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12070
Susanne van den Hooff MSc, LLM (PhD Candidate)1 and Anne Goossensen MSc, PhD (Endowed Professor)2
1
Cluster Management, Inholland University of Applied Sciences, MER, Alkmaar, The Netherlands and 2Presence and Mental Health Care,
University of Humanistic Studies, Utrecht, The Netherlands
Scand J Caring Sci; 2014; 28; 425–434 nursing home, coercion and factor. Finally, twenty-two
articles were included and analysed out of 1216.
How to increase quality of care during coercive
Results and conclusion: Articles were divided between
admission? A review of literature
those describing themes from patients’ perspective and
articles describing themes from professionals’ perspective.
Background: Involuntary admission is still raising in num- Findings show that most experiences of patients can be
bers and as a procedure a widely discussed subject from traced back to one core experience: not being listened to
ethical point of view. A common dilemma is the tension or listened to. When patients experience being listened to
between individual freedom and the need to protect the genuinely, they feel more respected as a human being.
patient. Patients who are coerced during the admission The challenge for the professional carer seems to explic-
process often report negative feelings or trauma. Finding itly pay attention and stay in touch with the patients’
out quality issues remains a challenge for providing good emotional struggles while making the necessarily decision
care during coercive admission. to admit the patient to prevent harm. Quality of care
Aim: This study aims to explore themes from patients’ during coercive admission improves when professionals
and professionals’ perspectives within scientific literature are able to do justice to both inside and outside perspec-
on involuntary admission. tives simultaneously.
Methods: A literature review of English articles using Aca-
demic Search Elite, Cinahl, Medline, PubMed and Social Keywords: literature review, experiences, long-term
Science Journals for the period 1995–2012 was conducted. care, quality of care, involuntary admission, ethics of
Additional studies were identified using the National Cen- care.
tre for Biotechnology Information (NCBI). Search terms
included involuntary, hospitalisation, ethical, admission, Submitted 8 May 2013, Accepted 23 July 2013
Anderson et al. 24 clinicians (5 To learn more about the A psycho-phenomenological Nine essential structural
(19)/USA psychiatrists, 5 actual process of clinical study. Interviews elements of the
registered nurses and decision-making during decision-making
14 counsellors) assessment for involuntary process: systematic
psychiatric admission. and individualised
process, state
mandated criteria,
investigation of
alternatives, decision
not made alone,
intuitive reasoning,
connection with the
client, caution, and
nability to control
all contingencies
Bennet et al. 157 admitted patients to To attend to patients Semi-structured interviews Inclusion in the process
(20)/USA a psychiatric hospital perceptions of the morality of the admission
(70 transcripts) of attempts by others – Degree of concern
primarily family members, Behave honestly and
friends and mental health openly
professionals – to influence
them to be admitted to the
hospital
Bonsack & Borgeat 87 admitted patients To assess the subjective A cross-sectional Social pressure from
(9)/Switserland (34% involuntary perception of psychiatric questionnaire survey family, friends or
admitted) admission by patients while clinicians
still in hospital
Cascardi et al. 120 admitted patients at To evaluate the admission Semi-structured interview Legal status
(21)/USA mental health centres process and pressures (Mac Arthur Admission (involuntary)
(voluntary n = 60 and experienced during Experience interview); locus Procedural justice
involuntary n = 60) admission and the of control (LOC) self-report Negative pressures
contribution of locus of measure and Brief
control and psychiatric Psychiatric Rating Scale-
symptom severity Anchored Version (BPRS-A)
Hiday et al. 331 involuntary admitted To develop a better Interviews in the hospital, Expectation levels
(22)/USA severely mentally ill understanding of coercion which included a diagnostic Having reference
patients in the hospital admission assessment, measures of groups awareness
process health and mental health of the use of
functioning and 15 coercion and any
true–false items of the deprivation in
MacArthur Interpersonal autonomy
Relations Scale
Hoge et al. 157 admitted patients To study patients Structured interview, the Procedural justice
