Reidun Norvoll, AFI Tonje Lossius Husum, SINTEF

1. How can we reduce the gap between patients and staff in the understanding of coercion?(Hvordan minske forståelseskløften om bruk av tvang mellom brukere og ansatte) Reidun Norvoll, AFI Tonje Lossius Husum, SINTEF

2. Presentation of a project in progress and preliminary results • Part of project: ” Voluntariness before involuntariness”. • For “Rådet for psykisk helse/ The Council for mental health”. • Cooperation between AFI and SINTEF. • A literature study of studies and other literature about patients and staffs understanding and experience of coercion, and of the gap between them.

3. Why? • The experience that patients and staff often understand use of coercion differently. • Patients often experience use of coercion very adversely. • Staff may not understand patients' view. • How do we reduce the gap in understanding?

4. Aims of study: • What is the gap between patients and staffs views? • Where is the understanding similar and where do they differ? • What factors seems to influence on the gap? • What can be done to reduce the gap?

5. Principles for litterature search: • Focus on aim 1 (what is the gap?). • Literature mostly from the last decade. • Main focus on literature/ studies form the Nordic countries, and some especially important International studies. • Searching for especially relevant studies, rather than searching for all (quality more important that quantity). • Doing in-depth/ thoroughly analysis of especially relevant literature and search for meaning rather than quantitative measures. • The study is of an exploratory character.

6. Principles… • Included studies on both experience of coercion in general and of specific kind of interventions (inv admission, seclusion, restraints, inv. medication, shielding). • Three groups of studies/ literature: • Patients experiences • Staff experiences • Both patients & staff experiences (and sometimes also relatives).

7. Where did we search: • Literature known from own PhD work (both researchers). • Review of literature in the Norwegian network for research on coercion (both researchers in this network). • www.tvangsforskning.no • Earlier and new literature search: • Goggle Scholar, PubMed, IsI Web of Science, BIBSYS, Idunn and Helsebiblioteket. • Important Norwegian books relevant to the topic: • Textbooks in psychiatry (Berg, Vaglum et al, Strand). • Patients stories and experiences (Thune, Vaaland ).

8. Analytic perspective: • Phenomenological • Search for meaning • Both staff and patients perceptions are influenced by individual and contextual factors • Searching for patterns in the differences

9. Patients perceptions are influenced by: • Personal values, experiences and ”personal ”life project”. • Life situation in daily living and network. • View on mental difficulties and treatment philosophy. • Previous experiences with the mental health services and the patients role given in meeting with the professionals. • Interaction between staff and patients. Previous and present.

10. Staff perceptions are influenced by: • Personal values and experiences. • Attitudes and feelings in meeting with people with mental difficulties. • Professional training/ treatment ideology and philosophy. • The institutions/ services ideology, culture and organizational culture. • Role and understanding of own role. • Interaction between staff and patients, previous and present.

11. Descriptions of staff perspectives • Berg (2007)Akuttpsykiatri + Vaglum & Friis (1994) ”Mot en mer moderne psykiatri” + Liv Strand(1990) Fra kaos mot mestring, samling og helhet. • Alexius, Berg & Åberg-Wistedt (2002) Psychiatrists perception of psychiatric commitment. • Kullgren, Jacobsson, Lynöe, Kohn & Levav (1996) Practices and attitudes among Swedish psychiatrists regarding the ethics of compulsory treatment. • Monahan et al (1995) Understanding Involuntary Mental Hospital Admission. • Stefan Sjöström (1997) Party or patient? Discursive practices relating to coercion in psychiatric and legal setting.

12. Descriptions og patients perspectives • Gro Hillestad Thune (2008): Overgrep – Søkelys på psykiatrien. • Johansson & Lundman (2002) Patients experiences of involuntary psychiatric care: good opportunities and great losses. • Enarsson, Sandman & Hellzen (2011) ”They can do whatever they want”: Meanings of receiving psychiatric care based on a common staff approach. • McKenna, Simpson & Laidlaw (1999). Patient perception of coercion in admission to acute psychiatric services. The New Zealand Experience. • Sørgaard (2004) Patients perception of coercion an acute psychiatric wards. An intervention study. • Gilburg, Rose & Slade (2008) The importance of relationships in mental health care: A qualitative study of service user experience of psychiatric hospital admission in the UK.

13. Descriptives of staff & patient perspectives • Jarret, M, Bowers, L & Simpson, A. (2008). Coerced medication in psychiatric inpatient care: literature review. Journal of Advanced Nursing 64 (6), 538-548. • Britta Olofsson (2000) Use of coercion in psychiatric care as narrated by patients, nurses and physicians. Dissertation from Umea University. • Kjellin et al (2004) Coercion in psychiatric care – patients and relatives experience from four Swedish psychiatric services. • Haglund, Von Knorrin & Von Essen (2002) Forced medication in psychiatric care: patient experiences and nurse perceptions.

14. Preleminary results: • Where is the gap? • What lies in the difference in views?

15. The main differences: • Different view on the human being and different ”pictures/ metaphor "of the patient (menneskesyn). • Different views on coercion. • Difference perception of amount/ episodes of coercion. • Difference in view on how much coercion may hurt and humiliate the patient (the consequences). • Different view upon when coercion is needed and not. • Different view on agitation, violence and danger. • Different view on mental difficulties and treatment. • Different understanding of communication and relation.

16. 1. “The quest for human dignity” • Differences in view upon the patient • Patients feel as being treated with less respect and dignity as others, or as expected, as a human being, and as something different than staff. • The staff maybe look upon patients as qualitative something different from oneself; as a “patient”, as a “child” or as ”the other”. The main theme as ”they and us” instead as ”us”.

17. Different views upon coercion • Staff and patients may have different perspectives of time • Staff ”here & now” • Patients in their own life perspective (longer perspective) • Difference in the view upon coercive interventions as needed, while patients often thought there did exist alternatives. • Or staff maybe look upon use of coercion as protection or as giving care. From the patients point of view as violating or as punishment.

18. Difference in the perception of amount of coercion • Staff may underestimate the amount of coercion the patient has experienced under the admission. • While the patient may overestimate the amount. • Staff and patients may also percept interventions differently. Patients as coercion and pressure, staff like treatment and care, and therefore underestimate patients perception of coercion.

19. Difference views upon how coercion are percepted • Staff tend to underestimate how humiliating/ violating and in general how negative patients experience to be treated with coercion. • Staff may overestimate positive effect of coercion like maintaining control and order, or as establishing safety and as protection for staff, the patient and other patients. • Patients tend to experience coercion as very negative and harmfull and as a threat towards their human dignity and integrity.

20. Coercion as needed • Staff tend to think use of coercion as needed and that there did not exit any alternative • While patients often think there did exist alternatives and that use of coercion was overuse of power in the situation.

21. This is how far we have come… • Too be continued…. • Questions? • Thank you very much for your attention 