Investigating the Associations between Patient-Reported Quality of Care and Perceived Coercion: A Norwegian Cross-Sectional Study

Abstract

Patient perspectives on the quality of care received are fundamental to mental health care. This study aimed to investigate the association between patient-reported mental health care quality, perceived coercion, and various demographic, clinical, and ward-related factors. Using a cross-sectional design, data were collected from 169 patients in Norwegian mental health wards using the quality in psychiatric care–inpatient (QPC-IP) instrument and experienced coercion scale (ECS). The analysis revealed a consistent pattern in which patients with higher perceived coercion consistently rated lower quality on all QPC-IP dimensions. The significant findings of the multiple regression models further supported this association. Beyond coercion, the factors influencing quality ratings include self-reported treatment results, participation in treatment planning, and knowledge of complaint procedures. Emphasizing the pivotal role of coercion in enhancing mental health care quality, these findings contribute to a nuanced understanding of patient experiences and underscore the importance of patient participation in mental health care improvement efforts.

Introduction

To truly understand the quality of inpatient mental health care, a comprehensive assessment approach is required, involving a careful examination of patients’ perspectives (Staniszewska et al., 2019). In the broader context of health care quality, patient experiences are increasingly emphasized as a foundational pillar (Doyle et al., 2013; Institute of Medicine, 2001). This emphasis is particularly relevant when assessing and enhancing the quality of mental health care services, which are closely tied to valuable insights derived from patients. Thus, this reciprocal relationship benefits both patients and providers, emphasizing the crucial significance of patient experiences (Kilbourne et al., 2018).

Perceived coercion is a pivotal issue in the mental health care experiences of patients. Coercion, broadly defined as the use of pressure to compel compliance, poses a significant challenge to patient autonomy and the overall quality of care provision (Sashidharan & Saraceno, 2017; Szmukler & Appelbaum, 2008). Within the realm of mental health care, coercion takes various forms, including formal, informal, and perceived (Hem et al., 2018; Lessard-Deschênes et al., 2022). Parameswaran et al. (2015) established consensus on the validity and importance of measures related to patient safety and coercion by developing a quality measurement framework. This study aimed to investigate coercion experiences in the context of the quality of care received, highlighting its significance.

Background

The term “quality of care” is multifaceted. Drawing upon Schröder et al. (2006), who described five categories constituting the quality of mental health care from a patient’s perspective, we present them here in a somewhat simplified manner. These categories—respect for dignity, a sense of security in care, active participation in care, recovery, and the environment—encapsulate what patients anticipate from high-quality care. This study used these categories to understand mental health care quality from the patient’s perspective.

Previous research on mental health care quality has explored diverse perspectives, including the relationship between quality of life and quality of care, responsiveness and quality of care, and quality of care and specific diagnoses (Basu, 2004; Bramesfeld et al., 2007; Rasmussen et al., 2020). Numerous initiatives have been undertaken to establish quality indicators for assessing and improving mental health care quality, often categorized as structural, procedural, or outcome-related (Samartzis & Talias, 2019). For example, indicators such as readmission rates and patient satisfaction are frequently used to assess mental health care quality (Donisi et al., 2016; Smith et al., 2014; Woodward et al., 2017).

Patients with first-hand hospitalization experience provide valuable perspectives on the quality of care, offering insights that can be utilized for quality improvement (Beattie et al., 2015). To assess the patients’ perspectives effectively, instruments rooted in patient experiences are vital (Powell et al., 2004). While few eligible instruments measure mental health care quality from a patient’s perspective (Fernandes et al., 2020), Moreno-Poyato et al. (2023) considered the quality-in-psychiatric care (QPC) instrument by Schröder et al. (2010) as the most suitable for evaluating the quality of mental health care.

In previous Nordic cross-sectional studies employing different QPC instruments, the factors associated with enhanced quality of care were identified. In an inpatient context, Schröder et al. (2010) highlighted self-reported mental health at discharge, awareness of diagnosis, satisfaction with treatment duration, and adequacy of the discharge day. For outpatients, Lundqvist et al. (2012) linked improved quality of care to female sex, older age, having a partner, lower educational level, employment status, shorter waiting times, comprehensive information, and interactions with fewer professionals. In a forensic inpatient setting, Schröder et al. (2016) reported gender disparities, with women rating the quality of care as lower. However, higher quality was associated with cohabitation, lower education, individuals being well-informed about their diagnosis, recognition by the responsible physician, and knowledge of complaint procedures.