(6)/USA perceptions Admission Experience Experiences of
of coercion Interview negative pressures
(threats and force)
Hoge et al. 27 newly admitted To study perceptions of Semi-structured interview Degree of procedural
(23)/USA psychiatric patients, 15 coercion in Mental (Mac Arthur Admission justice Legal status
clinicians and 12 family Hospital Admission Experience interview) Negative pressures
members
Table 1 (Continued)
Iversen et al. 223 admitted patients To investigate perceived Quantitative study: semi- Perception of negative
(7)/Norway (voluntary n = 73; coercion among patients structured interview and pressures Process
involuntary n = 150) admitted to acute wards in two instruments measuring exclusion
Norway perceived coercion (AES and
CL); statistical analysis
Jepsen et al. 13 Danish General To explore GP’s experiences Qualitative descriptive GP’s experienced
(24)/Denmark Practitioners from participating in analysis. One focus group involuntary admissions
involuntary admission interview and six individual as unpleasant,
interviews stressful and
time-consuming Not
taken seriously
Feelings of
satisfaction when
administering the patient
help that was needed
and handling the situati
on correctly
Johansson & 5 involuntary To obtain a deeper Phenomenological Being restricted in
Lundman hospitalised understanding of the hermeneutic method. autonomy being
(25)/Sweden psychiatric patients experience of being Narrative method violated by intrusion
subjected to involuntary on physical integrity
psychiatric care and human value
being outside and not
seen or heard being
respected as an
individual being
protected and cared for
Katsakou et al. 59 patients To explore involuntary Grounded theory and Feelings of powerlessness
(26)/England involuntary patients’ retrospective views thematic analysis. and lost control over
admitted on why they perceived their In-depth interviews. their lives feeling forced
hospitalisation as right or to comply with
wrong professionals’ decisions
Keown et al. To examine the rise in the Ecological analysis of Closure of mental illness
(3)/England rate of involuntary publicly available beds
admissions for mental administrative
illness. data.
Lidz et al. 171 admitted To predict patients’ Semi-structured interview Feelings of force and
(27)/USA patients perceptions of coercion (Mac Arthur Admission negative symbolic
surrounding admission to Experience interview) pressures (threats and
a psychiatric hospital. giving orders)
The process of
procedural justice
Community culture
plays a role
Luchins et al. 432 psychiatrists To examine whether Mailed survey Own responsibility for
(28)/USA psychiatrists’ attributions of both the onset and
responsibility for mental recurrence of their
illnesses affect their condition Severity of
decisions about involuntary the risk of harm
hospitalisation. Psychiatric diagnosis
Conviction of
effectiveness of treatment
Table 1 (Continued)
Mc Kenna et al. 138 patients (69 To understand patient Validated psychometric Feelings of loss of autonomy
(29)/New Zealand involuntary patients and perception of coercion. measure of patient Perception of threat and
69 voluntary patients) perception of coercion force Feelings of anger
within the Mac Arthur perception of procedural
Admission Experience justicea
Survey. Multiple stepwise
linear regression analysis.
Ng & Kelly 446 patients (voluntary To develop a better Retrospective three-year High rates of deprivation
(34)/Ireland n = 379 and understanding of certain period study Unmet forensic mental
involuntary n = 67) diagnostic or demographic health Social isolation or
correlated of psychiatric stressors may play a role
admission status
O’Donoghue et al. 81 involuntary To investigate people’s Semi-structured interview Insight into their illness
(30)/Ireland admitted patients perception of the and the Scale to Assess
involuntary admission Unawareness of Mental
and awareness of legal Disorder (SUMD)
rights and perception of tribunal.
O’Donoghue et al. 81 involuntary To determine the level of Semi-structured interview Level of respect and
(31)/Ireland admitted procedural justice (Mac Arthur Admission dignity
patients experienced by individuals Experience interview) and
at the time of involuntary an insight scale.
admission and whether this
influenced further
engagement with the
mental health services.
Olofsson & 18 involuntary To describe involuntary Qualitative descriptive– Being respected as a
Jacobsson hospitalised hospitalised psychiatric explorative study: narrative human being Presence
(32)/Sweden psychiatric patients ‘narrated approach. Domain analysis
patients experience of coercion. and thematic analysis.
