The use and impact of surveillance in inpatient mental health settings

WARNING: This content discusses sensitive topics related to hospital surveillance, patient harm, inappropriate advances by staff, and staff injuries. It may evoke distressing emotions or memories for some readers, particularly those with personal experiences in healthcare settings.�

The use of surveillance in mental health inpatient settings has become commonplace and, in recent years, has expanded to include new technologies like wearable sensors and body-worn cameras, the latter explored by survivor researcher Alison Faulkner on The Mental Elf in 2023. This increased interest in technology means that research is needed to understand its application, measure its effectiveness, and explore how it is experienced by those it directly or indirectly affects.

Some papers have argued in favour of surveillance, such as a 2023 study by Ndebele et al., which claims that “the VBPMM [vision-based patient monitoring and management] system helped staff to reduce self-harm incidents, including ligatures, in bedrooms”. However, some organisations like charity Rethink have expressed concerns about its risks, especially in the context of restrictive practice (Our Position on Oxevision, Rethink Mental Illness, 2023).

Thus far, research has been limited with mixed results, and so Jessica L. Griffiths and colleagues at the NIHR Mental Health Policy Research Unit attempted to explore:

1. How, where and how often surveillance-based technologies are used in mental health settings, by whom surveillance is used and who is being surveilled
2. How surveillance-based technologies are perceived and experienced
3. The effects of the use of surveillance-based technologies in inpatient mental health settings

Methods

Searches took place via five electronic databases for qualitative, quantitative and mixed method studies published in both academic and grey literature.

All full-texts were independently double-screened, and the quality of studies was determined using the Mixed Methods Appraisal Tool (MMAT), a tool for critically appraising studies for use in systematic reviews. Lived experience researchers, including those with lived experience of surveillance in inpatient mental health settings, took part in all stages of the research.

Results

In total, 32 studies were selected for inclusion in this study, with most (n = 23) having been conducted in the UK. The quality of studies was mixed overall, with half of the studies (50%) rated as low quality. Over a quarter of the studies (n=9) reported a conflict of interest. In general, lived experience involvement in studies was limited; out of the 32 studies included in this review, only 6 reported any form of lived experience involvement of any kind.

Succinctly, the authors found:

1) How are surveillance-based technologies in inpatient mental health settings being implemented and what are the related implementation outcomes?

• All 9 studies concerning VBPMM technologies related to inpatient settings that were using Oxevision by Oxehealth.
• Data on whether or not consent was obtained from patients prior to the use of surveillance-based technologies was limited. For instance, only 1 of the 9 studies into VBPMM devices described how consent was obtained from patients. Another of the 9 papers stated that patients could request for surveillance to be switched off.
• Implementation outcomes across all types of technology included predicting and preventing patient aggression or ‘incidents’ (i.e., self-harm, ligaturing) and monitoring and/or improving staff and patient behaviour.

2) How are surveillance-based technologies in inpatient mental health settings experienced (e.g., by patients, staff, carers, visitors)?

• The authors grouped reported perceptions of surveillance under five sections: pre-implementation; post-implementation; staff; carer and patient. Perceptions of all types of surveillance were mixed across all groups, both pre- and post-implementation.
• Most studies (n = 19) reported at least some findings relating to perceptions of surveillance. However, only 4 studies reported findings on perceptions of surveillance bothpre- and post-implementation. It is therefore difficult to compare how (or if) staff, patient and carer experiences of surveillance changed over the course of the technology’s implementation and subsequent use.

3) What is the effect, including benefits, harms and unintended consequences, of surveillance-based technologies in inpatient mental health settings for outcomes such as patient and staff safety and patient clinical improvement?

• Less than half of the studies included in this research (n = 15) reported any outcomes related to the effectiveness of surveillance technology in mental health settings. No studies explored unintended consequences related to iatrogenic harm, patient sense of psychological safety or unsafety, or staff and patient mental wellbeing.
• Of the 7 studies that reported on the effects of surveillance technology in mental health settings in terms of its effect on clinical outcomes, incidents or ‘aggression’, most (n = 5) did not find the technology to have a significant positive or negative effect on one or more of those areas. One study exploring the use of CCTV in a secure unit by Warr et al. (2005) stated that ‘there was no evidence of any association between the nature of incidents and the presence or use of CCTV’.

Conclusions

This study highlights limitations regarding the quality of research on surveillance technologies in inpatient settings and raises subsequent questions about the appropriateness of such research being funded by (or conducted by those who are paid by) organisations supplying the technologies to which the research pertains. The authors conclude:

There is currently insufficient evidence to suggest that surveillance technologies in inpatient mental health settings are achieving the outcomes they are employed to achieve, such as improving safety and reducing costs

Strengths and limitations

Methodologically, this systematic review provides an extensive investigation into current literature on surveillance technologies in inpatient mental health settings. By opting to include both qualitative and quantitative research, and both academic and grey material, the authors have produced a rich, comprehensive review that successfully identifies weaknesses in the available literature. Findings are strengthened by lived experience involvement at all stages, and a powerful lived experience commentary at the end of this review provides readers with context for the paper, and, thus, deeper understanding of its conclusions. The large number of studies included in the review (n = 32) strengthens its results.

