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NATIONAL CONFERENCE, OSLO, APRIL 5TH AND 6TH, 2011

This research study examines the concepts of perceived coercion, humiliation, and violation of integrity in psychiatric emergency units. The study investigates their impact on patient outcomes and explores the relationship between these concepts. Data was collected at Aalesund Hospital in Norway. The study aims to understand if the patients' responses are based on cognitive interpretations or emotional reactions.

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NATIONAL CONFERENCE, OSLO, APRIL 5TH AND 6TH, 2011

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  1. NATIONAL CONFERENCE, OSLO, APRIL 5TH AND 6TH, 2011 Marit FølsvikSvindseth PhDclinicalmedicine MHSc

  2. Data in my study collected inAalesund Hospital, 2 locked, psychiatricemergencyunits

  3. PerceivedCoercion, Humiliation or ViolationofIntegrity? How are theseconceptsrelated and is there a differenceregardingtheirimpactonoutcome?

  4. Background 10 yearsofexperience as chief nurse in a psychiatricemergencyunit. Beforethe chief nursebecame a quasiexpertonadministratingwages, controlling all economicaspectsincludingcontrollingeachindividualemployee ++++++ In otherwords, I spent much time withthepatients

  5. COERCION - DEFINITION • The useof force to persuadepeople to do thingswhichthey are unwilling to do The Cambridge Dictionary • Force is explained as usingphysicalpower, influencing or as giving no choice

  6. HUMILIATION Lindner (2002) states: • Humiliationmeans to be placed, against ones will, in a situationwhere one is forced to feelinferior Statman (2000) states: • To be humiliatedmeans to suffer an actualthreat to or fall in one´sself-esteem • Bothdefinitionstouchpainfulfeelings, ratherthancognitiveinterpretationofsituations

  7. INTEGRITY • The former definitionsofhumiliationtellsusthat • Humiliation ≈ violationofintegrity

  8. Patients´ viewoncoercion • In groupsessions and individualinterviewswithpatients (bothvoluntary and involuntarypatients) I recognizedstatements, repeated by many. • The statementsseemed to have theirorigin in emotions, ratherthancognitiveinterpretationsofthesituationstheydescribed

  9. Patients´ statements Whenaskedabouttheirexperiences in theadmissiionprocess, thepatientsstated: • I wasrelievedto, at last, gettinghelp • I felt I wasworthnothing • I wasnotallowed to give my opinion • Nobodylistened to me • I wasfeeling so small… • Theydidnot let me decideanything • I wasforced to followtheparamedicswithoutextra sets ofclothes • I waspersuaded to the hospital and when I wasinvoluntaryadmitted, I felt so stupid and angryofthosewhopersuaded me.

  10. Interest in coercion • The American Coercion Studies (MacArthur Group) inspiredus to gather data in a systematicway by usingchosenquestions from theAdmissionExperienceSurvey (AES), the Nordic AdmissionInterview (NorAI and theAdmissionExperienceInterview (AEI) • Whenexaminingthe instruments, I foundthatthestatements in thesurveyswereverysimilar to whatthepatientsalreadyhad told me

  11. Questioningthescale as ”coercionscale” • My interpretationofthestatements from thepatientswere: • Theydidnotreportcognitiveinterpretationofthesituations • Theyreported strong feelings and thestatementscoveredmanyofthequestions from thecoercionsurveys

  12. MEASURING COERCION • To me, and my discussion partners, it seemed like most ofthequestions in thecoercionsurveysmeasuredperceivedhumiliationratherthanperceivedcoercion

  13. Setting ofthe study • Aalesund Hospital, twoclosedpsychiatricemergencyunits • Eachunit, eight separate rooms, twoofthe beds (rooms) used for seclusion purposes • Data collected in a period from March 1st, 2005 to October 31st 2006

  14. Exclusioncriteria • Dementia • Organicallybasedconfusion • Manic or hypomanicstates • Poorability to speakNorwegian/English • Dischargewithinthe first 48 hours • Readmissions

  15. The sample Involuntary (voluntary) • 191 (160) admissions • 78 (48) mettheexclusioncriteria • 8 (12) declined to take part • 7 (11) were lost due to administrative reason • 98 (88) patientsincluded • Due to a high numberofvoluntaryadmissionsweonlyincludedonpredefineddaysoftheweek • Total sample: N = 186

  16. Questionsmodified from the AES, NORAI and AEI • Criterias for choosingquestionswerethatitemsshould be anchored in statements from patients, theyshould be short and easilyunderstandable. Theyshould be answered by yes or no. Theywerecalled negative experiences • Coercionmeasured as legal coercion status • Humiliation as reports from patientson a scale from 1 – 10 (as the ”coercionladder”)

  17. Back to my basicassumption • Qualitativeinterviews told me thattheselectedquestionsmeasureperceivedhumiliationratherthanperceivedcoercion • The negative experiencequestionshad a Cronbach`salphaof .74, tellingusthattheinternalconcistency is good but it doesnotsaywhetherwe are mesuringcoercion or humiliation

  18. CORRELATIONS N = 186 * Controlled for coercion ** Controlled for humiliation

  19. Negative experiences are much more correlatedwithperceivedhumiliationthan legal coercion A closerlook at one ofthe negative experiences: ”Notbeenheard” Coercionexplains 4.2% ofthevariancewhile Humiliationexplains 25.3% meaning a small overlap betweencoercion and the variable ”notbeenheard” and a large overlap betweenhumiliation and the same variable

  20. Decisionneeded • What are wemeasuring? • Perceivedcoercion? Humiliation? Violationofintegrity? • Do thepatientsansweraftercognitiveconsiderationsoncoercion? • Or – do theyreport a feeling (emotion)? • Iftheyreport an emotion, whichemotion? • And – are emotionsmasureable?

  21. Concequencesofmeasuringperceivedcoercion • Focusonminimizingcoercion (and this is important due to theimpactontheethicalimplicationsonAutonomy,++++) • increased focus on coercion and – hopefully – a reduction in coercion where a reduction is posssbible • Less focusontheimportantissuesthat are closelyconnectedwithcoercion

  22. Concequencesofmeasuringperceived coercion Otherfields in medicalpractice (like geriatricwards, wardsconcentratingonsubstanceabuse++) maynot be awareoftheimplications negative experiencesmay have ontheirpatients • Impactonself-esteem • The assumedlongdurationofhumiliatingevents

  23. Concequencesofmeasuringhumiliation (violationofintegrity) • Focusonminimizing negative experiencesthatincreaseperceivedhumiliation • The situationsthatincreaseperceivedhumiliation are alsoassociatedwithCoercion (legal status) • Focusonthepatients´ owncopingstrategies • Self-esteemissues • Better treatmentcompliance • Less assymetri in powerstructures

  24. Concequencesofmeasuringhumiliation (violationofintegrity) • A ”side-effect” ofhumiliationfocusmay be less involuntaryadmittedpatients • More ”global” useof a humiliation instrument, notonly in wardswherecoercion is a topic

  25. Recommendations • Develop an instrument wheretheoutcomechanges from PerceivedCoercion to PerceivedHumiliation (ViolationofIntegrity) • Coercionshouldalways be part of studies whereHumiliation (ViolationofIntegrity) is thedependent variable • Discussionsonthe proper waysofmeasuringCoercionshouldcontinue. May be weshould settle onthe legal admission status as coercionmeasure?

  26. Recommendations • Analyze and find which items are best fit to measure coercion • Analyze and find which items are best fit to measure humiliation/violation of integrity • More qualitative studies in order to determinewhatis ”reallymeasured”

  27. Thankyou for theattention

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