Significance of the study

This research is significant due to the prevalent issue of polypharmacy and its potential negative consequences. Firstly, it addresses a research gap regarding healthcare providers’ understanding and attitudes towards psychiatric polypharmacy, an area with limited data despite involving high-risk patient groups. Secondly, understanding provider perspectives is essential for developing tailored educational programs, policies, and clinical guidelines aimed at improving medication safety, adherence, and patient outcomes. Lastly, by identifying factors influencing prescribing choices—such as experience, training, institutional culture, and views on mental illness—this study can help create interventions to reduce inappropriate polypharmacy and enhance psychiatric care.

Study aim and research questions

Aim: To assess healthcare providers’ knowledge and attitudes regarding polypharmacy in psychiatric settings and explore the factors influencing prescribing behaviors and interprofessional collaboration.

Research design

This study employed a convergent mixed-methods design, in which quantitative and qualitative data were collected concurrently, analyzed separately, and subsequently integrated to provide a comprehensive understanding of polypharmacy practices in psychiatric care. While previous research has examined healthcare providers’ knowledge and attitudes regarding psychiatric polypharmacy, a mixed-methods approach is essential to:

1. Explore underlying reasons, clinical reasoning, and contextual factors influencing prescribing practices.
2. Enhance validity through triangulation, confirming findings across quantitative and qualitative datasets.
3. Examine cultural and institutional factors, such as stigma and organizational norms, which may affect prescribing decisions.
4. Inform the development of targeted interventions and policies to optimize medication management and patient outcomes.

Although previous research has offered insight into the knowledge and attitudes of healthcare providers regarding psychiatric polypharmacy, a mixed-methods design is required to explore the underlying reasons, clinical reasoning, and contextual factors that may contribute to prescribing practices [27]. The integration of qualitative and quantitative data also improves validity by triangulation to confirm findings, increasing the credibility and depth of the study [28]; permits the examination of contextual and cultural factors, such as stigma and institutional norms, that can influence prescribing decisions in psychiatric care [29]; and allows the development of targeted interventions and policies to better manage medications and ultimately patient outcomes [30].Therefore, the mixed-methods approach is not only appropriate but necessary to comprehensively address the research questions and contribute meaningful insights to the field.

The integration of multiple perspectives from psychiatric nurses, psychiatrists, and pharmacists, ensures a more nuanced understanding of polypharmacy practices, beyond what single-method studies can provide.

This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting observational studies [31]. Qualitative components were informed by the Consolidated Criteria for Reporting Qualitative Research (COREQ) [32], and sex and gender reporting followed the Sex and Gender Equity in Research (SAGER) guidelines [33]. A completed STROBE checklist is provided as a supplementary file to ensure transparency and methodological rigor.

Setting

The study was conducted at the Erada Complex for Mental Health and Addiction in Jeddah, Saudi Arabia—a Ministry of Health facility serving patients from Jeddah and neighboring regions (Makkah, Taif, and Alkonfedah). The complex includes six inpatient wards, six outpatient clinics, a 24-hour emergency unit, and serves as a teaching hospital for healthcare trainees.

Participants

The study included psychiatrists, psychiatric nurses, and pharmacists who were actively engaged in patient care and medication management. Participants were required to possess valid professional licenses and practical experience in prescribing, dispensing, or overseeing psychiatric medications. Although the initial recruitment strategy broadly considered other mental health professionals and psychiatric patients, these groups were excluded from the final analysis because of the study’s specific focus on medication-related decision-making among key prescribing and medication-management professionals. Patient participants were included only in the qualitative exploratory phase when relevant, provided that they were clinically stable, compliant with treatment, and capable of effective communication. Individuals exhibiting acute psychotic symptoms or significant communication challenges were excluded. Data collection was conducted from February 3–1^st of May 2025.

Sampling and recruitment

Based on a total population of approximately 250 healthcare professionals, a minimum sample of 152 participants was required, calculated at a 95% confidence level with a 5% margin of error. Additionally, an a priori power analysis was conducted using G Power (version 3.1), assuming a medium effect size (f² = 0.15), an alpha level of 0.05, a power of 0.80, and up to 10 predictors in a multiple regression analysis, which indicated a minimum sample size of 118. The larger sample size (n = 152) was retained to ensure sufficient power and enhance generalizability.

