Activities and technologies: developing safer acute inpatient mental health care
Authors: Alan Simpson
Journal: World Psychiatry (2022)

Johnson et al1 provide a comprehensive and illuminating review of the evidence and key issues in relation to acute and crisis mental health care. As they suggest, psychiatric inpatient care is most often un­­popular – with both patients and many staff – and can be traumatizing, re-traumatizing and coercive. Huge tensions exist around keeping se­­verely mentally distressed people safe whilst trying to build and sustain engaging, accepting, therapeutic relationships and milieu, often within health care sys­­tems and organizations that are inadequately funded and woefully understaffed. Those staff that commit their time and energies to providing inpatient care often do so with great skill and humanity. A cross-national comparative case study2 reported positive practice within acute in­­patient wards, with evidence of safe, respectful, compassionate care. Patients were aware of efforts taken to keep them safe, but did not feel routinely involved in care planning or risk management decisions. Research on increasing therapeutic contact time, shared decision making in risk assessment, and using recovery-focused tools could further promote personalized care planning. The ever-present issue of boredom on psychiatric wards is also highlighted in Johnson et al's paper. Freely available initiatives such as Star Wards (www.starwards.org.uk) provide multiple creative suggestions for increasing interactions on busy mental health wards, and can create opportunities for staff and patients to engage in conversations and collaboration to design and implement constructive activities. There is a pressing need for research to investigate the organizational factors that need to be put in place to support more interactive, productive environments in acute mental health care3. Whether such solutions are possible within restrictive and risk-averse contexts remains to be seen. Activities to be considered, in addition to relief of boredom, include encouraging engagement, appraising the ability to undertake activities of daily living, preparing for discharge, and supporting tentative steps towards recovery. It may be unlikely that all these needs can be adequately met in the typically short time spent on a ward, whilst also consid­ering the varying demographic and dia­g­nostic profiles. This applies in particular to the development of the necessary skills and confidence to build and maintain re­covery while engaging with an often threat­ening outside world. ­Multidisciplinary ap­­­­proaches involving occupational therapists and peer workers may offer a way forward. Johnson et al1 highlight evidence supporting the use of Six Core Strategies and Safewards to reduce conflict and the use of containment measures on inpatient wards. A recent review acknowledged the increased evidence base for the efficacy of Safewards on acute wards in various countries4. More research is required to evaluate adaptations in psychiatric intensive care units, secure mental health services, emergency departments, and wards for other age groups. However, the staff shortages and considerable pressures faced by those working in mental health care also create considerable barriers for those implementing interventions5 and undertaking related research6. A narrative review of the literature7 found a relatively small body of research on the use of closed circuits television (CCTV) to increase security for patients and staff in acute psychiatric units, but recognized the trade-off with privacy. CCTV increased sub­jective feelings of safety amongst patient and staff, but there was no evidence that it increased objective security or reduced vi­olence. CCTV and, more recently, infrared cameras have also been used to conduct close ob­servations and monitoring of vital signs in patients, including in seclusion. Such tech­nology can be less invasive for patients, reduce sleep disruption when making checks, and can be preferred by some patients as it avoids staff entering a person's private space. This may reduce triggers for conflict and aggression, and subsequent psychological harm associated with containment measures. Video monitoring can also allow over-stimulated patients to be left alone, while enabling staff to carry out their observations. On the other hand, the use of electronic surveillance can be seen as distancing and dehumanizing. Studies suggest that the main factor in comforting patients and re­­ducing trauma during an episode of se­clu­sion or restraint is contact and commu­nication with staff8. Symptoms of fear, dis­­­­trust or delusions can be worsened in some patients, and there are concerns that CCTV might increase paranoid thoughts or trigger distressing memories of prior abuse involving videos. Video cameras might di­rectly contribute to an atmosphere of de­tachment, control and fear, which could promote occurrence of the very events that surveillance is supposed to reduce. Video­ing patients, especially in distress, can fuel feelings of shame and touches the right to privacy. These concerns and the need for more re­search are important, as the increasing availability and affordability of digital technol­ogies has seen body worn cameras (BWC) being introduced to inpatient units, in emer­gency departments and for paramedics in ambulances. BWCs are small devices that can be worn on clothing, which record sights and sounds in the vicinity of the wearer. Men­tal health staff are being asked to wear BWCs and to switch them on during inci­dents, or sometimes at the request of a pa­tient. It is hoped that the use of BWCs will defuse situations, reduce aggression, and increase accountability and evidence-gathering around serious incidents. How­ever, a recent systematic review of the liter­ature identified only two low-quality eval­uations of BWC use in mental health wards, with mixed results though some indication of reductions in more serious incidents9. In conclusion, addressing the activity and engagement needs of patients on busy pressured wards can be regarded today as a priority, whereas the idea of using electronic surveillance in acute mental health settings is not supported at the moment by convincing research evidence and is generating significant concerns.