REVIEW ARTICLE
12070
How to increase quality of care during coercive admission? A
review of literature
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
How to increase quality of care during coercive
admission? A review of literature
Background: Involuntary admission is still raising in num-
bers and as a procedure a widely discussed subject from
ethical point of view. A common dilemma is the tension
between individual freedom and the need to protect the
patient. Patients who are coerced during the admission
process often report negative feelings or trauma. Finding
out quality issues remains a challenge for providing good
care during coercive admission.
Aim: This study aims to explore themes from patients’
and professionals’ perspectives within scientific literature
on involuntary admission.
Methods: A literature review of English articles using Aca-
demic Search Elite, Cinahl, Medline, PubMed and Social
Science Journals for the period 1995–2012 was conducted.
Additional studies were identified using the National Cen-
tre for Biotechnology Information (NCBI). Search terms
included involuntary, hospitalisation, ethical, admission,
Introduction
Involuntary hospitalisation remains a widely discussed
subject from ethical point of view. The dilemmas
between individual freedom of choice, autonomy and
the need to protect the patient to control damage are
evident (1). Many mental healthcare patients do need
an involuntary admission because of their mental state,
they cause danger or damage to themselves or others.
An increasing rate of involuntary admissions was
described in the Netherlands (2), England (3) and other
European countries. In England, the increasing rate has
been associated with a reduction in provision of beds for
people with mental illness since the 1980s, due to
Correspondence to:
Susanne L. van den Hooff, Inholland University of Applied
Sciences, Cluster Management, MER, Kamer A252, Bergerweg
200, 1817 MN Alkmaar, the Netherlands.
E-mail: susanne.vandenhooff@inholland.nl
© 2013 Nordic College of Caring Science
doi: 10.1111/scs.
nursing home, coercion and factor. Finally, twenty-two
articles were included and analysed out of 1216.
Results and conclusion: Articles were divided between
those describing themes from patients’ perspective and
articles describing themes from professionals’ perspective.
Findings show that most experiences of patients can be
traced back to one core experience: not being listened to
or listened to. When patients experience being listened to
genuinely, they feel more respected as a human being.
The challenge for the professional carer seems to explic-
itly pay attention and stay in touch with the patients’
emotional struggles while making the necessarily decision
to admit the patient to prevent harm. Quality of care
during coercive admission improves when professionals
are able to do justice to both inside and outside perspec-
tives simultaneously.
Keywords: literature review, experiences, long-term
care, quality of care, involuntary admission, ethics of
care.
Submitted 8 May 2013, Accepted 23 July 2013
policies to deinstitutionalise the care of people with
mental illness. That study indicated that the closure of
two mental illness beds was associated with one addi-
tional civil involuntary admission in the subsequent year
due to delays in planned admissions which may lead to
crises requiring involuntary admission (3). Also in the
Netherlands, the numbers of emergency involun-
tary admissions rose 16% (from 40.2 to 46.5 per
100 000 total population) during the years 2000–2004.
During this period, there were no changes in mental
health law (4).
Within the Netherlands, the Dutch Compulsory Admis-
sion Act (BOPZ) is the frame of reference in case of an
involuntary admission. According to this act, there are
three criteria governing compulsory admission: patients
do not agree with admission; they present a danger to
themselves and others and the ‘last resort’ principle
applies; in other words, there is no reasonable alternative
(5). If these criteria are met, a legal mandate is issued by
the court. Within the Netherlands, the government is
425
426 S. van den Hooff, A. Goossensen
currently working on new mental health legislation. The
requirements for an involuntary admission will be
adjusted. The danger criterion will be replaced by the cri-
terion of significant risk of serious harm, with suits better
to the internationally used criteria.
A formal legal status does not always reflect patients’
actual attitudes and expectations (6) of perceived coer-
cion (7). Even without a formal legal status the patient
can feel coerced. Involuntary hospitalisation is often
accompanied by negative experiences of the patients.
Looking back, they often evaluate that hospitalisation
was unnecessary, even harmful (8), and they report a
lack of improvement afterwards (9). Coercion in psychi-
atric care involves ethical tensions between the need to
respect patients’ autonomy and the obligation to help or
protect patients.
Ethical issues surrounding the justification, legal reg-
ulation and best practice of compulsory interventions
in mental health care have been widely questioned
and discussed (10). Jankovic et al. (11) found that a
substantial proportion of patients did not agree retro-
spectively with the appropriateness of the admission,
which shines a critical light on the ethical justification
of involuntary hospital admission (12). Katsakou (10)
presented a review of five qualitative studies and
described patients’ experiences under different stages of
involuntary care. This study offered some insight into
patients’ experiences and perceived outcomes of invol-
untary care. Katsakou concluded that when patients
feel that professionals genuinely care about them and
offer them some degree of participation in their treat-
ment, interventions are evaluated less negative. There
seems less negative impact on people’s sense of self-
value. Genuinely caring meant in this article that pro-
fessionals are honestly interested in the well-being of
the patient and are trying to understand how vulnera-
ble and insecure patients might be.
The relevance for our study roots in a project on
patients suffering Korsakoff’s syndrome. These patients
lack insight into their own condition (13, 14) and are not
aware that they need care. This produces an additional
tension during involuntary admissions between the need
to respect patients’ autonomy and the need to prevent
damage in these patients (15–17). They simply just drink
themselves to death when not involuntary admitted into
long-term care institutions.
The main question of this review is ‘Which quality
themes are reported by patients and professionals during
involuntary admission?’
Aim
The aim of this study was to explore patients’ and profes-
sionals’ perspectives within literature on involuntary
admission.
Methodology
This review contains a systematic search of published lit-
erature in peer-reviewed journals. The method used con-
tained different steps: specification of the assessment
problem, formulation of inclusion and exclusion criteria,
defining a search, the execution of the literature search,
selection of articles based on the criteria and analysis of
the material.
Data sources and keywords
The literature search was conducted in five different
international online bibliographic databases: Academic
Search Elite, Cinahl, Medline, PubMed and Social
Science Journals. The keywords used in the search were
‘involuntary’, ‘hospitalisation’, ‘ethical’, ‘admission’,
‘nursing home’, ‘coercion’ and ‘factor’. In addition, new
results from the National Centre for Biotechnology Infor-
mation (NCBI) in the search ‘involuntary’ and ‘admis-
sion’ in PubMed were included if applicable. Databases
were electronically searched for articles with the follow-
ing search options: apply related words, peer-reviewed
journal and abstract available. The material was restricted
to the English language, and articles should be published
between 1995 and 2012 in any country. The search was
carried out from November 2011 – July 2012. This search
yielded 1216 hits. All the searches were tracked and
administrated in a grid.
Literature searches and short listing
The data material was processed, analysed and reflected
through a stepwise procedure. First, the database output of
1216 titles was screened. Titles were excluded at this stage
if they were doubles, oral presentations, essays, reviews or
if the title did not refer to admission at all. 161 titles
remained and were screened on abstract information.
Excluded were abstracts with a focus on specific medical
diagnoses, a specific case study, adolescents/children, read-
mission, discharge, treatment, outcome, emergency admis-
sion, quantitative inquiries that solely described
involuntary admission in factors or (law)criteria or if the
text in the abstract did not refer to admission at all.
After this process, 62 articles remained and appeared
to contain the key issue: perspectives on involuntary
admission. Meanwhile, five articles had been found from
the NCBI in the search ‘involuntary and admission in
PubMed’. They were included. These 67 articles were
read in full text and summarised in a table. The content
of the 67 articles was examined and discussed between
the two reviewers. Disagreements about inclusion and
exclusion between reviewers were resolved by consensus.
Finally, 22 articles remained for inclusion in this review.
These articles met our inclusion criteria (Fig. 1).
© 2013 Nordic College of Caring Science

