Secure Mental Health Settings Research Articles

Virtual reality and social avoidance: an exploratory study of acceptance, and feasibility in an inpatient secure environment

Purpose Social avoidance disorders can be disruptive to the individual as they begin to over-manage their lives, at times avoiding social and work commitments. A potential therapeutic approach is exposure therapy and a virtual reality (VR) treatment approach, gameChange VR, has been developed. This provides an opportunity to test their fears in virtual environments. This study aims to investigate the feasibility of using this VR approach to treat people with social avoidance problems within a secure mental health setting. Design/methodology/approach Nine participants completed the gameChange VR sessions. Participants received 30-minute VR sessions for up to six weeks using selected scenarios at five levels of difficulty. Patients’ comments and behaviours were noted and clinical staff also provided feedback on their observations of patients’ use and experience with VR. Findings Overall, patients felt that the gameChange VR helped them to build their confidence and reduce their overall anxiety as they became more comfortable with the equipment. Both patients and staff generally found the intervention easy to use and the staff reported an overall high level of engagement among the participants. The key issues raised largely related to technical and safety issues. Originality/value While a previous study was carried out using gameChange VR with an outpatient cohort, this was the first using an inpatient group in a secure mental health setting. It has demonstrated that the intervention is viable in this setting, although further studies are required to identify the specific patient population that would benefit optimally from the therapy.

Understanding weight management in adult secure mental health services: findings from a mixed-methods study in Northern England

Purpose Obesity and associated morbidity and mortality are major challenges for people with severe mental illness, particularly in secure (forensic) mental health care (patients who have committed a crime or have threatening behaviour). This study aims to explore experiences of weight management in secure mental health settings. Design/methodology/approach This study used a mixed-methods approach, involving thematic analysis. A survey was delivered to secure mental health-care staff in a National Health Service (NHS) mental health trust in Northern England. Focus groups were conducted with current and former patients, carers and staff in the same trust and semi-structured interviews were undertaken with staff in a second NHS mental health trust. Findings The survey received 79 responses and nine focus groups and 11 interviews were undertaken. Two overarching topics were identified: the contrasting perspectives expressed by different stakeholder groups, and the importance of a whole system approach. In addition, seven themes were highlighted, namely: medication, sedentary behaviour, patient motivation, catered food and alternatives, role of staff, and service delivery. Practical implications Secure care delivers a potentially “obesogenic environment", conducive to excessive weight gain. In future, complex interventions engaging wide-ranging stakeholders are likely to be needed, with linked longitudinal studies to evaluate feasibility and impact. Originality/value To the best of the authors’ knowledge, this is the first study to involve current patients, former patients, carers and multidisciplinary staff across two large NHS trusts, in a mixed-methods approach investigating weight management in secure mental health services. People with lived experience of secure services are under-represented in research and their contribution is therefore of particular importance.

What are the key influences and challenges around weight management faced by patients in UK adult secure mental health settings? A focused ethnographic approach

ObjectivesExcess weight is highly prevalent in secure (forensic) mental health services and impacts negatively on patients’ physical and mental health. This study sought to identify the key influences and challenges...

Physical activity interventions for inpatients in secure mental health settings: what works, for whom, in what circumstances and why? A protocol for a realist synthesis

IntroductionThe physical health of individuals with severe mental illness (SMI) is a cause for concern. While the purpose of inpatient mental health settings is rehabilitation and treatment, the physical health...

The Need for Practicable Normative Right-based Social Work Practice in Secure and Forensic Mental Health Services

Abstract We (both author and reader) will explore the need to develop a practicable evaluative human rights-based approach to the care, treatment and discharge of forensic mental health patients. It can be argued that patients in secure and forensic services are potentially the most marginalised and extensively stigmatised of all patient cohorts, and that the extent to which they are discriminated against should not be underestimated. We will consider the concept of right-based practice in secure and forensic mental health settings, and how the quality of practice can be strengthened. We will ground our exploration in the lived experiences of secure and forensic mental health patients and seek through the lens of lived experience to envisage what could constitute fairer and more supportive systems of care.