Sibitz et al. 15 involuntary To establish a typology of A qualitative design drawing Physical restraint and/or
(8)/Austria admitted coercion perspectives and on a modified grounded forced medication Feelings
patients styles of integration into life theory. In-depth semi- of humiliation, disrespect,
story structured interviews helplessness and being
alone
Svindseth et al. 102 admitted To examine patients Qualitative interviews, the Humiliation experience that
(33)/Norway psychiatric experiences of humiliation AES questionnaire and the the admission was not right
patients (involuntary in the admission process to Cantrill Measure Ladder. exposed to force treated in
n = 35; voluntary two acute wards of a Regression analysis. a respectful manner/treated
n = 67) psychiatric clinic at a county as inferior persons the way
hospital. doctors and health workers
listened and responded
Wynn et al. 340 psychologists To examine the choices Questionnaire involving three Violence to others
(17)/Norway psychologists make when cases of patients suffering Patients obvious suffering
asked to decide whether from schizophrenia.
coercion should be used.
a
How much voice a patient has in the decision-making process.
helplessness or insecure (25). Patients felt not being receiving sufficient information and not being involved
allowed to decide what to do and where to be. They in decisions (26).
received a treatment not agreed to (25). They felt not Another important negative experience was humilia-
being listened to and not being heard (32). Patients felt tion. Patients felt not being treated as human beings or
out of control during their hospitalisation due to not having the same human value as healthy persons (25).
Patient Being powerless (25, 26, 32) Being guarded (8, 25, 32) Pressure (6, 7, 9, 20–22, 27, 29, 33)
Loss of Autonomy (29)
Being humiliated (8, 25, 32) Being seen (8, 25, 32) Procedural Justice (6, 7, 20, 22, 23, 29, 31)
Respect (21, 31)
Professional Being stressed (24) Being satisfied (24) Attitudes (17, 21, 28)
Connectedness (19) Admission criteria (3, 9, 17, 28, 31, 34)
They wanted to be seen as individuals. Being dependent involved in the admission process (29). Or as explained in
on healthcare professionals and health care increased another study ‘the challenge is to try to extend to all
experiences of vulnerability (25). Patients felt like an patients, at the time of their admission, a demonstration in
inferior kind of human being. Not being involved in deci- word and action that they are persons with opinions,
sions was experienced as meaningless and not satisfying desires, rights and dignity’ (22). Professionals should mini-
their needs (25, 32) and caused feelings of disrespect and mise patients’ feelings of coercion by a good explanation
helplessness (8, 25, 32). of the rationale for admission (9). A study of O’Donoghue
Patients reported positive experiences when they felt suggests that the majority of patients reflect positively on
they were being guarded and seen. Patients wanted to feel their involuntary admission if they have greater insight
safe (8), protected (32) and cared for (25). These feelings into their illness (30). If patients are excluded from partici-
enhanced respect. Respect is considered as a primary ethi- pation in the admission decision and the actions of others
cal principle, a basic requirement for any human interac- appear to be selfishly motivated, coercion may be more
tion and a fundamental component of nursing (32). likely to be perceived and resented (20).