However, considering the disproportionate percentage of studies with methodological limitations included (50%) and the high number of reported conflicts of interest, this review is potentially limited by the low quality of the studies included. As the authors have identified, the high number of studies with reported conflicts of interest increases the risk of publication bias, which, though the authors were unable to confirm, could have substantially impacted the findings drawn from this review.

To counteract this effect, it would have been interesting to have seen more grey literature utilised across each of the three research objectives as opposed to just objective 2. Grey literature related to the topic of surveillance in inpatient mental health settings, and in particular Oxevision by Oxehealth, tends to be more critical of its use, such as this blog post by Sophina Mariette (2024), a survivor of mental health services, published via survivor-led organisation NSUN, or this (2020) explainer developed in partnership by the Restraint Reduction Network and the British Institute of Human Rights. Although there are complications to using grey literature in systematic reviews, voices like Sophina’s – from those who have experienced the impact of surveillance first-hand – provide a wealth of knowledge that is critical to ensuring reviews such as this are relevant, balanced and effective.

Implications for practice

One of the crucial pieces of information this review has highlighted is the critical lack of evidence supporting the use of surveillance technologies in mental health settings. In respect of the current rapid rollout of Oxevision technologies across the UK (“Open letter on the use of Oxevision”, 2023), this finding feels especially relevant; Oxevision has the potential to enable iatrogenic harm, however this is not being acknowledged and Oxevision is being implemented regardless. These findings indicate the need for immediate action; surveillance technologies should not be used in mental health settings until further research supports (or undermines) their use.

The poor quality of research regarding Oxevision and its implementation (e.g., 8 out of the 9 papers related to VBPMM in this study were low quality) and the disproportionately high percentage of these papers reporting conflicts of interest (in this case, 8 out of 9 of VBPMM studies reported a conflict of interest) reveals a need to examine the appropriateness of research being conducted by those who have a vested interest in the study’s results. As Griffiths and Saunders identify, one of the VBPMM reports was actually produced bya surveillance company, and in the case of 4 studies, authors’ time was funded by a technology company. As a non-academic whose interest in mental health research stems purely from lived experience, I am baffled as to how these studies have been deemed acceptable. How can a study which promotes the use of surveillance not be considered biased when it is fundedby a surveillance company? Why is nobody challenging this? If one of the fundamental values of research is that it must be unbiased, then this study should never have been produced.

As someone who has experienced both restrictive practice and surveillance (namely CCTV) in mental healthcare, I view coercion and surveillance as intrinsically linked. Surveillance is in itself a restrictive practice (“Types of Restrictive Practice”, no date), and its presence in inpatient settings serves as a constant reminder that your life is not your own. The humiliation of staff watching your every move is crippling; I remember feeling exposed all the time. Not only had my control over my life been relinquished to another, but this ‘other’ had every moment of my life live-streamed to them through a camera into an office from which I was barred. I had no say in this, either – both times I was admitted to hospitals where surveillance was in use I was under 18; despite this nobody sought consent from me or my family. Nobody explained to me what the surveillance was for.

Seven years after my discharge from those hospitals, I still don’t understand why surveillance was used in my case, and I can’t understand why it continues to be implemented. Some providers argue surveillance protects their staff from violence, whilst others argue it protects their patients from poor quality care. In my experience, surveillance did neither of these things; incidents of staff injuries were high, and patients suffered harm at the hands of staff. I have a vivid memory of the first time a staff member made inappropriate advances towards me – in a hospital where there was CCTV in use, a staff member took advantage of a CCTV blind-spot in a corridor to put his arms around my waist. Who did the CCTV protect in this instance? Who does it protect now?

Statement of interests

I have previously been hospitalised in mental health settings where surveillance was used and I am co-founder of user-led, non-profit group First Do No Harm which aims to improve people’s experiences of inpatient mental healthcare and eradicate institutional abuse in mental health settings.

I am part of a working group for a separate piece of research that two of the authors of this paper – Professor Sonia Johnson and Professor Brynmor LLoyd-Evans – are also part of. I have no relationship with any of the authors outside of the working group and I had no involvement with this particular study.

Links

Primary paper

Griffiths, J.L., Saunders, K.R.K., Foye, U. et al. The use and impact of surveillance-based technology initiatives in inpatient and acute mental health settings: a systematic review. BMC Med 22, 564 (2024). https://doi.org/10.1186/s12916-024-03673-9

Other references

Faulkner A. Whose camera is it anyway? The use of body-worn cameras in acute mental health wards. The Mental Elf, 11 May 2023.

Mariette S. Surveillance is not ‘safety’. NSUN, 26 Jan 2024, last accessed 28 Jun 2024.

Ndebele F, Wright K, Gandhi V & Bayley D. (2023). Non-Contact Health Monitoring to Support Care in a Psychiatric Intensive Care Unit. Journal of Psychiatric Intensive Care, 18(2), 95–100(6).

Open letter on the use of Oxevision in inpatient settings. NSUN, 12 Jul 2023, last accessed 28 Jun 2024.

Restraint Reduction Network and The British Institute of Human Rights. Surveillance A restrictive practice and human rights issue (PDF).

Our position on oxevision the new monitoring system in mental health units. Rethink, 20 Nov 2023, last accessed 28 Jun 2024.

Warr, J., Page, M. and Crossen-White, H. (2005), The Appropriate Use of Closed Circuit Television (CCTV) in Secure Unit, Bournemouth: Bournemouth University.

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