Dignity: The elephant in the room in psychiatric inpatient care? A systematic review and thematic synthesis.

Involuntary psychiatric inpatient care presents a unique ethical challenge not least because the dignity of a person whose liberty and autonomy are restricted is inherently at risk. Understanding patients' experience of voluntary and involuntary care is an important part of ensuring that dignity is upheld as a key value. This study aimed to provide the first thematic synthesis of the existing literature on patient experience of dignity in voluntary and involuntary inpatient psychiatric care. PubMed (United States National Library of Medicine), PsycInfo (American Psychological Association), the Cochrane Library and bibliographies of relevant articles were searched for peer-reviewed, English-language studies from the start date of the databases through May 2020. Systematic searches identified 202 original papers. Consensus criteria were used to determine study inclusion through abstract and manuscript review. Eighteen articles were initially identified as suitable and nine met criteria for the final analysis. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Given the high proportion of qualitative literature, a thematic synthesis approach was adopted. Critical Appraisal Skills Program (CASP) checklists were used to assess quality of papers. Familiarization and line-by-line coding were carried out on qualitative studies and a thematic framework developed using an iterative approach. Six key themes emerged: coercion; powerlessness; care environment; relationship to staff; impact of involuntary treatment, and paradoxes. These encompassed 15 subthemes, comprising 111 individual statements. Despite dignity being at the core of this review, only five of the identified papers explicitly referenced the term. Nevertheless, core similarities in patient experiences and perspectives existed across a wide variety of primary studies from multiple sites. These themes can be taken to represent the components of dignified care and used as a framework for further research and service reform.