Background
The use of surveillance technologies is becoming increasingly common in inpatient mental health settings, commonly justified as efforts to improve safety and cost-effectiveness. However, their use has been questioned in light of limited research conducted and the sensitivities, ethical concerns and potential harms of surveillance. This systematic review aims to (1) map how surveillance technologies have been employed in inpatient mental health settings, (2) explore how they are experienced by patients, staff and carers and (3) examine evidence regarding their impact.
Methods
We searched five academic databases (Embase, MEDLINE, PsycInfo, PubMed and Scopus), one grey literature database (HMIC) and two pre-print servers (medRxiv and PsyArXiv) to identify relevant papers published up to 19/09/2024. We also conducted backwards and forwards citation tracking and contacted experts to identify relevant literature. The Mixed Methods Appraisal Tool assessed quality. Data were synthesised narratively.
Results
Thirty-two studies met the inclusion criteria. They reported on CCTV/video monitoring (n = 13), Vision-Based Patient Monitoring and Management (n = 9), body-worn cameras (n = 6), GPS electronic monitoring (n = 2) and wearable sensors (n = 2). Sixteen papers (50.0%) were low quality, five (15.6%) medium quality and eleven (34.4%) high quality. Nine studies (28.1%) declared a conflict of interest. Qualitative findings indicate patient, staff and carer views of surveillance technologies are mixed and complex. Quantitative findings regarding the impact of surveillance on outcomes such as self-harm, violence, aggression, care quality and cost-effectiveness were inconsistent or weak.
Conclusions
There is currently insufficient evidence to suggest that surveillance technologies in inpatient mental health settings are achieving their intended outcomes, such as improving safety and reducing costs. The studies were generally of low methodological quality, lacked lived experience involvement, and a substantial proportion (28.1%) declared conflicts of interest. Further independent coproduced research is needed to more comprehensively evaluate the impact of surveillance technologies in inpatient settings. If they are to be implemented, all key stakeholders should be engaged in the development of policies, procedures and best practice guidance to regulate their use, prioritising patients’ perspectives.
Background
Inpatient mental health settings are challenging environments, both for those receiving and those delivering mental healthcare. The core purpose of inpatient wards is to provide a physically and psychologically safe place for people experiencing acute mental health difficulties to recover and receive care; however, both patients and staff have reported feeling unsafe on wards [1,2,3]. Inpatient mental health patients report (re)traumatising experiences including abuse, coercion, aggression and violence on wards from staff and/or other patients [4,5,6,7,8]. Staff also report abuse and violence on the wards from patients [9, 10], as well as having to risk-assess for and respond to incidents of self-harm and suicide attempts, which are prevalent in these settings [11].
In this context, some mental health service providers in the UK are increasing their use of surveillance-based technologies in inpatient settings [12]. Such surveillance technologies include closed circuit television (CCTV), body-worn cameras (BWCs) and remote monitoring devices (such as smart watches, Global Positioning System (GPS) trackers and infrared cameras). Use of these technologies is justified on the basis that they may be able to detect or prevent aggressive and violent incidents, reduce self-harm incidents and suicide attempts, improve staff and patient safety, change patient behaviour and staff conduct, provide accurate records to help resolve complaints and to contribute to legal cases, and reduce staffing costs [13,14,15,16,17]. Conflict and providing adequate staffing on wards are costly [18] but interrelated [18, 19]. Reducing cost is a driving force for many service providers; therefore, surveillance technologies may appear to offer a cost-effective solution.
The use of video technologies implemented with the stated purpose of improving security is becoming increasingly common. For example, in the UK, BWCs are now used by the police [20], emergency healthcare workers including paramedics [21,22,23], and retail staff [24,25,26]. However, the use of some of these technologies on inpatient wards is controversial [27, 28]. Patient and service user groups, as well as advocates and disability rights activists, have consistently called for scrutiny of these technologies regarding potential risks of iatrogenic harm and ethical concerns [29, 30]. For example, issues raised by the Stop Oxevision campaign [31] include (i) ethical considerations around use of surveillance technologies and obtaining informed consent (for example, concerns about the ability of services to provide adequate information for informed consent, potential consequences for patients not providing or withdrawing consent, and whether consent can reasonably be given to being filmed or recorded whilst acutely unwell on an inpatient ward), (ii) concerns about data access, storage, security and human rights violations, (iii) distress caused by being recorded or monitored, or the exacerbation of existing paranoia, trauma or distress [14,15,16,17, 32] and (iv) fears that it could result in reductions in staffing and one-to-one contact between staff and patients on wards.