Coercion in mental health care

Coercion in mental health care encompasses objective (regulated by legal frameworks) and subjective dimensions (Iversen et al., 2002; Mental Health Act, 1999). Objective coercion includes involuntary hospitalization, mechanical restraint, seclusion, and compelling medication (Szmukler & Appelbaum, 2008). Moreover, informal coercion refers to practices employed irrespective of legal regulations, such as pressure, manipulation, persuasion, inducement, and threats (Hotzy & Jaeger, 2016; Szmukler & Appelbaum, 2008). Both formal and informal coercion necessitate the exploration of the subjective dimension involving either perceived or experienced coercion. This perspective acknowledges the complex interplay between external actions and internal experiences (Newton-Howes & Mullen, 2011), navigating the gray area between coercion and voluntariness in psychiatric care, as described by Eriksson and Westrin (1995). Notably, “perceived coercion” and “experienced coercion” are often used interchangeably in the literature.

Newton-Howes and Stanley (2012) emphasize perceived coercion in mental health care, which provides intriguing insights. Notably, ¼ of the voluntarily admitted inpatients felt coerced, while an equal ¼ of involuntarily admitted inpatients did not. Formal legal status is modestly correlated with perceived coercion (Kjellin et al., 2006; Monahan et al., 1995). However, research outcomes are mixed (Newton-Howes & Mullen, 2011), indicating that objective coercion does not always translate into a subjective experience of coercion (Newton-Howes & Stanley, 2012). Additionally, legal detention (Fiorillo et al., 2012; Newton-Howes & Stanley, 2012) and coercive measures (Guzmán-Parra et al., 2019) are associated with increased perceived coercion. In adverse coercion experiences, patients highlight moral injury, including humiliation and dignity violations, more than physical restrictions (Chambers et al., 2014; Nyttingnes et al., 2016). Furthermore, longitudinal studies have suggested a significant improvement in the perceived coercion of hospitalized patients over time (Fiorillo et al., 2012).

To the best of our knowledge, no previous studies have addressed the relationship between perceived coercion and experienced quality of mental health care. Therefore, this study aimed to investigate the association between how patients report the quality of mental health care and perceived coercion. Additionally, the study aimed to explore the relationships between patient-reported quality of care, demographic, clinical, and ward-related factors, and perceived coercion.

The study aimed to answer the following research questions:

1. Are there differences in the reported quality of care between patients who perceived high- and low-coercion?

2. Is there a difference in the reported quality of care between voluntarily and involuntarily admitted patients?

3. Are there differences in the reported quality of care between voluntarily and involuntarily admitted patients who report high levels of perceived coercion?

4. What are the associations between patient-reported quality of care and their demographic, clinical, and ward-related factors, as well as perceived coercion?

Methods

Design

This study employed a cross-sectional design. The STROBE statement checklist was used to report the study (Vandenbroucke et al., 2007).

Setting and recruitment

Inpatient mental health wards in Norwegian specialized hospital trusts constituted the study setting. Norway’s mental health care services comprise specialized hospital trusts, which include hospitals and district psychiatric centers (DPC), in addition to community health services such as general practitioners, local emergency services, home care, and various supported housing options. These services are publicly funded, and specialized health care services are delivered by four regional health authorities (Reitan & Lien, 2023).

A stepwise approach was used to gain access to this field of research. Initially, we approached six hospital trusts across three Norwegian regional health authorities, with three agreeing to participate. Subsequently, 14 wards from five locations (hospitals and DPCs) in the middle and eastern Norwegian regions agreed to participate. A clinically experienced nurse was assigned to each ward as the contact person responsible for recruiting patients.

Study participants

The study targeted patients admitted to the included mental health wards, and consecutive recruitment was conducted. The inclusion criteria required participants to have cognitive capacity to fill out the questionnaire; a hospital admission duration of at least 3 days before discharge; be ready for discharge, age ≥18 years; and could read, understand, and express themselves in Norwegian. All patients who met the inclusion criteria were invited to participate. The contact person addressed the eligible patients during the last 3 days before the expected discharge and informed them orally and in writing about the study. During the data collection period, 169 patients consented to participate and completed the questionnaire.

Data collection

Data were collected using a self-report questionnaire that participants completed during the final 3 days of their hospitalization. The questionnaire was delivered to the participants by a contact person who explained the delivery process and encouraged them to fill it out as soon as possible. At times, the contact person provided friendly reminders regarding the completion of the questionnaires. However, this process lacked systematic consistency and was dependent on the individual contact person’s discretion. Each ward participated for approximately 6 months, and data were collected between January 1, 2021, and July 1, 2022.