A stratified purposive sampling approach ensured representation across the professional roles. For the qualitative phase, recruitment continued until thematic saturation was reached, meaning that no new themes emerged.

Note on bias: Although purposive sampling may introduce selection bias, it was essential to ensure that the participants had relevant expertise in psychiatric polypharmacy. This limitation is explicitly acknowledged and discussed in this manuscript.

A flow diagram illustrating participant recruitment, inclusion, and completion is shown in Fig 1. The consort flow diagram shows the purposive sampling technique used to recruit psychiatrists, nurses, and pharmacists with direct experience in psychiatric medication management. While this approach ensured the inclusion of knowledgeable participants, it may have introduced selection bias and limited generalizability. To mitigate this, efforts were made to include diverse healthcare professionals (psychiatrists, pharmacists, and nurses) with varying levels of experience and roles in the study. Nonetheless, the findings should be interpreted within the context of this non-probability sampling approach.

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Fig 1. Consort flow diagram of sample recruitment N = 221.

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Recruitment was facilitated by the research team, in collaboration with the department heads, distributed study invitations to eligible participants. The inclusion criteria required at least six months of experience in psychiatric care. For the qualitative component, recruitment continued until data saturation was reached, meaning that no new themes emerged. The total number approached, those who consented, and those included in the final analysis will be reported to ensure transparency [9,10].

Self-reporting and bias mitigation

A major limitation of the knowledge assessment is its reliance on participants’ self-reported knowledge, which is inherently subjective and may not fully reflect actual prescription practices. To mitigate this limitation, this study incorporated a qualitative component alongside the quantitative survey. Semi-structured interviews allowed participants to describe their clinical reasoning, decision-making processes, and real-world experiences in managing psychiatric polypharmacy, and the integration of quantitative and qualitative findings provided a more comprehensive understanding of polypharmacy practices. While quantitative results indicated high knowledge and generally positive attitudes, qualitative data clarified the reasons behind these patterns. For example, pharmacists demonstrated moderately high knowledge scores and cautious yet supportive attitudes toward polypharmacy in the quantitative analysis, which was explained qualitatively by their emphasis on medication safety, drug interaction monitoring, and participation in multidisciplinary discussions. Similarly, although psychiatric nurses had comparatively lower knowledge scores, qualitative findings revealed that this was linked to limited exposure to prescribing guidelines and pharmacological decision-making rather than a lack of competence, as many nurses emphasized their need for continuous training and their primary role in medication administration and patient monitoring. In addition, the positive attitudes observed among frequent prescribers were contextualized by qualitative insights, indicating that such attitudes were driven by experience with complex, treatment-resistant cases requiring combination therapy. This triangulation demonstrates how qualitative themes directly inform the interpretation of quantitative scores, thereby enhancing the validity and depth of the findings [10,33].

While qualitative insights cannot eliminate self-report bias, they enhance the credibility and interpretive accuracy of the findings by revealing practical and nuanced information that surveys alone cannot capture. Additionally, anonymity was maintained in the survey responses to reduce social desirability bias.

Content validation

Content validity was established through review of the preliminary draft by a panel of five experts (two psychiatric nursing professors, two psychiatrists, and one clinical pharmacist), who rated each item for clarity, relevance, and representativeness using a four-point scale, with a mean Content Validity Index (CVI) of 0.92, indicating excellent agreement among reviewers [35]. The instrument was further refined and reduced to 25 items based on expert feedback to improve clarity and conceptual alignment.

Translation and pilot testing

The tool was then translated into Arabic using a forward–backward translation process to maintain linguistic and conceptual equivalence. A pilot study was conducted with 15 healthcare providers to assess the clarity, comprehension, and cultural appropriateness of the items, and minor revisions were made based on feedback to improve readability and face validity.