In order to plan effective and safe mental health service delivery, it is important to determine whether evidence supports the use of surveillance technologies. Both potential benefits and harms should be considered, including impacts on outcomes such as safety, care quality, mental health and treatment satisfaction. However, a comprehensive review of the evidence underpinning the use of surveillance technologies in inpatient settings has not yet been undertaken. Therefore, we conducted, to our knowledge, the first systematic review of a range of surveillance technologies in inpatient mental health settings.
Both quantitative and qualitative evidence is synthesised to answer the following overarching research question: how are surveillance-based technology initiatives being used and implemented in inpatient mental healthcare settings, and what is their impact? Our specific three research objectives were as follows:
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(1)
How are surveillance-based technologies in inpatient mental health settings being implemented and what are the related implementation outcomes?
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(2)
How are surveillance-based technologies in inpatient mental health settings experienced (e.g. by patients, staff, carers, visitors)?
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(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?
Methods
We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [33]. The PRISMA checklist can be found in Appendix A [see Additional File 1]. The protocol for our review was registered with PROSPERO (CRD42023463993). Amendments to this protocol are described in Appendix B, with justifications [see Additional File 1].
This review was conducted by the National Institute for Health and Care Research (NIHR) Policy Research Unit in Mental Health (MHPRU) based at King’s College London and University College London, which conducts research in response to policymaker need (e.g. in the Department of Health and Social Care or NHS England). Our working group met weekly, and included academic and lived experience researchers, and clinicians.
Lived experience involvement
The working group included five lived experience researchers, who took part in all stages of the research from design, screening and extraction to analysis and write-up. The lived experience researchers included people with experience of inpatient care; conducting patient-led ward inspections; peer advocacy and support; being a carer; and direct experience of surveillance technologies during admission to inpatient mental health services. Some of the lived experience researchers were in liaison with service user groups and patients with experience of surveillance technologies. Due to the sensitive nature of the topic and related experiences, some lived experience researchers in the group have chosen to remain anonymous. Two experts by experience who had direct experience of surveillance technologies, including in an inpatient mental health setting, contributed to the lived experience commentary.
Search strategy
We searched five electronic databases (Embase, MEDLINE, PsycInfo, PubMed and Scopus) for peer-reviewed literature relevant to our research objectives. We searched for grey literature relevant to research objective 2 on a grey literature database (the Health Management Information Consortium) and two pre-print servers (medRxiv and PsyArXiv). Database searches were initially conducted between 17/09/2023 and 18/09/2023, with no date or language restrictions and were updated on 19/09/2024. Screening of non-English language papers was conducted using Google Translate; extraction and quality appraisal of full texts was conducted by someone with knowledge of the language. We contacted experts (including from NHS England, the Care Quality Commission and research experts internationally) to request additional literature we may not have identified. Our lived experience networks supported the identification of additional grey literature. We also reference list screened and citation tracked included studies and relevant systematic reviews. Our search strategy included key terms relating to surveillance and inpatient mental health settings, as detailed in Appendix C [see Additional File 1].
Screening
Title and abstract and full text screening were conducted in Rayyan [34]. Title and abstract screening was conducted by seven researchers (KS, UF, JG, AG, CR and two NIHR MHPRU Lived Experience Researchers). One hundred percent of titles and abstracts were independently double screened. Full text screening was conducted by nine researchers (KS, UF, JG, AG, CR, RC and three NIHR MHPRU Lived Experience Researchers). One hundred percent of full texts were independently double screened. Any disagreements were resolved by discussion between KS, UF, JG and AG.