Use of coercion in treatment is controversial [1–5], and reducing use of coercion in psychiatric services is a priority health political issue in Western countries [6–8]. Too much use of coercion in mental health care may be a threat to the quality of care, as well as to patients' human rights. It is of crucial importance to develop a better understanding of the processes and factors involved to reduce the use of coercion. There is evidence of considerable variation in the extent to which coercive measures are used. This is shown in international comparative studies [9–11], and among wards and geographical areas in the same country [12–21]. A recent literature review of the incidence of seclusion and restraint comparing data from 12 countries concludes that available data suggest there are major differences among them in the percentage of patients subjected to coercion and the duration of coercive interventions . Several hypotheses are put forward on factors that may explain differences in coercion. These factors can be divided into four groups . The list is not exhaustive and some factors may belong to several categories.
Physical characteristics of ward, size of ward, double or single rooms, crowding and patient turnover [12, 13, 18, 21, 24–26].
Staff/patient ratio, age and sex of staff, experience of staff, proportion of unqualified staff, level of qualifications, de-escalation training, staff turnover, attitudes of staff and administrators [12, 13, 16, 27–39].
Diagnoses, level of aggression, symptoms, age and sex, ethnicity, time of day, season [12, 18, 20, 21, 32, 40].
Pharmacological treatment, use of psychotherapy, treatment by staff including limit setting, activities for patients, ward atmosphere, treatment philosophy and ideology, regulations and guidelines on use of restraint and seclusion, transitions in ward routines [1, 12, 28, 29, 34, 35, 37].
Taken together, the results from studies on differences in the use of coercive measures are not conclusive. Studies tend to be small, and there are few larger comparative studies. A key question is whether differences in the use of coercion among wards may be attributed mainly to composite differences in patient characteristics or to contextual effects such as ward culture, organization or staff attitudes. Our study investigates both patient and ward factors as possible predictors of differences in the use of coercion, and it is to our knowledge the first such study using a statistical multilevel approach.
The aims of the study are to:
(i) investigate frequency and variance in the use of coercive measures in acute psychiatric wards in Norway, and (ii) identify predictors of the use of coercion for involuntary admitted patients, with emphasis on patient, staff and ward characteristics, investigating especially whether mean ward-level staff attitudes to coercion influence the use of coercion.