Construct validity and reliability

Exploratory Factor Analysis (EFA) with principal component extraction and varimax rotation was conducted to test construct validity, which indicated a four-factor solution (67.8% of total variance) consistent with conceptual domains identified during development, and Cronbach’s alpha was 0.91 (excellent reliability), with subscale alphas ranging from 0.81 to 0.89 (strong internal consistency) [36]. However, confirmatory factor analysis (CFA) was not performed; therefore, the factor structure should be interpreted with caution, and further validation is warranted.

Scoring and interpretation

The final version of the PKAT consists of 25 items divided into the five domains mentioned above. Total scores are converted to a 0–100 scale and are interpreted as follows: •0–25: Low knowledge — further education strongly recommended•26–50: Moderate knowledge — basic understanding present, improvement needed•51–75: High knowledge — strong awareness of polypharmacy principles•76–100: Excellent knowledge — well-versed in clinical application of polypharmacy practices

On summary The PKAT underwent extensive development, expert review, translation, pilot testing, and psychometric evaluation and demonstrated strong content and construct validity and excellent internal consistency, thereby demonstrating that it is a reliable and valid tool for measuring the knowledge of healthcare providers on psychiatric polypharmacy in clinical and research contexts.

1. III. The Multidimensional Attitudes Toward Polypharmacy Scale (MAPS) developed by Köhler et al. in 2018 [36], provides a structured framework for assessing healthcare providers’ perspectives on polypharmacy. This scale evaluates multiple dimensions, including perceived necessity, concerns about adverse effects, and attitudes toward deprescribing, offering valuable insights into prescribing behaviors and medication management strategies. The scale is a 15-item instrument designed to evaluate healthcare providers’ attitudes toward polypharmacy. It assesses three key dimensions: (1) Perceived Necessity of Polypharmacy, which measures the belief that multiple medications are essential for effective treatment; (2) Concerns About Polypharmacy, capturing worries about potential risks like adverse drug interactions; and (3) Willingness to Deprescribe, reflecting openness to reducing or stopping unnecessary medications. Responses are rated on a 5-point Likert scale from 1 (Strongly Disagree) to 5 (Strongly Agree). Higher scores indicate stronger beliefs in the importance of polypharmacy or, in the case of concerns, greater apprehension about its risks. The MAPS has demonstrated strong psychometric properties, including good internal consistency, with reliability coefficients (Cronbach’s alpha) reported above 0.80, and solid construct validity, making it a reliable and valid tool for assessing healthcare providers’ views on polypharmacy.

MAPS translation & cultural adaptation

The MAPS instrument underwent translation and cultural adaptation using standard forward–backward translation methods in Brazil. Initially, two independent bilingual experts translated the original English version into Arabic. This was followed by creating a reconciled version, which was then back-translated into English by two independent translators who were unaware of the original instrument. An expert panel, including specialists in psychiatry, mental health nursing, and clinical pharmacy, reviewed the back-translated version to ensure that it maintained semantic, conceptual, and content equivalence. Cultural adaptation was evaluated through expert review and pilot testing with a small group of healthcare professionals (n = 15) from the target population. Feedback was gathered on the clarity, relevance, and cultural appropriateness of each item. Minor adjustments were made to ensure contextual suitability without changing the original meanings of the items. This process confirmed the validity and reliability of the adapted instrument for use in the Saudi psychiatric setting.

Data collection procedure

1. Quantitative Data Collection:
   • After receiving approvals from KAIMRC, the Ministry of Health IRB, and the Erada complex management, validated attitude and knowledge scales were converted into a Google Form and distributed electronically to healthcare providers (nurses, pharmacists, and physicians) working at the Erada complex for addiction and mental health.
   • AThe Google Form collected demographic information and responses to standardized knowledge and attitude scales regarding polypharmacy, including open-ended questions for qualitative insights.
   • ADistribution was managed to maximize participation, and reminders were sent to ensure adequate response rates. The recruitment of participants and data collection process for this study began on 03/02/2025 and ended on 01/05/2025.
2. Qualitative Data Collection Procedure Discussion Guide:

The interviews examined healthcare providers’ views on polypharmacy, including their understanding of it, their confidence in prescribing multiple medications, and related clinical issues. Participants talked about the benefits and risks of polypharmacy, how they explain treatment plans, times when patients resisted, and what training they need. The interviews also covered teamwork between professionals and gathered ideas for improving the system.

