Surveillance in Inpatient Mental Health Settings: Impact and Use

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 integration of surveillance technology in mental health inpatient environments has become increasingly prevalent, with innovative advances such as wearable sensors and body-worn cameras. Notably, survivor researcher Alison Faulkner delved into this topic on The Mental Elf in 2023, highlighting the urgent need for research to assess the effectiveness and implications of these technologies. Understanding how these tools impact patients and staff is crucial, as it influences not only patient safety but also the overall quality of care within these settings.

Proponents of surveillance, like the 2023 study by Ndebele et al., argue that technologies such as the vision-based patient monitoring and management (VBPMM) system can significantly reduce incidents of self-harm. However, organizations like the charity Rethink express valid concerns about potential risks, particularly concerning restrictive practices associated with these technologies, as articulated in their position statement on Oxevision in 2023.

Research regarding surveillance in mental health settings has been limited and yielded mixed results. To address this gap, Jessica L. Griffiths and her colleagues from the NIHR Mental Health Policy Research Unit aimed to investigate several critical aspects:

1. How, where, and how often surveillance-based technologies are deployed in mental health settings, including who is monitored and by whom.
2. The perceptions and experiences associated with the use of surveillance-based technologies.
3. The overall effects of these technologies on inpatient mental health environments.

Comprehensive Methodology for Investigating Surveillance Technologies

The researchers conducted thorough searches across five electronic databases to identify qualitative, quantitative, and mixed-method studies, drawing from both academic and grey literature. This approach ensured a wide-ranging view of the existing research landscape surrounding surveillance technology in mental health.

All identified full-text studies underwent an independent double screening process for quality assessment, employing the Mixed Methods Appraisal Tool (MMAT) to evaluate their suitability for systematic review. Importantly, lived experience researchers, who have direct experience with surveillance in these settings, participated throughout the research phases, contributing valuable insights.

Key Findings from the Systematic Review

A total of 32 studies were included in this review, with the majority (n = 23) conducted in the UK. Overall, the quality of studies varied significantly, with half rated as low quality. Alarmingly, over 25% of the studies (n=9) disclosed conflicts of interest. Moreover, the involvement of individuals with lived experience in these studies was limited; only 6 out of the 32 studies acknowledged any participation of those with firsthand experience.

The authors summarized their findings as follows:

1) Implementation and Outcomes of Surveillance-Based Technologies in Inpatient Settings

• All nine studies involving VBPMM technologies in inpatient settings utilized the Oxevision system developed by Oxehealth.
• Data regarding patients’ consent prior to implementing surveillance technologies was scarce; for instance, only one of the nine studies detailed the consent process. Another study indicated that patients had the option to request deactivation of surveillance.
• Implementation outcomes across various technologies included efforts to predict and prevent patient aggression or incidents of self-harm, alongside monitoring and enhancing both staff and patient behaviors.

2) Experiences of Surveillance Technologies from Different Perspectives

• Reported perceptions of surveillance were categorized into five areas: pre-implementation, post-implementation, staff, caregiver, and patient perspectives. Feedback regarding surveillance was mixed across all groups both before and after implementation.
• Most studies (n = 19) yielded insights into perceptions of surveillance; however, only four studies provided findings on perceptions both before and after implementation, complicating comparisons of how experiences evolved during the technology’s deployment and use.

3) Effects of Surveillance Technologies on Patient and Staff Safety

• Fewer than half of the studies (n = 15) reported outcomes that assessed the effectiveness of surveillance technology in mental health environments. Notably, no studies examined unintended consequences, such as iatrogenic harm or the psychological safety of patients and staff.
• Among the seven studies that addressed the impact of surveillance on clinical outcomes and incidents of aggression, most (n = 5) found little to no significant effect, whether positive or negative. A study by Warr et al. (2005) indicated that “there was no evidence of any association between the nature of incidents and the presence or use of CCTV.”

