HOW SAFE ARE WOMEN IN ADULT INPATIENT PSYCHIATRIC UNITS NEVIL TRAINING FEBRUARY 2010 Presenters: Jude Stamp, Julie D

2. Session Overview Introductions and pre session evaluation Brief history of the VWMHN Group activity � Case Scenarios Julie and Judes� Story Nowhere to be Safe, Gathering Information and Promoting Sexual Safety (Chief Psychiatrist Guidelines) Question Time Evaluation

3. Victorian Women and Mental Health Network� Established in 1988 to promote policies/ services responsive to needs of women Supported by Vicserv Membership open to both consumers and mental health service providers Network activities include : - Women�s mental health conference - Directory of women sensitive services - Training manual - Forums on key women�s mental health issues VWMHN membership � staff from Psych Disability Rehabilitation Support Services. Clinical mental health services, community health services, sexual assault services, women specific services Quarterly Forums : Promoting Recovery through Community Inclusion Self Harm Women, Mental Health and Sexual Abuse � Responding to Disclosures Issues for Women Consumers returning to Work Promoting Health Lifestyles for Female ConsumersVWMHN membership � staff from Psych Disability Rehabilitation Support Services. Clinical mental health services, community health services, sexual assault services, women specific services Quarterly Forums : Promoting Recovery through Community Inclusion Self Harm Women, Mental Health and Sexual Abuse � Responding to Disclosures Issues for Women Consumers returning to Work Promoting Health Lifestyles for Female Consumers

4. Julie and Jude�s Stories

5. CONSUMER AND STAFF SURVEY OUTCOMES

6. VWMHN Consumer Surveys� 117 surveys, 75 from women consumers 58.5 % of women identify feeling unsafe Issues raised related mainly to male patients : Witnessing verbal / physical aggression Experiencing intimidation / harassment Unwelcome sexual advances by males Males entering women�s bedrooms Threatened / actual assault including sexual assault

7. Consumer surveys cont�d� 63.5% of women had witnessed harassment / abuse of other women 61% of women identified personally experiencing harassment / abuse 51.5% of women would prefer to be cared for in female only wards A further 27% of women prefer mixed wards with female only facilities, separate sleeping areas, women�s lounges

8. Consumer surveys cont�d� 63.5% of women had witnessed harassment / abuse of other women 61% of women identified personally experiencing harassment / abuse 51.5% of women would prefer to be cared for in female only wards A further 27% of women prefer mixed wards with female only facilities, separate sleeping areas, women�s lounges

9. Survey results from Mental Health Staff 42 Mental Health Staff responded to the Survey: 70% reports harassment and abuse 30% indicated that it occurs frequently

10. Nowhere to be Safe Report Launched in 2008

11. Lack of privacy and safety � I woke up one night and there was a male patient standing at the end of my bed� another time someone was entering the patients bedrooms and swapping our clothes around�I felt vulnerable and� violated.� �People talk to your visitors and find out things about you.� During a period when she was acutely unwell, a woman was advised by other patients that her husband was never coming to visit her again and was pressured to have sex with another patient. When her husband next visited these patients informed him that his wife had had sexual relations with another patient on the ward. This woman was left feeling terrible and that what took place was her fault.

12. Intimidation, harassment and violence by male patients �On one occasion a male patient came into the room I was sharing, pulled out a knife and held it to my room-mate�s neck. Staff responded to this male but not once following this incident were we asked how we were�� Women reported that verbal intimidation by male patients was routine. When this was raised with staff, the response was often �if you�re frightened we�ll put you in HD.�

13. Inappropriate sexual activity �I observed patients engaging in sexual relations � I felt the women involved were too unwell to make informed decisions about these situations.� �We are all unwell and can�t cope with intimate relationships.� Some staff were strict�I felt safer knowing that staff were doing something.�

14. Women�s experiences in High Dependency Units �it can be you and three guys�the violence that goes on is terrifying�one man thought I was the devil�he put his fist through the glass window in his door trying to get me�lots of staff attended to him but no one ever spoke to me about how I was�. �The unisex bathrooms worried me a lot�I felt cut off at night and worried about being assaulted.�

15. High Dependency and Seclusion� Women reported feeling unsafe in HD because of : Lack of continuous staff presence at night Higher proportion of males in HD Being located next to male patients in rooms that do not lock Increased vulnerability associated with being heavily sedated

16. The needs of women with experiences of abuse One woman was asked to tell the story of her assault to an all-male staff team Anger expressed by male patients can �trigger� some women�s fears arising from pervious experiences. This response is often misinterpreted and responded to inappropriately. Many women with abuse histories experience generalised fear. On an inpatient unit there is often nowhere they can go where they feel safe.