A pilot focus group interview was held with three participants, one from each professional group in the study: nurses, physicians, and pharmacists. This assessed whether the discussion guide was clear, relevant, and useful. After improvements, four more focus group discussions were held using the updated guide. Participants were recruited in accordance with ethical guidelines, and recruitment continued until no new themes emerged. To fit participants’ schedules and preferences, semi-structured individual interviews were arranged. Nurses were interviewed in private rooms at their workplace. Physicians and pharmacists joined via Zoom. Each session began with ice-breaker activities, followed by open-ended questions about healthcare providers’ experiences, attitudes, challenges, and teamwork in managing polypharmacy.

Researchers used active listening and follow-up questions to help participants share detailed answers and explore their views more deeply. Each interview lasted 30–60 minutes and ended with a summary to ensure participants’ responses were accurate and complete. The interview guide had four parts: warming up, which explained the study and obtained consent; engagement, with introductory and ice-breaker questions; exploration, covering attitudes, challenges, and working with other professionals; and wrapping up, with a summary and closing remarks.

The interview guide had several steps. It began with a warm-up to explain the study’s purpose and collect both verbal and written consent. Next came questions to engage participants, followed by deeper questions about attitudes, challenges, and teamwork. The interview concluded with a summary and an opportunity for participants to share any final thoughts. All interviews were audio recorded and stored securely. Researchers also took notes on the setting and nonverbal cues.

The study used several methods to make sure the results were reliable and trustworthy. Credibility was improved by spending more time with participants, using different sources of information, and checking findings with participants. Detailed descriptions of the setting and participants helped others see if the results apply elsewhere. The research process was carefully documented to ensure dependability, and researchers kept journals to reduce bias and support confirmability.

Ethical considerations

Ethical approval for the study was formally secured from the Institutional Review Board (IRB) at King Abdullah International Medical Research Center (KAIMRC), part of the National Guard Health Affairs in Jeddah, Saudi Arabia (Ref. No: A02115). Further authorization was obtained from the Research Unit at the College of Nursing in Jeddah, and permission to carry out the research was granted by the Saudi Arabian Ministry of Health and the administration of the Erada Complex for Addiction and Mental Health Hospital. Before participating, all individuals were thoroughly informed about the study’s aims, procedures, and their rights. Participation was voluntary, and participants were informed that they could opt out at any time without repercussions. Informed consent was obtained from all participants, both in writing and verbally, prior to data collection. For those who completed the survey online, consent was recorded via a secure digital form, while participants interviewed face-to-face signed written consent forms in the researcher’s presence. Anonymity and confidentiality were rigorously upheld; no personal identifiers were collected, and all data were securely stored, accessible only to the research team. The study adhered to the Declaration of Helsinki (2013 revision) and followed the ethical guidelines set by the Saudi Ministry of Health and KAIMRC for research involving human subjects.

Data management and analysis plan

Data analysis incorporated both quantitative and qualitative methods. SPSS statistical software version 29.0 was used for the analysis. Categorical variables were described using frequencies and percentages, and continuous variables, such as knowledge and attitude scores regarding polypharmacy, were summarized using means and standard deviations. The Pearson correlation coefficient was used to assess the relationship between the knowledge and attitude scores. A multivariate analysis of variance (MANOVA) was performed to identify the factors influencing knowledge and attitudes toward polypharmacy. Significant predictors of overall knowledge and attitudes were examined using binary logistic regression. Statistical significance was set at p ≤ 0.05.

The quantitative aspects of the study were documented in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [37] guidelines, ensuring transparency, methodological rigor, and comprehensive reporting in observational research. For the qualitative aspect, thematic analysis was conducted using Braun and Clarke’s [38] six-phase framework, which involves familiarizing oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the final report. An inductive coding approach was used, with two researchers independently conducting the coding to enhance the credibility and minimize bias.

