The ward atmosphere of single-sex wards in a maximum-security forensic psychiatric hospital in Sweden

Gender and intersecting vulnerabilities on the mental health unit: Rethinking the dilemma

BACKGROUND

Gender is routinely pitched as a key determinant of vulnerability for staff and residents on acute mental health inpatient units. Since the 1960's mixed gender units have become more prominent in Western health systems, yet questions remain around the configuration of these units, including how to ensure emotional and physical safety of those living and working in them.

METHODS

This paper draws on a large study of the lived experiences of 42 staff and 43 service users from different acute mental health units in New Zealand. We conducted thematic analysis of interview data from four units with diverse architectural layouts to identify key themes central to decisions around gender and spatial design.

RESULTS

Key themes emerged around gender-related trauma histories, safety perceptions and vulnerabilities, accommodation of gender-diverse and non-binary mental health service users, and gender-specific needs and differences. A further theme, of it goes beyond gender emphasized that there are many other non-gender attributes that influence vulnerability on the unit.

CONCLUSIONS

While findings emphasize the need for safe places for vulnerable people, trauma-informed care, access to staff who "understand," and recreation that is meaningful to the individual, we question if the dilemma of gender-separation vs. gender-mixing is an outmoded design consideration. Instead, we argue that a flexible, person-centered approach to provision of care, which values autonomy, privacy, and safety as defined by each service user, and that promotes choice-making, obviates a model where gender accommodations are fore. We found that a gender-exclusive narrative of vulnerability understates the role of other identifiers in dynamics of risk and vulnerability, including age, physicality, past violence, trauma history, mental unwellness, and substance use. We conclude gender need not be a central factor in decisions around design of prospective built unit environments or in occupational and clinical decisions. Instead, we suggest flexible spatial layouts that accommodate multiple vulnerabilities.

Validating the Essen Climate Evaluation Schema modified for people with learning disabilities in a low-risk secure forensic setting

BACKGROUND

Research has shown that an empowering and nurturing yet challenging work climate is beneficial for people receiving clinical services as it increases patient satisfaction, motivation, engagement, therapeutic alliance and functional improvement. Therefore, for inpatients, monitoring, encouraging and understanding ward climate holds considerable potential for improving forensic mental health services. To date, the most widely employed tool for ward-climate, the Essen Climate Evaluation Schema (EssenCES), has been evidenced as useful in medium and high security hospitals, but little tested with people with learning disabilities or in low security services.

AIMS

To establish the internal consistency and factor validity of the EssenCES, modified for easier reading, in a low secure hospital unit for people with learning disabilities.

METHOD

Language in the EssenCES was simplified and picture supplements added to facilitate comprehension. Patients completed the scale as part of their clinical routine, supported by National Health Service (NHS) employed psychology assistants. The research team, entirely independent of NHS staff, extracted data from the electronic records of purposively sampled residents in a low-secure forensic hospital setting for people with learning disabilities.

FINDINGS

Two hundred and twenty-seven records (70% men) were acquired. The EssenCES was shown to have good factor validity and retained the original three factor model including the subscales: therapeutic hold, safety and cohesion. One single-item from the 'therapeutic hold' subscale was removed to improve the internal consistency (p < 0.05).

CONCLUSIONS

This study adds preliminary support for the use of the EssenCES (with removal of one item) in individuals with learning disabilities within low-risk secure forensic hospital settings.

Exploration of staff attitudes and experiences towards mixed- and single-sex wards in the National Secure Forensic Service for Young People

Mixed-sex wards in adult forensic secure services have been abolished and replaced by single-sex services. The National Secure Forensic Service for Young People (NSFSYP) continues to use a mixture of single-sex male and mixed-sex wards. This study aimed to explore staff experiences and attitudes towards placing young people in mixed- or single-sex wards in the NSFSYP. Mixed methodology was adopted in the form of focus groups (qualitative) and questionnaires (semi-quantitative). Content analyses of the qualitative data revealed five themes: care of female patients, normalization, safety, commissioning and social representation of women. The questionnaire was developed from the qualitative findings and comprised 22 statements measuring attitudes towards mixed- and single-sex wards. One hundred and forty-five questionnaires were returned: a 44% total response rate. Overall, the responses to the questionnaire confirmed the focus group data. There were statistically significant differences in responses between staff working on mixed- and single-sex wards. Staff working on mixed-sex wards felt that mixing genders on wards is a crucial part of adolescent forensic inpatient treatment. For them, mixed wards provide a more developmentally appropriate environment for young people. The needs of female patients broaden the debate beyond segregating and mixing gender.

Social climate along the pathway of care in women's secure mental health service: variation with level of security, patient motivation, therapeutic alliance and level of disturbance

BACKGROUND

Social climate has been measured in a variety of therapeutic settings, but there is little information about it in secure mental health services, or how it may vary along a gender specific care pathway.

AIM

To assess social climate in women's secure wards and its variation by level of security and ward type, therapeutic alliance, patient motivation, treatment engagement and disturbed behaviour.

METHOD

Three-quarters (80, 76%) of staff and nearly all (65, 92%) of patients in the two medium-security wards and two low-security wards that comprised the unit completed the Essen Climate Evaluation Schema (EssenCES) and the California Psychotherapy Alliance Scale (CALPAS); patients also completed the Patient Motivation Inventory (PMI). Pre-assessment levels of disturbed behaviour and treatment engagement were recorded.

RESULTS

Social climate varied according to ward type and level of security. EssenCES ratings indicative of positive social climate were associated with lower levels of security; such ratings were also associated with lower behavioural disturbance and with higher levels of motivation, treatment engagement and therapeutic alliance.

CONCLUSION

This serial cross-sectional survey indicated that use of the EssenCES alone might be a good practical measure of treatment progress/responsivity. A longitudinal study would be an important next step in establishing the extent to which it would be useful in this regard.

Motivating inpatients to engage with treatment: the role of depression and ward atmosphere

BACKGROUND

Although a number of effective treatments are available for patients on inpatient psychiatric units, the motivation of patients to engage with these treatments is frequently poor. Unmotivated patients may be more likely to drop out of treatment, or discontinue treatment after discharge.

AIM

The present study examined the relationship of depression and ward atmosphere in influencing motivation.

METHODS

Using a cross-sectional design, 60 patients at a South London Medium Secure Unit completed the Centre for Epidemiological Studies Depression Scale, the Ward Atmosphere Scales and the Patient Motivation Inventory.

RESULTS

Regression analyses demonstrated that depression predicts motivation in a relationship that is mediated by ward atmosphere. In addition, ward atmosphere predicts motivation in a relationship that is mediated by depression.

CONCLUSIONS

The findings suggest a reciprocal relationship between depression and ward atmosphere, and both factors are important in influencing a patient's motivation to engage with treatment. Improving motivation of psychiatric inpatients seems to require both factors to be addressed.