Critical Insights on Surveillance Technologies in Mental Health

This systematic review underscores significant limitations in the quality of research surrounding surveillance technologies in inpatient settings, raising concerns about the validity of studies funded by organizations that supply these technologies. The authors notably 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 of the Review

This systematic review methodologically offers an in-depth examination of the literature on surveillance technologies within inpatient mental health settings. By including both qualitative and quantitative studies from academic and grey literature, the authors have created a comprehensive review that highlights the significant gaps in existing research. The findings are further reinforced by the involvement of lived experience researchers at every stage, culminating in a powerful commentary that contextualizes the study’s conclusions for readers.

Nonetheless, the review is potentially compromised by the inclusion of a substantial proportion of studies that exhibit methodological flaws (50%) and a concerning number of reported conflicts of interest. This prevalence raises the possibility of publication bias, which, while not confirmed by the authors, could heavily influence the review’s conclusions.

To mitigate these concerns, the inclusion of more grey literature across all research objectives would have proven beneficial, rather than being restricted to just one objective. Grey literature often provides a more critical perspective on surveillance in inpatient mental health settings, as demonstrated by a blog by Sophina Mariette (2024), a survivor of mental health services. This piece, published by the survivor-led organization NSUN, and another explainer developed by the Restraint Reduction Network in partnership with the British Institute of Human Rights (2020), emphasize the need for critical voices in this discourse. Engaging with firsthand experiences can enrich reviews like this, ensuring they remain relevant, balanced, and impactful.

Practical Implications of the Findings

This review brings to light a critical lack of evidence supporting the use of surveillance technologies in mental health environments. Given the ongoing rapid deployment of Oxevision technologies throughout the UK, as highlighted in an open letter from 2023, this discovery is particularly concerning. The potential for iatrogenic harm associated with Oxevision is not being adequately addressed, yet its implementation continues unabated. These findings underscore the urgent necessity for action; surveillance technologies should be suspended in mental health settings until further research either supports or contradicts their application.

The subpar quality of research related to Oxevision and its deployment (notably, 8 of the 9 papers concerning VBPMM in this review were rated as low quality) and the high percentage of these studies reporting conflicts of interest (8 out of 9 VBPMM studies) indicate a pressing need to scrutinize the appropriateness of research conducted by those with vested interests in the results. As Griffiths and Saunders noted, one of the VBPMM reports was produced by a surveillance company, and for four studies, the authors received funding from a technology firm. As a non-academic whose interest in mental health stems purely from lived experience, I find it perplexing how these studies have been deemed acceptable. How can a study advocating for surveillance be considered unbiased when it receives funding from a surveillance company? Why is there no challenge to this?

My experiences of both restrictive practices and surveillance, particularly CCTV, within mental healthcare have led me to perceive coercion and surveillance as fundamentally interconnected. Surveillance inherently acts as a restrictive practice, imposing a constant reminder that individuals in inpatient settings have limited control over their lives. The humiliation of being monitored closely by staff creates an environment where individuals feel perpetually exposed. I vividly recall moments when my autonomy was stripped from me, and my life was effectively live-streamed to observers behind closed doors, a situation I had no power to alter. During both of my hospitalizations, where surveillance was in place, I was under 18, and yet, no one sought consent from either me or my family, nor explained the purpose of the monitoring.

Seven years later, I still grapple with the reasons for the surveillance I endured and struggle to understand its continued application. Some facilities argue that surveillance safeguards staff against violence, while others contend it protects patients from inadequate care. However, my firsthand experience revealed that surveillance achieved neither goal; incidents of staff injuries remained high, and patients suffered harm at the hands of caregivers. I will never forget the first instance when a staff member made inappropriate advances towards me in a hospital equipped with CCTV. This staff member exploited a blind spot in the corridor to wrap his arms around my waist. In this scenario, who did the CCTV truly protect? And who does it protect now?

Disclosure of Personal Experiences and Interests

I have a personal history of hospitalization in mental health environments where surveillance was employed, and I am a co-founder of the user-led, non-profit initiative First Do No Harm, which seeks to enhance the experiences of individuals in inpatient mental healthcare while eradicating institutional abuse.

I also participate in a working group associated with a different research project involving two authors of this paper, Professor Sonia Johnson and Professor Brynmor Lloyd-Evans. Aside from this working group, I have no relationship with any authors and did not contribute to this specific study.

Essential References for Further Reading

Primary Research Article

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

Additional 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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