To ensure rigor and transparency in qualitative reporting, this study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [39] guidelines. These standards guided the reporting of the research team’s characteristics, study design, data analysis procedures, and findings to ensure methodological trustworthiness. A coding framework (codebook) was developed to guide thematic analysis, incorporating both inductive codes derived from the data and concept-driven categories aligned with the study objectives and theoretical framework. Codes were organized into themes and subthemes reflecting healthcare providers’ knowledge, attitudes, decision-making processes, professional roles, and system-level influences on polypharmacy. The coding framework was iteratively refined through discussion between two independent researchers to ensure consistency and reliability. A summary of the coding framework is provided in (Supplementary S File [5].

The qualitative themes centered on healthcare providers’ attitudes, clinical experiences, and perceived challenges related to polypharmacy in psychiatric settings. During the interpretation phase, quantitative and qualitative findings were integrated using a mixed-methods triangulation approach. The quantitative results (knowledge and attitude scores) were aligned with the qualitative themes to provide a more comprehensive understanding of prescribing behaviors, decision-making processes, and interprofessional differences in psychiatric polypharmacy.

Quantitative part

Table 1 summarizes the demographic characteristics of the 221 healthcare providers in the study. The participants are relatively young, with a mean age of 35.9 years (SD = 7.7), and predominantly male (60.2%). Psychiatric nurses constitute the largest professional group (71.5%), followed by psychiatrists (14.5%) and pharmacists (14.0%). Regarding psychiatric experience, 36.2% have over 10 years, 27.6% have 6–10 years, 23.5% have 1–5 years, and 12.7% have less than 1 year. Most work in inpatient male psychiatric units (41.2%), outpatient mental health care (20.8%), or inpatient female psychiatric units (11.8%). Educationally, nearly half hold diplomas (47.5%), 39.8% have bachelor’s degrees, and smaller proportions hold master’s (6.8%) or PhD degrees (5.9%). Most (71.5%) lack additional psychopharmacology training, though the majority feel confident managing polypharmacy—43.9% very confident and 38.5% somewhat confident. A large majority frequently prescribe multiple medications, with 38% always and 45.7% often doing so. Most providers primarily care for adults (87.8%), with fewer focusing on geriatrics (6.8%), adolescents (3.6%), or children (1.8%). Overall, the cohort is experienced, mostly male psychiatric nurses focused on adult care, with many lacking specialized psychopharmacologies training but generally confident in their prescribing practices, which often involve polypharmacy consistent with their patient population’s needs

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Table 1. distribution of the participants according to their Demographic data (N = 221).

https://doi.org/10.1371/journal.pone.0327104.t001

Table 2 shows that psychiatrists achieved the highest knowledge scores, averaging 84.2 ± 11.0, with pharmacists scoring 81.5 ± 10.0 and psychiatric nurses at 79.5 ± 9.8. This difference was statistically significant (p = 0.044). In terms of attitude scores, psychiatrists again led with an average of 3.79 ± 0.49, followed by pharmacists at 3.69 ± 0.48 and psychiatric nurses at 3.63 ± 0.49, though this variation was not statistically significant (p = 0.367). These findings underscore a notable disparity in knowledge levels among different roles, especially highlighting the gap for psychiatric nurses.

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Table 2. Differences in total knowledge and attitude scores toward polypharmacy in psychiatry by professional role (N = 221).

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Fig 2 displays the enhanced box plots, which incorporate knowledge level thresholds and depict the distribution of knowledge scores on polypharmacy among the different professional groups. Overall, participants mostly displayed high to comprehensive knowledge levels, with most scores concentrated above the 75-point mark. Psychiatrists had the highest central tendency (median = 85, mean = 84.6 ± 11.2), followed by pharmacists (median = 82, mean = 81.6 ± 11.6) and psychiatric nurses (median = 80, mean = 80.2 ± 11.4). Despite these differences, the interquartile ranges showed significant overlap across all groups, suggesting that the distribution of the knowledge scores was broadly similar.

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Fig 2. Total knowledge score about polypharmacy among health care professionals.

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The variability in the scores within each group was moderate, with no extreme outliers significantly affecting the overall trend. The distribution of knowledge-level bands showed that most participants were in the “comprehensive” range (76–100), a smaller number were in the “high” range (51–75), and none were in the low or moderate ranges. An inferential analysis using the Kruskal–Wallis’s test found no statistically significant differences in knowledge scores among psychiatrists, pharmacists, and psychiatric nurses (H (2) = 4.42, p = 0.110), suggesting similar knowledge levels across these professional groups.