A mixed methods programme of study exploring weight management in adult secure mental health settings

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Supporting staff at a low secure mental health setting during the COVID-19 pandemic

Supporting staff at a low secure mental health setting during the COVID-19 pandemic

Moral injury in secure mental healthcare: part I: exploratory and confirmatory factor analysis of the Moral Injury Events Scale

ABSTRACT In recognition that existing theoretical paradigms may not offer a comprehensive account of the range of occupational stressors and responses experienced by healthcare professionals, interest in moral injury has grown. The Moral Injury Events Scale (MIES) remains the dominant assessment tool used to measure potentially morally injurious experiences (PMIEs) across different occupational groups, including healthcare professionals. Given the proliferation of research using the MIES in healthcare, in the context of ongoing debates about its structure and utility, an exploration of the psychometric properties of the MIES with this population is timely. Using the data (N = 235) from a study exploring the prevalence of exposure to PMIEs, the current study reports on the factor structure of the MIES in healthcare professionals working within a secure mental health setting. The results yielded a two-factor model representing transgressions and betrayals by ‘others’, and transgressions committed by the ‘self’. Exploration of the internal consistency of the scale yielded a McDonald’s ω of .93. Multi-group confirmatory factor analysis highlighted the model was an adequate fit for White females, tentatively suggesting that experiences of moral injury may vary by gender, intersected by ethnicity. Accordingly, future frameworks, measures and interventions to remediate the impact of moral injury may require an intersectional approach.

Sleep disturbance and aggression incidents in secure mental health settings

Sleep disturbance and aggression incidents in secure mental health settings

A Feasibility Evaluation of Discovery Group: Determining the Acceptability and Potential Outcomes of a Patient-led Research Group in a Secure Mental Health Inpatient setting

AimsPatient and public involvement and engagement (PPIE) is recognised as an essential part of health research. It provides an opportunity for patients to shape health research and acquire research skills, in the inpatient mental health setting, PPIE may have additional value in providing meaningful activity and enhancing recovery, as defined using connectedness, hope, identity, meaning and empowerment (CHIME) principles. An eight -session PPIE programme (“Discovery Group”) was designed to support patient-led research in a secure mental health hospital. This feasibility study aims to evaluate the acceptability of the programme from the perspective of patients and identify potential outcomes.MethodsA retrospective single-arm post-programme evaluation of Discovery Group was undertaken. Participants attended an evaluation workshop where they were interviewed individually to complete an acceptability questionnaire designed using the domains of the Theoretical Framework of Acceptability. Participants also completed an outcomes questionnaire, which included CHIME-based recovery items. Quantitative data were analysed descriptively. Direct content analysis was applied to qualitative data.ResultsIn our sample, eight participants attended at least one session of the discovery group with one patient attending all sessions. Most of the participants felt positive about taking part in the group and expressed interest in joining another group in future. All participants experienced some burden from the effort required during group sessions, but a low level of opportunity cost in terms of the extent to which they perceived they had to forfeit benefits to participate in the programme.Some described the group as effective in helping them learn about research. Of the five CHIME recovery domains, only connectedness was reported as a benefit of the group. The participants valued the opportunity to use their time.ConclusionDiscovery Group is a novel intervention that offers high level, non-tokenistic PPIE suitable for use in secure mental health inpatient settings. It produces research of value to patients through a programme of high acceptability and provides them with potential benefits of recovery as well as research knowledge and skills, and an activity that alleviates boredom, enhances autonomy, breaks down some important power and paternalistic barriers that can be experienced by patients detained in secure mental health settings. Finally, a future evaluation study that involves patients during the design, implementation, evaluation and writing stages, aiming to measure the potential outcomes identified in the present study using pre- and post-testing with a control group would reliably demonstrate the effectiveness of the revised Discovery Group and ensure meaningful involvement with patients as co-researchers.

Commentary on “Developing a logic model for implementing citizen advocacy for adults with learning disabilities based on the experience of community inclusion centres for disabled people”

PurposeThis commentary reflects on peer advocacy in relation to citizen advocacy in the context of the vital need for advocacy in all its different forms.Design/methodology/approachThe authors reflect from the standpoint of developing peer advocacy in secure mental health settings as an organisation based on self-advocacy and co-production.FindingsBy reflecting on peer advocacy and citizen advocacy side by side, the authors affirm both and all kinds of advocacy as being vital to people with learning disabilities living full and free lives as citizens.Originality/valueThe authors hope this commentary will enrich people’s understandings of the essential role of peer advocacy within different kinds of advocacy, and the need to enlarge the range of possibilities and choices open to a person.

Sleep quality and adverse incidents in secure mental health settings

ABSTRACT Sleep disturbance has been associated with adverse incidents among male forensic inpatients. This study examined relationships between sleep quality and the occurrence/severity of adverse incidents among male and female patients in a secure psychiatric hospital setting. Sleep disturbance was assessed in 756 (361 female) patients at baseline (assessment 1), with 476 (253 female) patients followed up ≥1 month later (assessment 2). The occurrence and severity of adverse incidents was extracted from health records. Risk associated with sleep disturbance was assessed in adjusted binary logistic regression models with the occurrence of at least one adverse incident during the 7-day baseline period, or during the subsequent 30-day follow-up period as dependent. Prospective associations with adverse incidents among new cases of sleep disturbance, and ‘good sleepers’, were analysed using X2. Sleep disturbance and female gender were independently associated with a significantly elevated risk of adverse incidents in the baseline models. At follow-up, new cases of sleep disturbance showed the highest level of participation in adverse incidents, while ‘good sleepers’ showed both the lowest participation in, and the lowest impact scores resulting from adverse incidents. The management of sleep quality could help reduce participation in adverse incidents among inpatients in secure psychiatric environments.