The outside perspective on the patient The inside perspective of the professional
Other literature measured themes which were important dur- The themes we found in this category were being stressed,
ing admission. Themes that played a major role in this cate- being satisfied and connectedness. Only three articles
gory were pressure, loss of autonomy and procedural justice. taught us something about the feelings, motives and atti-
Pressure is divided in literature as negative and positive tudes of frustrations of the professional during involuntary
symbolic pressure. Negative pressure consisted, for exam- admission. Jepsen (24) described that professionals, gen-
ple, of treats, giving orders, deception and show of force eral practitioners (GPs), were stressed and frustrated due
(6, 27, 29). Positive pressure consisted of persuasion, to the uncertainty about what was going to happen, the
promises, inducements, asking for a preference and using time-consuming procedure and the fact that they had
words to encourage individuals to make the ‘right’ choice repeatedly admitted patients who never seemed to benefit
(6, 20, 21, 27). Bonsack found that voluntary admitted from the admissions. On the other hand, satisfaction was
patients felt more pressure from family and friends than found when administering obtained the necessary help to
involuntary admitted patients (9). the patient and the professional was able to handle the sit-
The second theme appeared to be loss of autonomy. It uation correctly. Connectedness was another positive
can be described as a loss of liberty, limited possibilities experience described by the professionals (19). Clinicians
of moving and being dominated by others (25, 29). in this study pointed out the importance of being flexible
Finally, considerable attention is directed to the percep- and individualising the process according to patients’
tion of procedural justice. Procedural justice concerns the needs and tolerance. Connectedness facilitated the sharing
fairness and the transparency of the processes by which of experiences and helped to clarify risks and the aware-
decisions are made. For patients, this means that their ness of vulnerabilities of the patient (19).
voice is heard and that they have the opportunity to
express, explain and participate in the admission decision
The outside perspective on the professional
themselves (29) (7, 20, 27, 31). Considerable clinical skills
are required to initiate aspects of procedural justice, to rec- Within literature describing the outside perspective of the
oncile these situations and ameliorate perception of coer- professional, admission criteria come to the fore, for
cion. A great need mentioned is the identification of example the diagnostic and legal criteria (3, 9, 17, 28).
effective interpersonal communication and the teaching of Additionally dangerousness, risk of harm and violence to
these methods to all professionals who are liable to be others are criteria to take into account (17, 28, 35).
Attitudes of the professional that influence the willing- different ways at the same time: seeing the patient sub-
ness to admit a patient were described as important: atti- jectively as a person with feelings and seeing the patient
tudes about the personality of the patient, symptom objectively as a person with a diagnose in need of invol-
characteristics (21) and the assumption that the patient is untary admission. Quality of care during coercive admis-
responsible for his own condition (28). For example, the sion is raised when professionals are able to handle these
attitude that patients who do not pose a danger to others perspectives simultaneously.
may not be coerced under any circumstance regardless of Professional care relationships are role-orientated and
how much they suffer as a consequence of their disease. related to a person’s specific need in the context of
The professionals studied placed a great importance on health and illness (36). The word ‘professional’ is often
patients’ autonomy (17). Persons with substance depen- understood as ‘keeping sufficient distance, not being
dence were considered more responsible than persons with overly involved (restraining emotions) and being objec-
other disorders for both the onset and recurrence of their tive’(37). However, in the case of involuntary admission,
condition (28). Also, higher age, female and prior experi- this may cause harm. More is necessary: being there in
ence with coercion were positive predictors of reasons to an attached way. Two articles mentioned the concept of
use coercion (17). Another study focused on factors that presence as a deep sense of availability to the patient (19,
mediate the risk of an involuntary admission. Demographic 32). This pleas for staying in touch with patients during
factors, such as continent of origin, occupational and mari- the process of coercive admission: listen to them and do
tal status, diagnostic factors related to the patient, social set- not leave them alone emotionally nor existentially.
ting (deprivation) and nature and extent of mental Martinsen discussed this professional double perspec-
healthcare service provided, all played a role (34). tive by describing a recording and a perceiving eye, with
recording she meant the putting of oneself in an outside
position, classifying, systematising and differentiating
Discussion
within the framework of an already existing conceptual
Our findings are in line with the findings from the review system. The perceiving eye was characterised by open-
mentioned in the introduction (10). When patients feel ness towards the world and other persons, where sensa-
that they are given the chance to participate in decisions tion and emotions are working together. It opens for ‘a
regarding their care and that professionals are genuinely seeing emotion’ in which we are touched and emotion-
interested in their well-being, patients find it easier to jus- ally involved and understand the needs of the other (37).
tify and accept compulsory treatment. However, our To improve caring during involuntary admission, profes-
review focused on involuntary admission and did not sionals may achieve success if they combine their record-
explore only the experiences of patients, but distinguished ing eye with their perceiving eye.
between patients’ and professionals’ perspectives from an Good coercive admission is encouraged as well by pro-
inside and outside point of view. Our review adds some fessionals taking into account their own needs during the
new insights into the differences between patients’ and admission. Mature care, as described by Hem and Petter-
professionals’ perspectives and the necessity to be aware of sen, is in this light an interesting concept (38, 39). It
both perspectives during an (in)voluntary admission. means to portray care as a relational, not isolated, activity.