Table 3 illustrates the understanding of polypharmacy in psychiatry among psychiatrists, nurses, and pharmacists (N = 221). On average, scores are high (3.7–4.45), suggesting a solid grasp of polypharmacy concepts, associated risks, and management strategies across these professional groups. Psychiatrists typically achieved slightly higher scores than nurses and pharmacists, this difference was statistically significant (p = 0.044), indicating variability in knowledge levels across professional groups. The highest scores were recorded for items focusing on regular medication reviews, patient involvement, and side effect reporting, indicating a strong acknowledgment of monitoring and patient-centered practices. Conversely, lower scores were found in areas like cognitive impairment risks, knowledge of deprescribing strategies, and awareness of clinical guidelines, pointing to possible knowledge gaps. The overall similarity in scores among the roles (p > 0.05 for most items) suggests consistent knowledge levels, while also highlighting the need for targeted continuing education and improved interprofessional collaboration to enhance polypharmacy management in psychiatric care. Given the significant overall difference observed for Item #1 (understanding of polypharmacy), Bonferroni-adjusted post-hoc pairwise comparisons were conducted. The results indicated that psychiatrists had significantly higher scores than psychiatric nurses (p < 0.05), while no statistically significant differences were found between psychiatrists and pharmacists or between pharmacists and nurses.

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Table 3. Knowledge scale of polypharmacy in psychiatry by professional group (N = 221).

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Table 4 presents the perspectives of healthcare providers, including psychiatrists, nurses, and pharmacists (N = 221), on the practice of prescribing multiple psychiatric medications. The average scores, ranging from 1.95 to 4.35, indicate a generally favorable view of polypharmacy when deemed clinically necessary. Psychiatrists tend to show slightly more confidence and support for the benefits of using multiple medications, particularly in enhancing cognition, preventing relapses, and maintaining patient functionality (means 4.15 ± 4.35). However, these differences are not statistically significant (p < 0.05). Concerns about over-sedation or unnatural effects are moderate (means 3.8 ± 4.05), while worries about fatigue or sluggishness are low (means 1.95 ± 2.00), suggesting that most providers consider these side effects infrequent or less significant. Overall, the findings indicate a cautious yet generally supportive stance on polypharmacy, emphasizing the importance of careful clinical judgment, symptom management, and patient well-being, with minimal variation across different professional roles.

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Table 4. Adapted DAI-10 attitudes toward polypharmacy by professional group (N = 221).

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Table 5 displays the MANOVA analysis, revealing the key factors influencing healthcare providers’ knowledge and attitudes toward psychiatric polypharmacy. Prior to regression analysis, Pearson correlation analysis showed a statistically significant positive correlation between overall knowledge and attitude toward polypharmacy (r = 0.653, p < 0.001; N = 221). Knowledge was significantly influenced by education (F = 10.506, p = 0.001, ŋp² = 0.048), confidence in managing polypharmacy (F = 27.300, p = 0.001, ŋp² = 0.115), and frequency of prescribing multiple medications (F = 33.299, p = 0.001, ŋp² = 0.137), indicating that providers with higher education levels, greater confidence, and more frequent prescribing practices demonstrated stronger knowledge. On the other hand, attitudes were significantly affected by age (F = 6.944, p = 0.009, ŋp² = 0.032), years of experience (F = 4.933, p = 0.027, ŋp² = 0.023), and the frequency of prescribing multiple medications (F = 21.826, p = 0.001, ŋp² = 0.094), suggesting that older and more experienced providers, as well as those with higher prescribing frequency, held more defined attitudes toward polypharmacy. Other variables, including gender, professional role, work setting, and psychopharmacology training, did not significantly impact knowledge or attitudes. These findings highlight that confidence and clinical practice patterns play a critical role in enhancing knowledge, whereas age and experience significantly shape healthcare providers’ attitudes toward psychiatric polypharmacy.

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Table 5. Multivariate analysis of variance (MANOVA) of polypharmacy knowledge and attitude by participant characteristics (N = 221).