1216 titles identified through database
searching and screened on title
161 abstracts were screened on
information
62 of full text articles were assessed for
eligibility
5 new found articles were included (n =
67)
22 articles included in qualitative
synthesis
Figure 1 Selection process of the articles.
Data extraction and analysis
This review used the guidelines of Preferred Reporting
Items for Systematic reviews and Meta-Analyses (PRIS-
MA) to report as fully and transparently as possible to
allow readers to assess the strengths and weakness of the
investigation (18). We identified twenty-two articles and
integrated them. The analysis existed of four phases.
Firstly, the full-text articles were read and examined for
content. They were summarised on study aim, research
method and main findings (Table 1). Secondly, the arti-
cles were divided into two main categories: articles
describing patients’ experiences and articles describing
professional health carers’ experiences as starting point of
research. Thirdly, themes playing a major role within
each perspective were identified, explored and discussed
by the authors until consensus was reached. Fourthly,
the emerged themes were described within each perspec-
tive (see below). Finally, the outcomes were analysed,
compared and contrasted within and between the differ-
ent perspectives to draw conclusions.
Results
To explore patients’ and professional health cares’ per-
spectives during involuntary admission, a division was
made between articles describing patients’ perspectives
and articles describing professionals’ perspectives. Within
each perspective, we could divide articles that took the
inside perspective of the respondent as major topic and
articles that took the outside perspective as most impor-
tant. The inside perspective describes the experiences of
© 2013 Nordic College of Caring Science
Increasing quality of care during coercive admission 427
1055 titles were excluded after removal of duplicates,
oral presentations, essays, reviews or if the title did not
refer to admission at all.
99 abstracts excluded because of focusing on medical
diagnoses, specific case studies, adolescents/children,
family, readmission, discharge, treatment, outcome,
emergency admission, quantitative inquiries that solely
described involuntary admission in factors or
(law) criteria or if the text in the abstract did not refer to
admission at all.
5 new articles included from new results from the
National Centre for Biotechnology Information (NCBI)
in the search “involuntary and admission in PubMed”.
45 articles excluded that did not met our inclusion
criteria: the studies had the patient perspective or
professional health carers’ perspective of coercion
during involuntary admission or the evaluation of the
admission process as their central focus
the respondents themselves. The outside perspective is a
description from an external point of view of the behav-
iours and the situation.
Mostly the inside perspective was inquired through nar-
rative methods (25, 32) meaning that patients freely told
their story of the involuntary admission or in-depth in
semi-structured interviews (8, 19, 24, 26). Here, the ques-
tions were open-ended allowing a wide range of relevant
topics to be explored. The outside perspective was inquired
through semi-structured interviews (20), questionnaires (9,
17, 21, 28, 29) or a combination of both (7, 22, 30, 31, 33).
The Admission Experience Survey (AES) (7, 29, 33)
appeared most often used, as well as the Admission Experi-
ence Interview (AEI) (6, 21, 23, 27, 31). The AES is devel-
oped by the MacArthur Research on Mental Health and the
Law in the United States. It is a 15-item questionnaire
reflecting the absence of autonomy with true/false state-
ments. Also used were available administrative data (3, 34).
After dividing the articles in an inside–outside perspec-
tive, we could attribute themes we found in the articles
to the different perspectives. In Table 2, the experiences
and themes are described that played a major role within
each perspective (Table 2). The findings within each per-
spective will now be described.
The inside perspective of the patient
In this category, a division can be made between nega-
tive and positive experiences. The two most commonly
mentioned negative experiences reported powerlessness
and humiliation. Experiences of powerlessness consisted
of not being understood, being ignored, feeling
428 S. van den Hooff, A. Goossensen