Questionnaire

The questionnaire consisted of a section with demographic variables and two validated instruments: the quality in psychiatric care–inpatient (QPC-IP) Instrument and the experienced coercion scale (ECS).

The quality in psychiatric care–inpatient instrument (QPC-IP)

The QPC-IP (Schröder et al., 2010) is a 30-item instrument developed in Sweden that assesses six dimensions of quality of care: Encounter, Participation, Discharge, Support, Secluded Environment, and Secure Environment. Each item is rated on a 4-point Likert-type scale ranging from “totally disagree” (1) to “totally agree” (4), with a “not applicable” option available. Mean scores above 2.5 indicate high quality. The original QPC-IP has a total Cronbach’s alpha of 0.96, indicating excellent reliability (Schröder et al., 2010; Schröder & Lundqvist, n.d.). The QPC-IP has demonstrated clinical and statistical relevance, which has been corroborated in various language versions globally (Lin et al., 2021; Lundqvist et al., 2018; Sanchez-Balcells et al., 2021). It was translated, adapted, and validated in Norwegian language and context in our previous study (Unpublished observations) and yielded a Cronbach’s Alpha of 0.94.

The experienced coercion scale (ECS)

The ECS (Nyttingnes et al., 2017) is a unidimensional, 15-item self-report instrument developed in Norway to measure and compare experienced coercion [perceived coercion] across various care settings and clinical pathways. Patients rated their level of coercion on a 5-point Likert scale. The interpretation of the ratings was as follows: 0–1 indicates no perceived coercion, 1–2 indicates low perceived coercion, 2–3 indicates noteworthy perceived coercion, and 3–4 indicates high perceived coercion. The cutoff is ≥2 for being assigned to the “high-perceived coercion” group. Two items were reverse-scored (items 5 and 6) (Nyttingnes, 2016). The ECS demonstrated promising psychometric properties and a Cronbach’s alpha coefficient of 0.95, indicating high internal consistency (Nyttingnes et al., 2017). The Cronbach’s alpha was 0.94 in this study.

Analysis of data

All statistical analyses were conducted using IBM SPSS Statistics version 29.0. Before analysis, questionnaires with ≥30% missing items on the QPC-IP (14 questionnaires) and ≥33% missing items on the ECS (29 questionnaires) were discarded (Nyttingnes, 2016; Schröder & Lundqvist, n.d.). A total of 130 participants completed both the QPC-IP and ECS. Imputation procedures were employed exclusively for the QPC-IP, where missing values were replaced with group mean values for each dimension (Fox-Wasylyshyn & El-Masri, 2005). In total, 17 items were imputed across a total of 13 questionnaires on the QPC-IP. In line with the ECS manual, the data were not imputed into the ECS (Nyttingnes, 2016). Participants with a rating of two or above on the ECS instrument were classified into the high-perceived coercion group.

Descriptive statistics, including frequencies, percentages, means (M), and standard deviations (SD), were used. Group comparisons were assessed using the Mann-Whitney U tests (Tabachnick & Fidell, 2013).

Univariate and multiple linear regression analyses were conducted to explore the associations between the dependent variable (QPC-IP total score) and ECS score, along with other potential explanatory variables. Initially, univariate regression analyses were performed on the QPC-IP total scores with all background variables (participant characteristics and clinical- and ward-related factors), as well as the scores on the ECS, all serving as independent variables. Having 130 participants limited the number of independent variables included in the multiple regression models. Excluding variables with p value ≥ 0.20 (Katz, 2011) from the subsequent multiple regression models reduced the number of variables. Subsequently, all variables that met the specified criteria were entered into backward and forward multiple regression analyses. Variables found to be significant at p ≤ 0.05 were then included in a fixed (Enter) model, resulting in Model 2. Additionally, Model 1, adjusted for age and sex, was created, despite age and sex having p-values > 0.20 in the initial univariate analyses.

All variables were checked for multicollinearity and interactions to ensure statistical robustness. Living arrangements were dichotomized into “cohabitating” or “living alone.” The significance of the multiple regression models was assessed through residual distribution using the Kolmogorov-Smirnov and X² tests, both of which were preferred to be non-significant (Tabachnick & Fidell, 2013).

All tests were considered statistically significant at a p-value ≤ 0.05.

Ethical considerations

This study adhered to the principles outlined in the Declaration of Helsinki and was approved by the Norwegian Regional Ethical Committee REC Central (Ref. 113987). The front page of the questionnaire contained information about the study, emphasizing the voluntary nature of participation, confidentiality, and ethical approval.