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Fig 3 displays the forest plot emphasizing the main factors influencing healthcare providers’ views on psychiatric polypharmacy. Being 35 years old or older was associated with notably less positive attitudes (OR = 0.36, 95% CI: 0.14–0.89), whereas possessing a PhD (OR = 8.00, 95% CI: 1.26–14.5) and routinely prescribing various medications (OR = 5.02, 95% CI: 2.04–12.5) were linked to more positive attitudes. Other elements like gender, professional position, psychiatric experience, work environment, and self-assurance were not important predictors. In general, the level of education and prescribing practices seem to be the key factors influencing attitudes.

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Fig 3. Forest plot of all predictors factors affecting the knowledge and attitudes of participants.

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Fig 4 shows a forest plot of demographic factors associated with attitudes toward polypharmacy. The results indicate that being 35 years or older was a significant predictor of a more favorable attitude toward polypharmacy (OR = 1.45, 95% CI: 1.05–2.00), since the confidence interval did not include 1. However, female gender and having at least 10 years of professional experience were not significant predictors, as their confidence intervals included 1. Overall, these results suggest that older age was the only significant demographic factor related to a more favorable attitude toward polypharmacy.

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Fig 4. Forest plot of demographic predictors of attitudes toward polypharmacy.

https://doi.org/10.1371/journal.pone.0327104.g004

Thematic analysis of psychiatric nurses, pharmacists, and psychiatrists’ perspectives on polypharmacy

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https://doi.org/10.1371/journal.pone.0327104.t007

Strengths

This study had several notable strengths. First, this is the first regional study in Saudi Arabia to examine healthcare providers’ knowledge, attitudes, and practices toward psychiatric polypharmacy, addressing a critical gap in the literature. Second, the use of a convergent mixed-methods design allowed for a comprehensive understanding by integrating quantitative and qualitative data. Third, the inclusion of psychiatrists, nurses, and pharmacists offered diverse multidisciplinary insights into polypharmacy management. Fourth, this study emphasized the essential role of psychiatric nurses, who are often central to daily medication management, highlighting their impact on patient care. Finally, analyzing the link between knowledge and attitudes provided valuable insights into how education and clinical experience shape decision-making regarding psychiatric medication use.

Limitations

Although this study offers valuable insights, it has several limitations. First, the generally high knowledge and attitude scores suggest a possible ceiling effect, limiting the sensitivity to detect stronger differences between groups. Second, self-reported measures may introduce social desirability bias, particularly among health care professionals. Third, the observed intergroup differences were modest and should not be interpreted as strong categorical distinctions. Furthermore, although the Polypharmacy Knowledge Assessment Tool (PKAT) showed good internal consistency and initial construct validity through exploratory factor analysis, the lack of confirmatory factor analysis and the small pilot sample size limit the robustness of its psychometric validation. Additionally, the absence of previous regional data on psychiatric polypharmacy practices made it challenging to determine whether the observed patterns were influenced by the workplace environment or broader professional standards. Further research is necessary to verify its factor structure and relevance in larger population samples. These limitations highlight the need for future longitudinal studies to address these issues. Therefore, any conclusions about clinical behavior should be approached with caution, and multicenter studies are needed to enhance the understanding of changing clinical practices.

Recommendations and implications of the study

This study suggests that improving knowledge and interprofessional collaboration may support more informed clinical decision-making; however, further research is needed to evaluate their impact on actual prescribing practices. Therefore, recommendations are divided into three main categories: policy and institutional, educational and training, and research implications.

Research recommendations

Future research should employ longitudinal and multi-center study designs to investigate how healthcare providers’ knowledge, attitudes, and clinical practices related to polypharmacy evolve over time and across various healthcare settings. Studies are also needed to evaluate the effectiveness of structured educational programs in enhancing theoretical understanding and real-world prescribing behaviors among different professional groups.

Furthermore, research should explore the impact of organizational factors—such as hospital environment, institutional policies, and workload distribution on the safe management of psychiatric polypharmacy. Finally, demographic characteristics, including age, educational background, and clinical experience, should be examined to identify predictors of attitudes and practices, facilitating the development of tailored interventions that promote safe and effective medication use.