Table 1 Characteristics of the 22 included articles

Main findings which

Authors experiences/themes play a
(Reference Sample size role during perceived
no/country) participant group Study aim Research method coercion at admission?

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

© 2013 Nordic College of Caring Science

 Increasing quality of care during coercive admission 429

Table 1 (Continued)

Main findings which

Authors experiences/themes play a
(Reference Sample size role during perceived
no/country) participant group Study aim Research method coercion at admission?

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

© 2013 Nordic College of Caring Science

430 S. van den Hooff, A. Goossensen

Table 1 (Continued)

Main findings which

Authors experiences/themes play a
(Reference Sample size role during perceived
no/country) participant group Study aim Research method coercion at admission?

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
allowed to decide what to do and where to be. They
received a treatment not agreed to (25). They felt not
being listened to and not being heard (32). Patients felt
out of control during their hospitalisation due to not
receiving sufficient information and not being involved
in decisions (26).
Another important negative experience was humilia-
tion. Patients felt not being treated as human beings or
having the same human value as healthy persons (25).

© 2013 Nordic College of Caring Science


Table 2 Themes in experiences
Inside perspective (reference number)
Negative experiences
Patient Being powerless (25, 26, 32)
Being humiliated (8, 25, 32)
Professional Being stressed (24)
They wanted to be seen as individuals. Being dependent
on healthcare professionals and health care increased
experiences of vulnerability (25). Patients felt like an
inferior kind of human being. Not being involved in deci-
sions was experienced as meaningless and not satisfying
their needs (25, 32) and caused feelings of disrespect and
helplessness (8, 25, 32).
Patients reported positive experiences when they felt
they were being guarded and seen. Patients wanted to feel
safe (8), protected (32) and cared for (25). These feelings
enhanced respect. Respect is considered as a primary ethi-
cal principle, a basic requirement for any human interac-
tion and a fundamental component of nursing (32).
The outside perspective on the patient
Other literature measured themes which were important dur-
ing admission. Themes that played a major role in this cate-
gory were pressure, loss of autonomy and procedural justice.
Pressure is divided in literature as negative and positive
symbolic pressure. Negative pressure consisted, for exam-
ple, of treats, giving orders, deception and show of force
(6, 27, 29). Positive pressure consisted of persuasion,
promises, inducements, asking for a preference and using
words to encourage individuals to make the ‘right’ choice
(6, 20, 21, 27). Bonsack found that voluntary admitted
patients felt more pressure from family and friends than
involuntary admitted patients (9).
The second theme appeared to be loss of autonomy. It
can be described as a loss of liberty, limited possibilities
of moving and being dominated by others (25, 29).
Finally, considerable attention is directed to the percep-
tion of procedural justice. Procedural justice concerns the
fairness and the transparency of the processes by which
decisions are made. For patients, this means that their
voice is heard and that they have the opportunity to
express, explain and participate in the admission decision
themselves (29) (7, 20, 27, 31). Considerable clinical skills
are required to initiate aspects of procedural justice, to rec-
oncile these situations and ameliorate perception of coer-
cion. A great need mentioned is the identification of
effective interpersonal communication and the teaching of
these methods to all professionals who are liable to be
© 2013 Nordic College of Caring Science
Increasing quality of care during coercive admission 431
Outside perspective (reference number)
Positive experiences Themes
Being guarded (8, 25, 32) Pressure (6, 7, 9, 20–22, 27, 29, 33)
Loss of Autonomy (29)
Being seen (8, 25, 32) Procedural Justice (6, 7, 20, 22, 23, 29, 31)
Respect (21, 31)
Being satisfied (24) Attitudes (17, 21, 28)
Connectedness (19) Admission criteria (3, 9, 17, 28, 31, 34)
involved in the admission process (29). Or as explained in
another study ‘the challenge is to try to extend to all
patients, at the time of their admission, a demonstration in
word and action that they are persons with opinions,
desires, rights and dignity’ (22). Professionals should mini-
mise patients’ feelings of coercion by a good explanation
of the rationale for admission (9). A study of O’Donoghue
suggests that the majority of patients reflect positively on
their involuntary admission if they have greater insight
into their illness (30). If patients are excluded from partici-
pation in the admission decision and the actions of others
appear to be selfishly motivated, coercion may be more
likely to be perceived and resented (20).
The inside perspective of the professional
The themes we found in this category were being stressed,
being satisfied and connectedness. Only three articles
taught us something about the feelings, motives and atti-
tudes of frustrations of the professional during involuntary
admission. Jepsen (24) described that professionals, gen-
eral practitioners (GPs), were stressed and frustrated due
to the uncertainty about what was going to happen, the
time-consuming procedure and the fact that they had
repeatedly admitted patients who never seemed to benefit
from the admissions. On the other hand, satisfaction was
found when administering obtained the necessary help to
the patient and the professional was able to handle the sit-
uation correctly. Connectedness was another positive
experience described by the professionals (19). Clinicians
in this study pointed out the importance of being flexible
and individualising the process according to patients’
needs and tolerance. Connectedness facilitated the sharing
of experiences and helped to clarify risks and the aware-
ness of vulnerabilities of the patient (19).