Participants who voluntarily consented to participate completed an anonymous questionnaire, placed it in a sealed envelope, and deposited it in a designated sealed box within the staff area. Returning the completed questionnaire was considered equivalent to providing written consent.

The research group had no means of tracing the participants’ identities. Although no linking key connected participants to the collected data, it is important to note that the questionnaire included a code enabling tracking of the originating ward. The results were aggregated at the group level to ensure the anonymity of the individual participants. The presentation of the results avoids granularity beyond the group level, preventing identification at the hospital or ward level.

Results

Sample characteristics

Of the 14 wards, 11 reported a response rate of 61.3% from invited participants. Due to ethical considerations and the approval granted by the REC, we were restricted from conducting an analysis of non-participants. The participants had a mean age of 41.17 (SD = 18.4), and 58.5% were women. Out of the total sample, 104 participants (80%) reported low-perceived coercion, and 26 participants (20%) reported high-perceived coercion. The high- and low-perceived coercion groups did not show significant differences in age (z = −1.22, p = 0.22), sex (x² = 0.03, p = 0.89), or living arrangement (z = −0.36, p = 0.72). Further study participants characteristics are presented in Table 1.

Table 1. Descriptive characteristics, encompassing all background variables, of the total sample and the two perceived coercion groups.

		Perceived coercion groups
Characteristic	Total sample	Low	High
	M (SD)	M (SD)	M (SD)
Age	40.3 (17.8)	42.5 (19.3)	36.0 (13.0)
	Total N (%)	N (%)	N (%)
Sex
Male	54 (41.5)	44 (81.5)	10 (18.5)
Female	76 (58.5)	60 (78.9)	16 (21.1)
Living arrangement
Living alone	89 (58.5)	61 (58.7)	17 (65.4)
Cohabitating	65 (24.6)	42 (40.4)	9 (34.6)
Education
Not finished compulsory school	2 (1.5)	1 (1.0 %)	1 (3.8)
Compulsory school	20 (15.4)	17 (16.3)	3 (11.5)
Senior high school	69 (53.1)	56 (53.8)	13 (50.0)
University exam	39 (30.0)	30 (28.8)	9 (34.6)
Daily activity/employment
In paid employment	61 (47.9)	49 (47.1)	12 (46.1)
Long term disabled	44 (33.9)	32 (30.8)	12 (46.1)
Other	24 (18.3)	22 (21.2)	2 (7.7)
Previously admitted
Yes	92 (70.8)	72 (69.2)	20 (76.9)
No	38 (29.2)	32 (30.8)	6 (23.1)
Self-reported treatment result
Much worse or worse	13 (10.0)	2 (1.9)	7 (41.6)
Better or much better	111 (85.4)	97 (93.3)	14 (53.9)
Missing data	6 (4.6)	5 (4.8)	1 (3.8)
Participation in treatment planning
No	26 (20.0)	15 (14.4)	11 (42.3)
Yes	102 (78.5)	89 (85.6)	13 (54.2)
Length of hospital stay
Up to 2 weeks	40 (25.8)	28 (26.9)	5 (19.2)
2–4 weeks	55 (35.5)	37 (35.6)	7 (26.9)
4 weeks–2 months	23 (14.8)	16 (15.4)	5 (19.2)
More than 2 months	35 (22.6)	22 (21.2)	9 (34.6)
Information of diagnosis
No	25 (19.2)	20 (19.2)	5 (19.2)
Yes	87 (66.9)	69 (66.3)	18 (69.2)
Have not received a diagnosis	17 (13.1)	14 (13.5)	3 (11.5)
Admission status
Voluntary	90 (69.2)	80 (76.9)	10 (38.0)
Involuntary or observation	37 (28.5)	21 (20.1)	16 (62.0)
Do not know	3 (2.3)	3 (2.9)	0
Knowledge of complaint procedures
No	66 (50.8)	52 (50.0)	14 (53.8)
Yes	64 (49.2)	52 (50.0)	12 (46.2)
Want to return to the ward if necessary
Absolutely not or rather not	14 (10.8)	4 (3.9)	10 (38.4)
Maybe	18 (13.9)	13 (12.5)	5 (19.2)
Gladly or absolutely	98 (75.4)	87 (83.7)	11 (42.3)
Mental health at discharge
Very good or good	67 (51.5)	95 (56.7)	8 (30.7)
Not good or bad	38 (29.2)	27 (26.0)	11 (42.3)
Bad or very bad	25 (19.3)	18 (17.3)	7 (26.9)
Physical health at discharge
Very good or good	59 (45.5)	49 (47.1)	10 (38.4)
Not good or bad	47 (36.2)	38 (36.5)	9 (34.6)
Bad or very bad	24 (18.5)	17 (16.3)	7 (26.9)

