliefs and experiences of Alberta nurses concerning withholding and withdrawal of treatments from incurably or terminally ill patients. A mailed survey containing closed and open-ended questions was used to gather data. A response rate of 47% was achieved. The majority of respondents believed patients should legally be able to request that treatments be withheld (98%) or withdrawn (97%). More than half of the respondents had received requests from patients, families or physicians to withhold or withdraw treatments. Occasionally, nurses acted without physicians' knowledge. Three different positions with respect to decision-making in withholding and withdrawing of care, 'subordinate', 'collaborative' and 'independent', emerged from nurses' written comments on the questionnaire. Consensus among health care practitioners and consumers is critical to end-of-life decision-making.

Retrospective case analyses of two people with cancer who followed the Bill Henderson Protocol.

OBJECTIVE: To provide a retrospective case analyses of Bill Henderson Protocol adherence, a dietary cancer treatment regimen. DESIGN: Case study analysis based on the National Cancer Institute's Best Case Series approach. SUBJECTS: Using Mr Henderson's listserv (N = 31,000), members meeting certain criteria were invited to submit case documentation (diagnostic, treatment, outcome information). Ninety-two people responded. RESULTS: Two people met the Best Case criteria. Both used conventional treatment initially (surgery, radiation, chemotherapy), but later turned exclusively to the Bill Henderson Protocol. Each case perceived benefit. One person eventually passed away. The second has returned to full health. CONCLUSIONS: The 2 cases provide a preliminary, detailed description of Bill Henderson Protocol adherence. They do not provide clear evidence of the protocol's effectiveness but do suggest further research be undertaken to assess the extent to which the Bill Henderson Protocol is followed in real-world settings, including consideration of adherence, side effects, and outcomes.

Negotiating consent: exploring ethical issues when therapeutic massage bodywork practitioners are trained in multiple therapies.

INTRODUCTION: Obtaining informed consent from competent patients is essential to the ethical delivery of health care, including therapeutic massage and bodywork (TMB). The informed consent process used by TMB practitioners has not been previously studied. Little information is available about the practice of informed consent in a treatment-focused environment that may involve multiple decision points, use of multiple TMB therapies, or both. METHODS: As part of a larger study on the process of providing TMB therapy, 19 practitioners were asked about obtaining informed consent during practice. Qualitative description was used to analyze discussions of the consent process generally, and about its application when practitioners use multiple TMB therapies. RESULTS: Two main consent approaches emerged, one based on a general consent early in the treatment process, and a second ongoing consent process undertaken throughout the course of treatment. Both processes are constrained by how engaged a patient wants to be, and the amount of information and time needed to develop a truly informed consent. CONCLUSIONS: An understanding-based consent process that accommodates an acknowledged information differential between the patient and practitioner, and that is guided by clearly delineated goals within a trust-based relationship, may be the most effective consent process under the conditions of real practice conditions.

Exploring the nature of therapeutic massage bodywork practice.

BACKGROUND: Research on therapeutic massage bodywork (TMB) continues to expand, but few studies consider how research or knowledge translation may be affected by the lack of uniformly standardized competencies for most TMB therapies, by practitioner variability from training in different forms of TMB, or from the effects of experience on practice. PURPOSE: This study explores and describes how TMB practitioners practice, for the purpose of improving TMB training, practice, and research. PARTICIPANTS SETTING: 19 TMB practitioners trained in multiple TMB therapies, in Alberta, Canada. RESEARCH DESIGN: Qualitative descriptive sub-analysis of interviews from a comprehensive project on the training and practice of TMB, focused on the delivery of TMB therapies in practice. RESULTS: TWO BROAD THEMES EMERGED FROM THE DATA: (1) every treatment is individualized, and (2) each practitioner's practice of TMB therapies evolves. Individualization involves adapting treatment to the needs of the patient in the moment, based on deliberate and unconscious responses to verbal and nonverbal cues. Individualization starts with initial assessment and continues throughout the treatment encounter. Expertise is depicted as more nuanced and skilful individualization and treatment, evolved through experience, ongoing training, and spontaneous technique exploration. Practitioners consider such individualization and development of experience desirable. Furthermore, ongoing training and experience result in therapy application unique to each practitioner. Most practitioners believed they could not apply a TMB therapy without influence from other TMB therapies they had learned. CONCLUSIONS: There are ramifications for research design, knowledge translation, and education. Few practitioners are likely able to administer treatments in the same way, and most would not like to practice without being able to individualize treatment. TMB clinical studies need to employ research methods that accommodate the complexity of clinical practice. TMB education should facilitate the maturation of practice skills and self-reflection, including the mindful integration of multiple TMB therapies.

A descriptive study of chiropractors' opinions and practices regarding office-based health product sales.

BACKGROUND: Although the sale of non-prescription health products is ubiquitous, the views of health professionals, such as chiropractors, regarding the sale of such products are not well known. Practitioner opinion is important to understand and inform professional practice. The purpose of this study was to describe chiropractors' perspectives and practices on the sale of health care products from practitioners' offices. METHODS: Chiropractors were invited to provide written comments about health product sales at the end of a fixed choice, mailed survey. Respondents' comments were analyzed using qualitative description. Ethics approval was received from the Conjoint Health Research Ethics Board at the University of Calgary. RESULTS: One hundred seven of the 265 respondents (response rate of 51%) provided written comments. Approximately 30 pages of double-spaced, typed text were gathered. Respondents did not consistently endorse or condemn health product sales, and engaged in the practice to greater and lesser extents. While some were opposed to health products sales, some accepted the practice with a degree of ambivalence whereas others clearly embraced it. Some respondents acknowledged a professional conflict of interest in such sales and marketing, and described strategies used to mitigate it. Others provided a range of justifications for the practice. Personal integrity and professional standards were discussed and a need for monitoring identified. CONCLUSIONS: A wide range of opinions and practices were described and this is consistent with resulting variation in practice. In light of this, standards that facilitate consistency in practice may benefit professionals and the public alike.

No-suicide agreements: current practices and opinions in a Canadian urban health region.

OBJECTIVE: To determine the extent to which no-suicide agreements (NSAs)--one method of intervening with people at risk of suicide--are used by a population of outpatient mental health therapists in a Canadian urban health region, and to describe therapists' perceptions and practices surrounding their use. METHOD: The survey was mailed to 516 therapists, including psychiatrists, psychologists, nurses, social workers, and occupational therapists. RESULTS: Completed surveys were returned by 312 therapists (response rate = 60.5%). NSAs were used by 83%, although 43% had no formal training in their use. Among those who had used NSAs, 31% reported having had at least one patient attempt or complete suicide while an agreement was in place. Therapists from nonmedical disciplines were most likely to have used these agreements. Most therapists believed NSAs communicated care and concern to patients. Respondents were divided in their perceptions of whether NSAs afforded liability protection in the event of a patient suicide. Contextual factors associated with the perceived degree of suicide risk, the patient-therapeutic relationship influenced a therapist's use of NSAs. Most therapists attempted to have patients admitted to hospital if the patient refused to enter into an NSA. CONCLUSIONS: Use of NSAs is prevalent in this population of outpatient psychotherapists, suggesting that these therapists believe they are a useful intervention in the management of suicidal patients. Practitioners might benefit from increased formal training opportunities in the use and legal implications of NSAs.