The outside perspective on the professional
Within literature describing the outside perspective of the
professional, admission criteria come to the fore, for
example the diagnostic and legal criteria (3, 9, 17, 28).
Additionally dangerousness, risk of harm and violence to
others are criteria to take into account (17, 28, 35).
432 S. van den Hooff, A. Goossensen
Attitudes of the professional that influence the willing-
ness to admit a patient were described as important: atti-
tudes about the personality of the patient, symptom
characteristics (21) and the assumption that the patient is
responsible for his own condition (28). For example, the
attitude that patients who do not pose a danger to others
may not be coerced under any circumstance regardless of
how much they suffer as a consequence of their disease.
The professionals studied placed a great importance on
patients’ autonomy (17). Persons with substance depen-
dence were considered more responsible than persons with
other disorders for both the onset and recurrence of their
condition (28). Also, higher age, female and prior experi-
ence with coercion were positive predictors of reasons to
use coercion (17). Another study focused on factors that
mediate the risk of an involuntary admission. Demographic
factors, such as continent of origin, occupational and mari-
tal status, diagnostic factors related to the patient, social set-
ting (deprivation) and nature and extent of mental
healthcare service provided, all played a role (34).
Discussion
Our findings are in line with the findings from the review
mentioned in the introduction (10). When patients feel
that they are given the chance to participate in decisions
regarding their care and that professionals are genuinely
interested in their well-being, patients find it easier to jus-
tify and accept compulsory treatment. However, our
review focused on involuntary admission and did not
explore only the experiences of patients, but distinguished
between patients’ and professionals’ perspectives from an
inside and outside point of view. Our review adds some
new insights into the differences between patients’ and
professionals’ perspectives and the necessity to be aware of
both perspectives during an (in)voluntary admission.
Our review identified that the majority of the twenty-
two articles reviewed described the outside perspective.
Ten articles described the outside perspective on the
patient, and six articles described the outside perspective
on the professional. The inside perspective was men-
tioned in six articles.
Answering the research question resulted in the find-
ing of one most important core experience: ‘not being lis-
tened to’. When patients are not being listened to, they
experience powerlessness, humiliation, not being seen or
disrespect. On the contrary, when they have the oppor-
tunity to express their feelings and have the possibility to
participate in the process, they evaluate their admission
more positive; they seem to feel better afterwards.
For professional health carers, this implies that quality
improves if they acknowledge and explicitly pay atten-
tion to patient’s emotional struggles while making the
decision to involuntarily admit the patient to prevent
harm. Professionals have to look at the patient in two
different ways at the same time: seeing the patient sub-
jectively as a person with feelings and seeing the patient
objectively as a person with a diagnose in need of invol-
untary admission. Quality of care during coercive admis-
sion is raised when professionals are able to handle these
perspectives simultaneously.
Professional care relationships are role-orientated and
related to a person’s specific need in the context of
health and illness (36). The word ‘professional’ is often
understood as ‘keeping sufficient distance, not being
overly involved (restraining emotions) and being objec-
tive’(37). However, in the case of involuntary admission,
this may cause harm. More is necessary: being there in
an attached way. Two articles mentioned the concept of
presence as a deep sense of availability to the patient (19,
32). This pleas for staying in touch with patients during
the process of coercive admission: listen to them and do
not leave them alone emotionally nor existentially.
Martinsen discussed this professional double perspec-
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
within the framework of an already existing conceptual
system. The perceiving eye was characterised by open-
ness towards the world and other persons, where sensa-
tion and emotions are working together. It opens for ‘a
seeing emotion’ in which we are touched and emotion-
ally involved and understand the needs of the other (37).
To improve caring during involuntary admission, profes-
sionals may achieve success if they combine their record-
ing eye with their perceiving eye.
Good coercive admission is encouraged as well by pro-
fessionals taking into account their own needs during the
admission. Mature care, as described by Hem and Petter-
sen, is in this light an interesting concept (38, 39). It
means to portray care as a relational, not isolated, activity.
The centre of attention is the interaction between the carer
and the person being cared for. It implies a balancing of
one’s own interests and those of others and highlights reci-
procity (p. 66).With this interpretation of care, dialogue is
the aspiration. To relate this to the professional health
carer and involuntary admissions, it means that the profes-
sional has to develop into a person who has the capacity to
balance both at the same time – both the contact with
himself and the contact with the patient. During involun-
tary admission, this means that professionals have to be
open to their own weaknesses, attitudes and develop the
ability to really listen empathically to the patient.
Conclusion
The reviewed articles could be arranged in a matrix with
respect to inside and outside perspectives of the patient
and professional as starting point to analyse the data.
Findings show that most experiences of patients can be
© 2013 Nordic College of Caring Science
 Increasing quality of care during coercive admission 433