Reported quality of care related to perceived coercion levels and admission status

Overall, the participants consistently rated the Secluded Environment dimension as the highest in quality while assigning the lowest ratings to the Participation dimension. This pattern persisted when participants were grouped into low- and high-perceived coercion groups, with both groups consistently rating Secluded Environment as the highest and Participation as the lowest in quality of care. Subsequently, the rating levels varied across the remaining QPC-IP dimensions between groups. In the high-perceived coercion group, lower quality ratings were observed across all dimensions, with statistical significance reached in all dimensions except for Secluded Environment, where the p value slightly exceeded 0.05. These findings highlight the differences in the reported quality of care between patients with high- and low-coercion perceptions. The mean and standard deviations of the six QPC-IP dimensions by the low- and high-perceived coercion groups are presented in Table 2.

Table 2. Mean and SD of QPC-IP dimensions in the total sample and between the low- and high-perceived coercion groups.

		Perceived coercion
	Total (n = 130)	Low perceived coercion (n = 104)	High perceived coercion (n = 26)	Mann Whitney U test
QPC-IP dimension	Mean (SD)	Mean (SD)	Mean (SD)	Z	p
Encounter	3.46 (0.63)	3.63 (0.46)	2.79 (0.76)	−5.290	>0.001
Participation	3.10 (0.71)	3.27 (0.57)	2.28 (0.65)	−5.775	>0.001
Support	3.38 (0.62)	3.51 (0.49)	2.85 (0.78)	−4.292	>0.001
Discharge	3.26 (0.64)	3.37 (0.57)	2.81 (0.69)	−4.191	>0.001
Secluded environment	3.60 (0.52)	3.67 (0.43)	3.36 (0.73)	−1.943	0.052
Secure environment	3.40 (0.60)	3.50 (0.52)	3.03 (0.75)	−3.067	0.002

The mean (M) and standard deviation (SD) of the QPC-IP dimensions by ECS score were dichotomized as low and high-perceived coercion. Responses ranged from 1 (totally disagree) to 4 (totally agree). Mann-Whitney U test for differences between groups.

When examining the differences in the reported quality of the voluntary and involuntary admission groups, the findings showed that Secluded Environment received the highest rating, while Participation received the lowest rating in both groups. Notable differences were observed only in the Encounter and Participation dimensions. Voluntarily admitted patients rated these dimensions higher than involuntarily admitted patients, as shown in Table 3.

Table 3. Mean and SD at QPC-IP related to admission status groups.

	Admission status
	Voluntary admitted (n = 92)	Involuntary admitted (n = 38)	Mann Whitney U test
QPC-IP dimension	Mean (SD)	Mean (SD)	Z	p
Encounter	3.53 (0.62)	3.37 (0.56)	−2.062	0.039
Participation	3.20 (0.68)	2.85 (0.64)	−3.124	0.002
Support	3.43 (0.58)	3.28 (0.66)	−1.431	0.152
Discharge	3.27 (0.66)	3.28 (0.46)	−1.026	0.305
Secluded environment	3.67 (0.43)	3.53 (0.63)	−1.183	0.237
Secure environment	3.43 (0.62)	3.32 (0.60)	−1.270	0.204

Means (M) and standard deviations (SD) of QPC-IP dimensions related to admission status. Responses ranged from 1 (totally disagree) to 4 (totally agree). Mann-Whitney U test for differences between groups.

When examining the group with high perceived coercion in relation to admission status, the Secluded Environment received the highest rating and Participation the lowest. The groups exhibited significant differences only in the Support and Secure Environment dimensions, with those who were voluntarily admitted with high-perceived coercion rating these dimensions lower, as presented in Table 4. The “voluntarily admitted high-perceived coercion” group was the only group rating quality below the middle-point for good quality of care (≤2.5) in every dimension except for Secluded Environment.

Table 4. Mean and SD at QPC-IP dimensions related to a high level of perceived coercion, grouped by admission status.