17. The importance of staff responses �They listen but they don�t hear.� �If you�re a voluntary patient staff listen to you a bit, but if you�ve been certified, it can feel like you have no rights.� �Awareness has really changed in the ward where I am admitted�they always make sure I have a female contact nurse and if she goes off the ward, she tells me who else I can talk to.�

18. Staff Responses cont�d� Women expressed concern that some staff may become �de-sensitised� �Women reported that when they try to raise issues relating to lack of safety, they are often told they have misinterpreted other patients� behaviour or that it is part of their psychosis Women also reported that their physical health issues were often not taken seriously.�

19. Ward design �There needs to be a lockable door between the women�s and men�s sleeping quarters.� Women felt safer in wards where their bedrooms were mainly in one corridors, and men�s elsewhere.

20. Support for women through talking Women identify the focus on medication during inpatient treatment as too narrow � �You get in there and no-one talks to you� Women would welcome increased opportunities to talk with staff, to be involved in psychotherapy and therapy that would help them to identify strategies for self-soothing and managing emotional distress. Women also supported an increase in activities like cooking and walks.

21. Top 10 changes to increase gender sensitivity in IPU�s NUMS AND CC�S Separate facilities Staff education Policy development Lockable b�room doors Separate HDU facilities GS Group Programs Codes of Conduct Trauma informed care Staff portfolio positions Increased staff presence on the ward WOMEN CONSUMERS Locate bedrooms in separate corridors Separate lounges, family, outdoor areas Lockable bedrooms and bathrooms Separate bathrooms in HDU and LDU Patient codes of conduct Early intervention to protect women Better staff support Awareness of previous trauma Treated by female staff- particularly at night More opportunities for therapeutic contact with staff (Nowhere to be safe report 2008)

22. Increasing Safety and Gender Sensitivity in mixed sex psychiatric units Gathering Information about clinical mental health service initiatives

23. Lack of Safety in inpatient units Clear identification by staff of significant safety concerns associated with inpatient environments for: Women consumers Vulnerable male patients Staff

24. Safety issues for women consumers �During our consultation� women identified that there was nowhere on the ward where they could be safe� their priority was to be safe in their bedrooms (NUM) �Women�s main concerns are witnessing aggressive behavior of other patients and patients wandering into rooms while relaxing or changing (NUM) ��Behavior can have distressing effects on women with past trauma history and older patients.� (NUM)

25. Risk of sexual assault �We all know what happens on inpatient units that a number of women are unsafe�you don�t come onto an impatient ward expecting to be assaulted� (CC) Many incidents aren�t disclosed at the time largely because women feel they won�t be believed� (NUM) Both women and men have shocking experiences in acute units� it is not necessarily harassment by other consumers but also by staff� (CC)

26. Lack of safety for Vulnerable Males Some males are going through similar things�women can be disinhibited and approach male �patients� (NUM) Guys feel unsafe too�sometimes this related to sexual orientation.� (CC) �Many males also have a trauma history� (NUM)

27. Initiatives to address safety and gender sensitivity in mixed sex psychiatric units

28. Women�s Corridors Implemented in 16 out of 26 wards (62%) Two wards were established when the ward was built or being redeveloped. 14 units have established corridors from current physical environment. Units with clear corridor design have one women designated corridor. Horseshoe design have door separating areas. Strategically locked doors.

29. Staff Experience NUM�s of wards where corridors had been established unanimously identified that their initiative had significantly improved inpatient conditions for women.

30. Women consumers experience of women�s corridors Women�s feedback is very positive, they feel safer. Most of the women have a history of abuse and are frightened by male patients. Relatives, especially partners are reassured. Women report they are able to provide better support to each other.

31. LOCKABLE BEDROOM DOORS Seventeen wards offer this provision. A further five wards are planning to introduce lockable doors. One unit is planning to install peepholes in women�s bedrooms for added safety. One NUM was not in favor of lockable doors.

32. Lockable Bathrooms 77% of units provide bathrooms with lockable doors. Some units have shared on-suites, resulting in occasions where males and females share the same facility.