traced back to one core experience that makes the differ-
ence: ‘Am I being listened to?’ If patients experience gen-
uinely listening, they feel more respected as a human
being and less emotionally abandoned. The challenge for
professional carers is to explicitly pay attention and really
listen empathically to patients’ struggles while at the
same time make the decision to admit the patient. Qual-
ity of care during coercive admission improves when pro-
fessionals are able to do justice to both inside and outside
perspectives simultaneously. Theoretically we find many
concepts that underline these conclusions. However,
detailed descriptions on how professionals deal with both
perspectives and what barriers might be experienced are
lacking. The challenge for future studies is to explain
boundaries and tensions involved in caring in involun-
tary situations for theoretical perspectives, as for instance
the field of care ethics. Concepts as vulnerability and
autonomy might need to be ‘reinvented’ with respect to
preventing harm in patients who are subjected to invol-
untary admission. More and deeper empirical knowledge
about types of emotional and existential harm in these
patients will make the debate richer and possibly provide
openings for further humanising health care in situations
that challenge professionals and systems most.
suitable for the aim of this review. Another potential
limitation is that the themes were removed from their
original contexts, which could invite misinterpretation.
We included both qualitative and quantitative studies.
This resulted in a heterogeneous sample of studies and
might have blurred. The number of databases searched
as well the search path chosen may have been insuffi-
cient to identify all relevant references. In the process
of analysis, we only had access to published data in
the reviewed articles; this may have biased our conclu-
sions. Original empirical data are necessary to confirm
our findings.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
Susanne van den Hooff was responsible for the study
conception, design, literature collection, review and
critical analysis and drafting of manuscript and revi-
sions. Anne Goossensen made revisions of the manu-
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

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