The experience of inequality and its impact on mental illness – thematic analysis of patients’ lived experiences admitted to secure mental health hospital

PurposeThe concept of inequality refers to being treated unfairly in society and its impact on mental illness has been explored primarily using a quantitative research approach. Patients’ lived experiences of inequalities prior to their admission to a secure care setting need to be addressed with a higher priority as they can serve to improve our understanding of the factors underlying the development of mental illness at a personal level. The aim of this study is to explore participant’s views on whether for them the experience of inequality is associated with the development of mental illness.Design/methodology/approachA qualitative study, using a thematic analytical approach, was carried out to explore patients’ lived experiences of inequalities. A total of 11 participants, who were receiving treatment in a UK secure mental health hospital, were recruited into this study. The concept of inequality was explored using semi-structured interviews.FindingsData showed that patients had experienced a variety of inequalities which had negative impact on their mental health. Four main themes were identified from thematic textual analysis – abuse and its impact, a lack of support, the issue of labelling and the importance of understanding.Practical implicationsData showed that patients had experienced a variety of inequalities which had negative impact on their mental health. Four main themes were identified from thematic textual analysis – abuse and its impact, a lack of support, the issue of labelling and the importance of understanding.Originality/valueThis is the first study, to the best of the authors’ knowledge, to consider intersectionality and admission to mental health units by interviewing patients in secure mental health setting.

Inequalities in women’s medium or low secure mental health settings: a scoping review

Purpose The more disadvantaged members of society generally experience poorer outcomes following the development of mental ill-health. The purpose of this paper is to scope the literature and synthesise findings on the inequalities and mental health within secure mental health settings. Design/methodology/approach Six electronic databases were searched to identify relevant studies. These were included if they examined the association between inequalities and mental health in women’s secure mental health settings. Findings Of the 608 studies reviewed, 14 met the inclusion criteria. In these papers, violence and/or abuse were described as the most prevalent inequalities. The second most frequent group of inequalities identified were socio-economic. Only three published studies researched the impact of ethnicities. Physical health, alcohol abuse and a dysfunctional family upbringing were only mentioned in one of the studies. Gender identity, transitioning and sexual orientation was not considered in any papers. These are areas, which require further investigation to determine their specific impact in this setting. Research limitations/implications This review highlights the dearth of high-quality research-based evidence underpinning an understanding of the impact of inequalities on women in secure mental health settings. The existing studies suggest that inequalities have a very particular impact and that intersectionality plays a key role. Further research is required to further understand how inequalities impact the lives of women in secure mental health settings. Practical implications The inequalities that women experience in relation to mental health need to be further researched in the context of intersectionality. There are also research gaps in terms of gender identity, sexual orientation and socio-economic background. Further primary research using a more complex methodological paradigm is required to explore these factors and their impact on mental health service provision. Social implications The role of inequalities should be considered as part of an overall care package, including the experiences of adverse childhood experiences and this should contribute towards the development of a trauma-based care approach. Originality/value To the best of the authors’ knowledge, this is the first study to scope literature about inequalities experienced in women’s secure psychiatric settings considering intersectionality.

The omnipresence of risk and associated harms in secure and forensic mental health services in England and Wales.

Current legislation and policy frameworks regulating the detention and treatment of mentally disordered offenders in England and Wales are predicated on the assumption that a minority of patients have enduring violent tendencies and pose a serious long-term risk to the safety of others. This paper seeks to consider the manner in which notions of risk and the imperative to contain and minimise the potential for harm, present and impact patients in secure and forensic mental health settings. Within this, we consider how mental health stigma and Beck’s concept of the Risk Society can affect the thoughts and actions of those who may be held accountable for rare but potentially serious harmful events. We consider what changes may need to be enacted within secure and forensic mental health services to reduce the incidence and severity of consequent risks of harm to patients and their mental health recovery.

Predicting and understanding seasonal influenza vaccination behaviour among forensic mental health inpatients

Objectives This study aimed to identify demographic and psychological predictors of seasonal influenza vaccination intentions and behaviour among a sample of inpatients in a secure forensic mental health service. It also sought to explore patient experiences about being offered the vaccine. Design This study used a mixed-methods design. The quantitative element employed a prospective design using a questionnaire; both cross-sectional and prospective findings are reported. For the qualitative part of the study, semi-structured interviews were conducted and analysed using Interpretative Phenomenological Analysis (IPA). Main outcome measures Seasonal influenza vaccination intentions and behaviour Results Past behaviour, vaccine knowledge and cues to action were predictors of vaccination intention (N = 57). Cues to action remained as the only statistical predictor of vaccination behaviour (N = 55). Nine interviews were conducted with four vaccinated and five unvaccinated participants. Three main themes were formed in the IPA analysis; these were ‘Managing Decisional Conflict’, ‘Interaction with Immune Function’ and ‘The Role of Others’. Conclusions The results highlighted the integral role of health professionals in shaping patient’s vaccination behaviour within a secure mental health setting. Recommendations for vaccination promotion strategies were offered.