Our review identified that the majority of the twenty- The centre of attention is the interaction between the carer
two articles reviewed described the outside perspective. and the person being cared for. It implies a balancing of
Ten articles described the outside perspective on the one’s own interests and those of others and highlights reci-
patient, and six articles described the outside perspective procity (p. 66).With this interpretation of care, dialogue is
on the professional. The inside perspective was men- the aspiration. To relate this to the professional health
tioned in six articles. carer and involuntary admissions, it means that the profes-
Answering the research question resulted in the find- sional has to develop into a person who has the capacity to
ing of one most important core experience: ‘not being lis- balance both at the same time – both the contact with
tened to’. When patients are not being listened to, they himself and the contact with the patient. During involun-
experience powerlessness, humiliation, not being seen or tary admission, this means that professionals have to be
disrespect. On the contrary, when they have the oppor- open to their own weaknesses, attitudes and develop the
tunity to express their feelings and have the possibility to ability to really listen empathically to the patient.
participate in the process, they evaluate their admission
more positive; they seem to feel better afterwards.
Conclusion
For professional health carers, this implies that quality
improves if they acknowledge and explicitly pay atten- The reviewed articles could be arranged in a matrix with
tion to patient’s emotional struggles while making the respect to inside and outside perspectives of the patient
decision to involuntarily admit the patient to prevent and professional as starting point to analyse the data.
harm. Professionals have to look at the patient in two Findings show that most experiences of patients can be
traced back to one core experience that makes the differ- suitable for the aim of this review. Another potential
ence: ‘Am I being listened to?’ If patients experience gen- limitation is that the themes were removed from their
uinely listening, they feel more respected as a human original contexts, which could invite misinterpretation.
being and less emotionally abandoned. The challenge for We included both qualitative and quantitative studies.
professional carers is to explicitly pay attention and really This resulted in a heterogeneous sample of studies and
listen empathically to patients’ struggles while at the might have blurred. The number of databases searched
same time make the decision to admit the patient. Qual- as well the search path chosen may have been insuffi-
ity of care during coercive admission improves when pro- cient to identify all relevant references. In the process
fessionals are able to do justice to both inside and outside of analysis, we only had access to published data in
perspectives simultaneously. Theoretically we find many the reviewed articles; this may have biased our conclu-
concepts that underline these conclusions. However, sions. Original empirical data are necessary to confirm
detailed descriptions on how professionals deal with both our findings.
perspectives and what barriers might be experienced are
lacking. The challenge for future studies is to explain
Conflict of interest
boundaries and tensions involved in caring in involun-
tary situations for theoretical perspectives, as for instance No conflict of interest has been declared by the authors.
the field of care ethics. Concepts as vulnerability and
autonomy might need to be ‘reinvented’ with respect to
Author contributions
preventing harm in patients who are subjected to invol-
untary admission. More and deeper empirical knowledge Susanne van den Hooff was responsible for the study
about types of emotional and existential harm in these conception, design, literature collection, review and
patients will make the debate richer and possibly provide critical analysis and drafting of manuscript and revi-
openings for further humanising health care in situations sions. Anne Goossensen made revisions of the manu-
that challenge professionals and systems most. script for important intellectual content and supervised
the study.
Limitations
Funding
This review on involuntary admission has a number of
limitations. The study could have been strengthened by This study was funded by Inholland University of applied
the inclusion of more criteria. However, the inclusion sciences.
and exclusion criteria are well described and found
psychiatric hospital admissions of and good faith: the morality of coer- 30 O’Donoghue B, Lyne J, Hill M, Lar-
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