	High perceived coercion AND voluntary admitted (n = 10)	High perceived coercion AND involuntary admitted (n = 16)	Mann Whitney U test
QPC-IP dimension	Mean (SD)	Mean (SD)	Z	p
Encounter	2.39 (0.80)	3.04 (0.64)	−1.927	0.054
Participation	2.03 (0.62)	2.43 (0.64)	−1.530	0.126
Support	2.46 (0.55)	3.09 (0.82)	−2.351	0.019
Discharge	2.46 (0.52)	3.25 (0.52)	−1.768	0.077
Secluded environment	3.25 (0.54)	3.42 (0.84)	−1.323	0.186
Secure environment	2.60 (0.73)	3.29 (0.64)	−2.237	0.025

Means (M) and standard deviations (SD) of the QPC-IP dimensions related to highly perceived coercion grouped by admission status. Responses ranged from 1 (totally disagree) to 4 (totally agree). Mann-Whitney U test for differences between groups.

Multiple relationships of the findings

The multiple regression models revealed that higher levels of perceived coercion were significantly associated with lower QPC-IP ratings, as shown in Table 5. Among background variables, only self-reported treatment results, participation in treatment planning, and knowledge of where to complain were significantly associated with higher QPC-IP ratings. Model 1, adjusted for age and sex, did not show an association between these background characteristics and QPC-IP.

Table 5. Multiple associations with the QPC-IP.

	Model 1				Model 2
	R^2	Kolmogorov-Smirnov	X^2		R^2	Kolmogorov–Smirnov	X^2
	0.619	0.088	0.239		0.616	0.200	0.262
Variable	Standardized Beta	Unstandardized B	CI B	p-value	Standardized beta	Unstandardized B	CI B	p-value
QPC-IP (constant)		2.344	1.818–2.870	<0.001		2.386	1.935–2.836	<0.001
Perceived treatment result	0.311	0.233	0.138–0.328	<0.001	0.304	0.227	0.134–0.321	<0.001
Participation of planning	0.150	0.187	0.030–0.344	0.020	0.151	0.189	0.034–0.344	0.017
Know where to complain	0.149	0.148	0.030–0.266	0.015	0.152	0.151	0.035–0.267	0.011
ECS (perceived coercion)	−0.507	−0.277	−0.349–−0.206	<0.001	−0.505	−0.276	−0.348–0.205	<0.001
Age	−0.033	−0.001	−0.004–0.002	0.583
Sex	0.044	0.044	−0.071–0.160	0.449

The two models for the explanation of ratings on the QPC-IP.

The residuals in both models exhibited a normal distribution, as confirmed by the non-significant Kolmogorov–Smirnov and X² tests.

Discussion

To our knowledge, this is the first study to investigate the association between the quality of mental health care and perceived coercion. Overall, the participating patients consistently rated the quality of care as high but reported low levels of perceived coercion. This positive trend indicates that the care received is generally of good quality. Remarkably, in both the total sample and across various subgroups, patients consistently rated the Participation dimension as having the lowest quality. This dimension encompasses crucial aspects such as influencing one’s care, involvement in decisions, and receiving necessary information. Our findings indicate that the factors within this dimension may not have been adequately addressed in the wards.

Our findings, coupled with the global recognition of patient participation in mental health policymaking since the early 21^st century, including its status as a legal right (Patient and User Rights Act, 2001; World Health Organization, 2023), suggest a gap between ideals and realities in clinical practice. This observation aligns with the findings of a Norwegian qualitative study in which participants revealed that their involvement in decision-making was disregarded, even when service providers demonstrated kindness in their care (Storm & Davidson, 2010). Furthermore, experiences of not being given the choice to participate and staff exerting unnecessary control were reported in another Norwegian study (Husum et al., 2019). The reported findings are interesting, particularly considering the advocacy for a fundamental shift in the mental health provider-patient relationship to genuinely integrate patient participation (Newman et al., 2015). Together, these findings highlight the need to overcome the gap between policy ideals and the practical implementation of patient participation in mental health care.

The significant association between the quality of care and perceived coercion implies that patients could have been affected by similar factors, such as the ward atmosphere or culture (Staniszewska et al., 2019). However, the cross-sectional nature of our study design did not allow us to determine the causality of this relationship. Hence, it remains unclear whether patients perceived less coercion due to a more positive view of care quality or if a high level of perceived coercion led to lower ratings of care quality. Moreover, the factors contributing to these evaluations may act independently, necessitating further investigation. By contrast, Hansson et al. (2007) argued that varying evaluations of psychiatric patients’ perceptions of care may reflect an overarching attitude within the individual. Their findings revealed that >50% of the variability in patient ratings, including quality of life, needs, symptoms, and treatment satisfaction, were associated with a general tendency for either positive or negative appraisals (Hansson et al., 2007). Therefore, our findings regarding the association between the quality of care and perceived coercion could be understood with regard to such a general tendency for positive or negative appraisals among patients. However, further research is required to explore this relationship.