Inpatient perspectives on physical activity in a secure mental health setting

This study offers the first insight into the perspectives of secure inpatients regarding exercise. Individuals living with severe mental illness (SMI) engage in less exercise and more sedentary behaviour than their counterparts in the general population. Secure psychiatric hospitals are often considered obesogenic environments that inadvertently promote inactivity. Access to exercise is often restricted due to issues of risk and patient safety. Existing literature exploring exercise perspectives is dominated by SMI populations living in the community. This study involved semi-structured interviews with 15 medium secure inpatients (aged 19–40, mean age 27.8). Primary diagnoses included; schizophrenia and affective disorders, mood disorders and personality disorders. Data were analysed using reflexive thematic analysis. Findings denoted three overarching themes; (i) Barriers to exercise; mental or environmental? (ii) Is exercise always holistically beneficial? (iii) Staff; a barrier and facilitator to exercise. Acute mental health symptoms and unwanted medication side effects, such as lethargy and weight gain limited exercise motivation. The restrictions of a secure environment limited opportunities to regularly exercise. Exercise provided a relief from both psychiatric symptoms and associated low mood, however in some cases engaging in exercise exaggerated manic symptoms and led to acts of aggression. Inpatients considered staff crucial to facilitate exercise, however access, education and inconsistent attitudes limit provision. Strategies to change the sedentary ‘culture’ within secure wards should involve both staff and patients.

Evaluation of a participatory approach to improve healthy eating and physical activity in a secure mental health setting

Purpose The prevalence of obesity in secure mental health units is higher than in the general population, having a negative impact on the physical health and mental well-being of people with severe mental health illness (SMI). The purpose of this study was to describe the feasibility of a programme aimed to help people with SMI to eat healthily and be physically active. Design/methodology/approach A mixed-methods approach was used. A questionnaire administered to patients in both wards measured acceptability, demand, implementation and practicality of the project. Individual semi-structured interviews and focus groups were used to explore staff and patients’ perceptions of the project; as well as the barriers and enablers towards an effective implementation and participation in the project’s activities. Findings Patients were, overall, satisfied with the activities implemented. Successful activities were easy to implement, had staff actively engaged and did not require logistic or administrative planning beforehand. Barriers included unawareness around funding mechanisms of activities, staff capacity issues or lack of patients’ permission to leave the ward. Originality/value Few studies have assessed the feasibility of real-life interventions aimed to improve healthy eating and physical activity in secure mental health units. The results of this study can inform commissioners and providers of mental health services to design and implement new interventions and programmes.

The perceived challenges of working with patients who use new psychoactive substances: a qualitative study in a medium secure unit

PurposeNew psychoactive substances (NPS) are increasingly being used in secure mental health settings. Within these settings, NPS use presents a range of challenges and staff currently lack adequate training to manage these challenges. The purpose of this paper is to explore nursing staffs’ perception of the challenges of working with patients who use NPS and to explore nursing staffs’ perception of their training needs in relation to NPS.Design/methodology/approachA cross-sectional qualitative design was employed. Semi-structured interviews were conducted with eight nursing staff from a medium secure unit (MSU).FindingsA thematic analysis identified three overarching themes: “There Will Always Be Something”, “We Are Doing Our Best” and “If We Know More, We Can Do More”. The findings describe how nursing staff manage NPS use at present, and their perceptions of how training could improve their management of NPS use in the future.Practical implicationsThe findings suggest that MSUs require a local policy for managing NPS use. The research implies that staff training programmes should recognise the existing methods staff use to manage NPS use. The findings also suggest that NPS interventions should target the whole peer group and not just the individual using NPS.Originality/valueThis paper contributes to the limited literature on NPS. The findings demonstrate the importance of developing evidence-based mechanisms for managing NPS use. Changes to practice are suggested, with the view of developing ways in which staff currently manage NPS use by complementing this with specific training on NPS.

Conducting research in a secure mental health setting

Research is a key element in putting the patients at the centre of care provision in secure mental health settings. This Departmental Review provides reflections on conducting research in a secure mental health setting. Key reasons for conducting research, issues and patient perspectives are considered to illustrate how secure mental health care providers can engage in research, to ensure high-quality care.