Places of safety? Fear and violence in acute mental health facilities: A large qualitative study of staff and service user perspectives

Abstract

Aim To understand violence on acute mental health units according to staff and service user perspectives and experiences. Background The collateral damage of violence in acute inpatient mental health settings is wide-ranging, impacting on the health and wellbeing of staff and service users, and detrimental to public perceptions of people who are mentally unwell. Despite international research on the topic, few studies have examined psychiatric unit violence from both staff and service user perspectives. Methods We conducted in-depth interviews with 85 people (42 staff, 43 service users) in four adult acute mental health inpatient units in New Zealand. We undertook a thematic analysis of perspectives on the contributing factors and consequences of violence on the unit. Results Both staff and service users indicated violence was a frequent problem in acute inpatient units. Four themes regarding the causes of violence emerged: individual service user factors, the built environment, organisational factors, and the overall social milieu of the unit. Staff often highlighted complexities of the system as causal factors. These included the difficulties of managing diverse service user illnesses within an inadequate and unsafe built environment whilst having to contend with staffing issues and idiosyncrasies relating to rule enforcement. In contrast, service users talked of their needs for care and autonomy not being met in an atmosphere of paternalism, boredom due to restrictions and lack of meaningful activities, enforced medication, and physical confinement as precipitants to violence. Two broader themes also emerged, both relating to empathy. Both staff and service users exhibited ‘othering’ (characterised by a profound lack of empathy) in relation to acutely unwell individuals. Explanations for violent behaviour on the unit differed between groups, with service users being more likely to attribute unwanted behaviour to contextual factors and staff more likely to ‘blame’ mental illness. The consequences of violence included stress, physical injury, and a culture of fear and stigma. Conclusion Violence in acute inpatient mental health units in New Zealand is a significant, complex, and unresolved problem negatively impacting the therapeutic mission of these settings. Further in-depth qualitative investigations are urgently required into what is experienced as violence by service users, their view of how violence occurs, the role of fear and power relations, and the contributions of the built and organisational environment to all forms of violence to all unit users. A core function of the acute mental health unit is to offer a therapeutic environment for individuals at their most vulnerable. For this to happen, the unit must be a rewarding place to work, and a safe place to be.

‘My Work Matters’: A Qualitative Exploration of Why Staff Love Working in Acute Mental Health

“…In the interviews conducted for the current study, our participants described many challenges, including inadequacies in resourcing, poor facilities, short staffing, high demand for services and challenges managing issues such as smoking and aggression. These are reported elsewhere [ 4 , 28 , 29 ]. The positive side of working in mental health care has received very little attention in the research and literature.…”

“…However, chronic staffing shortages in the mental health workforce add to the already challenging workload and stress of existing staff and affect staff retention [ 1 , 2 , 3 ]. Understaffing can adversely affect the therapeutic goals of mental health care and contribute to violence in mental health inpatient settings [ 4 ]. Staffing shortages and reported negative work experiences are likely to have been compounded by the stressors of the COVID-19 pandemic on the health workforce, particularly for nurses [ 5 , 6 ].…”

The Role of Courtyards within Acute Mental Health Wards: Designing with Recovery in Mind

“…In our research, limited governmental investment was deemed responsible for both a lack of suitable facilities for meaningful activities and a lack of supervision. Spaces designed for activity were often locked or unused due to staff shortages [ 16 ]. When there is a varying typology in a spatial design, there is no limit to the number of interactions a service user can have within said space.…”

“…Similar to the overall acute mental health facility in New Zealand, where the purpose has been questioned [ 12 ], the role the courtyard is also questioned in terms of its contribution to recovery. Activities ranging from physical exercise and socialisation through to relaxation all feature in the literature [ 14 , 15 , 16 ]. Similarly, means of addressing contentious issues, such as the need for a place to go outside and engage with nature or the strategies for addressing for smoking, are only recently being mentioned in the literature [ 9 ].…”

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

“…Irrespective of gender's role in unit safety, measures to ensure the physical and emotional safety of people who reside and work on the unit are essential. Measures of surveillance, de-escalation, and practices and design features that assure privacy, are recommended and other recommendations to address safety on the unit have been explored in a related paper from this study ( 83 ). The units in our study had divergent approaches to these measures.…”