33. Nurse Call Buttons Ten units had this provision. Staff experience indicated that nurse call buttons were used appropriately

34. Women�s Lounges Eleven units (42%) have established women�s lounges. A separate recreational space planned in a further six units. One service has established a sensory/therapeutic room for women. One unit provides pamper products � a massage mat, oil and foot massager.

35. Staff experience of women�s lounges �Women�s lounge is well used for a variety of purposes�women feel very comfortable in the space� (NUM) The women�s quiet area is somewhere to get away from difficult males who pester then. It�s used by women when children are visiting and also promotes therapeutic contact between staff and consumers so may be used to one-to-one contact� (NUM)

36. Consumers� experience of women�s lounges �Women consumers are happy about having access to separate recreational space � they feel comfortable and safe� (CC) Some reaction by males with one unit suggesting that a male lounge is needed.

37. Women�s Outside Recreation Areas A number of units have instituted or a planning a women�s outdoor recreation space/courtyard. Staff concerns re safety/security were noted in one unit �initially the women�s garden was operative only when nurses made it available�now the garden courtyard is freely available to use with the door left unlocked in day light hours and no extra supervision is required. (WMHC)

38. Family Visiting Areas Lack of appropriate family visiting areas within wards was an issue commonly raised by NUM�s and CC�s. One unit developed a Sensory Garden for use of families and women. This was achieved in partnership with TAFE and involved male patients in the development. Garden also provides separate space for women�s group to meet.

39. Gender Sensitive Practice in HDU�s �If women are feeling sexually vulnerable they are generally placed in HD where they feel protected� (NUM) �Staff are aware that women may be particularly vulnerable in this environment with very unwell men engaging in very disinhibited behavior such as publicly masturbating� (NUM) Recognition that witnessing sexual and aggressive acts can re-trigger past traumatic experiences for women. Many NUM�s expressed the view that HDU�s should be separated into male and female areas. The need for constant staff presence, including overnight, was highlighted. Thirteen units(50%) which had more than one bathroom had designated separate male and female facilities One unit with three bathrooms has a practice of designating a female bathroom if there are at least three women in HDU.

40. Access to Female Contact Nurse Women desire to be treated by female staff where possible, particularly at night. A commitment to responding to women�s expressed preference for a female contact nurse was frequently mentioned by staff and consumer consultants.

41. Gender Specific Group Programs: Women�s Groups NUM�s spoke positively about the establishment of women�s groups as part of the ward program, both as beneficial for the women and valuable source of information for staff. One NUM noted that �prior to the group women consumers had tended to keep things to themselves. Some staff can become blas�regular feedback from our women�s group helps to heighten staff awareness�women will talk differently when men aren�t around� (CC)

42. Men�s Groups The potential for the establishment of Men�s Groups was raised by Staff and CC�s. �A lot of male patients need information and coaching about how to conduct relationships in non power-using ways. You wouldn�t want to admit the same men and have them behaving inappropriately in these kind of ways time after time� (CC) Certain staff hold beliefs that gender sensitive practice is too difficult and that we have to expect and accept that incidents will happen in inpatient units� (CC) Some areas are exploring collaboration with local PDRS Services who have experience facilitating men�s groups.

43. Patient Orientation Information The need for clear information regarding standards was identified by both staff and consumer consultants. Services have developed pamphlets, clients rights and responsibilities as part of patient orientation. �consumers need to be educated that harassment is not okay� (CC) In addition to written material recognition that verbal communication is vital. �staff need to communicate more with women consumers �make sure they know who their contact nurse is and who they can talk to if they have a concern (NUM) Some men are sensitive too and get embarrassed when other male patients are hitting on women patients (CC) We talk to people about not forming intimate relationships when they�re on the ward� (NUM)

44. Policies to promote gender sensitive practice Development of policies that promote gender sensitive practice seen as key strategy. Service guidelines which clearly state that sexual activity in IPU�s is unacceptable are essential to promoting sexual safety. The need for policies to guide staff in responding to physical assault was identified. One units has developed a Patient Code of Conduct which clarifies expectations regarding acceptable and unacceptable behaviour in the ward environment. .

45. Incorporation of gender-sensitive practice principles in core training for MH staff At the time of the Gender Sensitivity and Safety Report no services were identified as including gender issues in their training program and that limited information about gender issues was available to staff. Information through project found that two services now routinely include the issue of gender sensitive practice as a topic in mandatory core skills staff training.