Our findings revealed that 20% of the patients reported high-perceived coercion during hospitalization. Remarkably, the group perceiving high coercion consistently reported a significantly lower quality of care across all dimensions except the Secluded Environment dimension. However, it is noteworthy that even for this dimension, the reported values were lower. The Secluded Environment dimension comprises items related to access to a private place, individual room, or private area for receiving visitors. In Norwegian mental health hospitals, the provision of individual rooms in psychiatric hospital settings is a common practice and legal recommendation, as stipulated in the Regulation on Mental Health Care (2011). This implies that, in this dimension, only minor differences between the groups were expected.

While it is anticipated that increased perceived coercion will be associated with lower quality ratings, the phenomenon of perceived coercion was present in hospital wards in this study. Drawing on important findings from Husum et al. (2022), the authors suggest that instances of infringement and violations are commonplace in the Norwegian mental health care system, potentially contributing to more perceived coercion. Notably, in the current study, the percentage of patients reporting coercion (20%) was lower than what was observed in another Norwegian sample reported by Kjøllesdal et al. (2017), where 30% reported feeling inadequate respect or experiencing humiliation during their care. When comparing the findings of these studies, it must be clarified that the terms “humiliation” and “inadequate respect” do not directly translate into “perceived coercion”, as is the concept used in the ECS instrument.

Interestingly, Nyttingnes et al. (2018) reported from a sample of Norwegian adolescent inpatients using the ECS that 34.4% of the participants reported a high level of experienced coercion. However, questioning the comparability between an adolescent and adult sample raises concerns, warranting caution in the interpretation of these comparisons. Similarly, the choice of instrument may contribute to the prevalence of coercion, as discussed by Newton-Howes and Stanley (2012). They reported a higher prevalence of perceived coercion in studies using the MacArthur Perceived Coercion Scale (MPCS) compared to studies using visual analog scales or the Coercion Ladder. Unfortunately, we have not identified further studies using the ECS beyond that conducted by Nyttingnes et al. (2018), as mentioned earlier. This poses challenges in comparing prevalence and establishing benchmarks in the assessment of perceived coercion in similar contexts.

In terms of admission status, formal coercion appeared to have less influence on the reported quality of care than perceived coercion. Nevertheless, the group of involuntarily admitted patients rated quality lower across all dimensions, except for Discharge, where the ratings were comparable to those of the voluntary group. Significant differences were observed only in the Encounter and Participation dimensions. These findings align with those of previous studies reporting lower satisfaction with care among patients admitted involuntarily (Katsakou et al., 2010; Smith et al., 2014; Sørgaard, 2007). In contrast, Goula et al. (2021) reported that involuntarily admitted patients were significantly more satisfied with the overall quality of services provided during hospitalization. Patient satisfaction, though not directly interchangeable with quality of care, is considered as an indicator thereof; thus, measuring it is a common approach when measuring care quality (Woodward et al., 2017).

Examination of the high-perceived coercion group, especially when divided by admission status, revealed noteworthy findings. The voluntarily admitted subgroup consistently rated care quality below the middle value for good quality (Schröder & Lundqvist, n.d.) across all dimensions except for the Secluded Environment. However, because of the small sample size of only 10 patients, these results must be interpreted with caution. Nonetheless, the other subgroups consistently rated above the middle point for good quality in most dimensions except for Participation. Our results align with Newton-Howes and Mullen (2011) study, emphasizing a consistent correlation between a patient’s lack of involvement in treatment decisions [participation] and perceived coercion linked to a sense of feeling dehumanized. These insights underscore the need for future studies with larger sample sizes to validate and better understand this pattern.

The number of patients perceiving high coercion was relatively low, limiting the ability to analyze variance across patients in different wards. As internal ward cultures may contribute to increased coercion and infringement (Keski-Valkama et al., 2007), investigating coercion across wards would have been interesting. In wards, the physical environment can be restrictive, and power imbalances between professionals and patients can easily lead to coercive experiences (Andersson et al., 2020). However, our univariate analysis did not reveal any significant influence of the ward type. Concurrently, the limited number of patients perceiving high levels of coercion may also be ascribed to measurement timing (last 3 days before discharge). According to a previous study, perceived coercion decreases significantly over time (Fiorillo et al., 2012). Thus, it is reasonable to suggest that perceived coercion may have been higher at the time of admission among our study participants, highlighting the relevance of screening for perceived coercion during hospitalization for future research and treatment.