46. Women�s Portfolio Positions Project identified two services that have established women�s portfolio staff positions with dedicated allowance of hours. Another two services have nominated women�s portfolio positions with no dedicated hours or resources.

47. Formation of Women�s Mental Health Interest Groups A number of service have established such groups In one service the group is multi-disciplinary and mixed gender. Another service has formed a working group to develop, deliver and evaluate gender sensitive staff education package. A further service has established a Women�s Safety Consultation Group consisting of inpatient and community mental health staff. Another has established an �Inpatient Group� to identify actions needed to improve the ward environment.

48. Preventing and promoting Gender Sensitive Practice � (most freq resp) Preventing Lack of staff time Patient acuity / changing client populations Lack of staff awareness Lack of consideration of consumers experience Promoting Team approach Education Senior management awareness Staff presence on wards / communication / positive relationships with clients.

49. Staff Responsiveness Maintaining responsiveness to women�s experience was identified as a challenge for staff by both NUM�s and CC�s. �After a while, staff don�t see these things or you minimize them�staff can underestimate how fearful or stressed someone can be because you�ve become so accustomed to the ward environment�there�s many times that patients won�t speak up� (NUM)

50. Staff Presence Many NUM�s and CC�s expressed the view that safety on wards was greatly expanded when there was a constant staff presence. �nurses being out on the floor talking to patients�patients feel safe�they don�t feel alone�it makes a big difference.� (NUM)

51. Consumer Consultant Issues Only a handful of areas were found to employ both female and male consumer consultants. NUM�s from one service identified difficulties with accessing consumer consultants as an issue. A number of CC�s and staff identified that the CAG in their area had difficulty attracting members and in three areas there was no group at all.

52. Responding to allegations of sexual assault The importance of demonstrating belief for women who disclose sexual assault during an impatient admission, coupled with a recognition that this response is not always available to women, was particularly highlighted by CC�s. �Staff sometimes raise questions � are women saying something has happened because they are unwell? Women need to be responded to with belief and awareness that the inpatient environment many have triggered past trauma. (CC)

53. Alternatives to Admission One alternative is the women�s crisis house model developed in the UK. Some areas have developed self contained women only inpatient units, other have established smaller community based facilities which are located in ordinary residential streets.

54. Establishment of Women�s Portfolio Positions At a minimum a women�s portfolio position needs to be identified within each areas service with a designated allocation of hours.

55. LAST WORDS FROM MENTAL HEALTH STAFF �When I�m visiting the ward and I witness an awful and dramatic incident , I am reminded that nurses are keeping the lid on so many things � I understand that gender sensitivity can feel like just one more thing but we need to find a way for it to be recognised�I feel like we�ve only just begun�the gender upgrade grant began things but it�s a work in progress � (Women�s MH Consultant)

56. PROMOTING SEXUAL SAFETY, RESPONDING TO SEXUAL ACTIVITY AND MANAGING ALLEGATIONS OF SEXUAL ASSAULT IN ADULT ACUTE INPATIENT UNITS Chief Psychiatrist's Guideline November 2009

57. Purpose The Chief Psychiatrists Guideline sets out the relevant legislation and policy, and establishes minimum standards for the clinical management of sexual activity and the appropriate staff response to patients who report inappropriate sexual activity� �is intended to assist �managers, clinical directors and clinical staff in their obligations to promote a therapeutic culture and environment that recognises sexual vulnerability..

58. PROMOTING SEXUAL SAFETY Service management have a clear role in providing leadership and direction at all levels of the organisation to underpin a culture of sexual safety. Physical environment�steps can be taken in any unit to make it safer and to prevent sexual activity Early identification of those who are vulnerable to risk of sexual activity, harassment, abuse or assault Allocation of a risk level�and assigned appropriate level of nursing care.

59. Promoting Sexual Safety cont. Detailed treatment or care plan that is known to all staff, specifies the risk behaviours, details the approach to be adopted to protect the patient, describes specific interventions, is regularly reviewed by treating team. Orientation to the unit � the first step in developing a therapeutic relationship. Should be written and verbal.

60. TO OBTAIN COPIES OF CHIEF PSYCHIATRIST�S GUIDELINE PHONE 9096 7571 USING THE NATIONAL RELAY SERVICE 13 36 77 IF REQUIRED OR AVAILABLE IN PDF FORMAT www.health.vic.gov.ua/mentalhealth/cpg

61. QUESTIONS

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