The variable that demonstrated the strongest relationship with quality of care in the multiple regression models was perceived coercion. Due to the absence of studies that have directly examined this relationship, it is difficult to make comparisons. However, considering the study by Norvoll et al. (2017) that identified structural and cultural factors in mental health services as key sources of moral unease, the participants expressed concerns about unwarranted coercion and compromised treatment quality. These findings, coupled with our finding of a strong correlation, underscore the significance of perceived coercion as a crucial factor in evaluating the quality of mental health care and, thus, an issue to investigate further.

Other variables demonstrating a significant relationship with the QPC-IP ratings were self-reported treatment results, participation in treatment planning, and knowledge of where to complain. When comparing these findings with those from other studies utilizing QPC-IP instruments, no consistent findings regarding demographic, clinical, and ward-related factors correlated with quality of care were observed. For instance, in our study, we did not find a significant association with female sex, whereas other studies (Lundqvist et al., 2012; Schröder et al., 2016) reported it as significant.

Methodological considerations

One limitation of this study is the lack of monitoring for coercive measures administered during hospitalization. The use of coercive measures could have influenced both the ECS and QPC-IP ratings. However, it is crucial to note that subjecting voluntarily admitted patients to coercive measures is generally not permitted in Norway. Therefore, this limitation primarily applies to patients who were admitted involuntarily.

Participation in the study was restricted to patients with proficiency in reading and understanding Norwegian. Consequently, it is possible that significant information regarding patients lacking proficiency in reading Norwegian was inadvertently disregarded.

As a vulnerable group, the participants in this study played a crucial role in shaping and evaluating mental health care services. Amplifying their voices and opinions is of great significance and is considered a strength of this study. With a response rate of 61.3% considered acceptable in this setting, caution should still be exercised regarding generalizability (Polit & Beck, 2017).

The QPC-IP instrument employed in this study demonstrated its robustness as a measure of quality of care from a patient’s perspective. The ECS instrument, while less commonly used, was designed to address some challenges faced by earlier instruments aimed at measuring perceived or experienced coercion. Widely utilized instruments for assessing perceived coercion include the Coercion Ladder and MacArthur Perceived Coercion Scale (MPCS), both developed for measuring perceived coercion at admission (Hoyer, 1999). Although the ECS has been less tested, it is intended to overcome some challenges with previous instruments. Specifically, it is designed to be applicable throughout the entire hospitalization period, not only at admission time (Nyttingnes et al., 2017).

Conclusions

This study investigated the associations among quality of care, perceived coercion, and various factors in mental health inpatient settings. The findings revealed a significant correlation between the quality of mental health care and perceived coercion. Patients reporting high-perceived coercion consistently rated lower across all QPC-IP dimensions. Factors such as self-reported treatment results, participation in treatment planning’, and knowledge of where to complain were associated with higher quality ratings.

In conclusion, our study pioneered a quantitative investigation of the association between the quality of care and perceived coercion in mental health care settings. Despite the overall high care quality ratings from patients, a consistent and concerning trend emerged, indicating lower ratings in the Participation dimension. This dimension, covering crucial factors such as influencing one’s care and involvement in decisions, highlights potential shortcomings in care provision within clinical settings. The findings indicate a need to improve how patient participation is addressed in mental health care to enhance the quality of care. Additionally, quality of care could be improved by addressing perceived coercion, ensuring that patients feel more involved and less coerced in their treatment process.

Implications for practice

Based on our findings, addressing perceived coercion in clinical practice is crucial. Recognizing perceived coercion is imperative for leaders, policymakers, and clinicians, highlighting that its determination lies not solely within legal statutes but also in the subjective perception of the treatment experience. Clinicians face the challenge of deepening their understanding of the factors influencing perceived coercion and developing strategies, including interventions that minimize harm, particularly through active engagement in fostering patient participation.

Acknowledgements

We would like to thank all the participants for their invaluable responses to the questionnaires. Our appreciation also goes to the leaders and contacts in the wards for their valuable support in the recruitment, distribution, and collection of the questionnaires. Special thanks to Jan Porthun (Faculty of Medicine and Health, Institute of Health Sciences, NTNU, Gjøvik, Norway) and Lars-Olov Lundqvist (Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden) for their expert statistical supervision.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.