Access provided by
London Metropolitan University
• To recognise that many women who receive inpatient mental healthcare have negative experiences
• To update your knowledge of the importance of gender-sensitive and trauma-informed inpatient mental health services for women
• To understand women’s experiences of care and support in an NHS mental health rehabilitation service
The importance of providing women who experience mental health issues with gender-sensitive and trauma-informed care has been emphasised in research and policy. However, the literature highlights that many women who receive inpatient mental healthcare have negative experiences including restrictive interventions, feeling coerced to take medicines, lack of empathy and re-traumatisation. It is important to continue exploring women’s experiences in inpatient mental health services to determine to what extent the care offered is gender-sensitive and trauma-informed.
This article reports on a service evaluation conducted in 2023 at one mental health rehabilitation service in England to explore the experiences of female service users. Six women were interviewed and the data obtained were analysed thematically. Most participants reported positive experiences of the service but there were areas where care could be improved.
Mental Health Practice. 27, 4, 28-34. doi: 10.7748/mhp.2024.e1696
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Rees C, Kadir S, Kidd K (2024) Exploring women’s experiences of an inpatient mental health rehabilitation service. Mental Health Practice. doi: 10.7748/mhp.2024.e1696
Published: 04 July 2024
Published online: 23 April 2024
The Women’s Mental Health Taskforce was set up in 2017 to define and address priorities for improving the mental health of women and their experiences of mental health services in England. In its final report, it stated that services should be trauma-informed and consider women’s gender-specific needs and risks, including their greater risk of experiencing abuse outside and in mental health services (Department of Health and Social Care (DHSC) 2018). In a report for the British Medical Association on addressing unmet needs in women’s mental health, Abel and Newbigging (2018) stressed that women have distinct and specific needs and that mental health services must be gender-informed and co-designed with women who have experience of poor mental health. Gender-sensitive and trauma-informed care implies safety, compassion, respect and avoidance of re-traumatisation (DHSC 2018).
A literature review into women’s experiences of inpatient mental health services, in the UK and globally, highlighted negative experiences such as restriction, re-traumatisation, coercion and feeling unheard (van Daalen-Smith et al 2020). Some women felt that the focus of their inpatient stay was on adherence to drug treatment and felt coerced into taking medicines. Some felt unheard or silenced and experienced a lack of empathy from staff, which exacerbated their trauma and contributed to self-blame and feelings of worthlessness (van Daalen-Smith et al 2020).
In a phenomenological study into women’s experiences of occupational engagement in an acute psychiatric unit in Australia, for which five women were interviewed, participants reported feeling ignored and unimportant to staff (Kennedy and Fortune 2014).
Scholes et al (2022) interviewed 20 women about their experiences of restrictive interventions in inpatient mental health services in the UK. Some reported experiencing restrictive interventions including being restrained by a male member of staff, which could trigger flashbacks, nightmares and fear related to previous trauma; a lack of dignity during pre-seclusion clothing removals and searches; and a lack of hygiene and sanitary products while in seclusion (Scholes et al 2022). Some reported that the fear they experienced led them to take the medicines they were prescribed so that they would avoid further restrictive interventions (Scholes et al 2022).
Kennedy and Fortune (2014) found that connecting with other female service users of a similar age and with similar personalities and illness experiences was important to women, as was having gender-segregated areas to talk privately with other women and reduce the fear of harm by male residents. Morton et al (2022) explored the lived experiences of 42 staff and 43 service users in acute mental health units in New Zealand. Participants highlighted that gender-segregated wards ensured that women with a history of trauma, particularly trauma from violence perpetrated by a man, felt emotionally and physically safe (Morton et al 2022). The UK NHS guidance on same-sex accommodation in inpatient mental health units states that service users should not have to share sleeping accommodation or bathroom facilities with the opposite sex and that women-only day rooms should be provided (NHS England and NHS Improvement 2019).
Scholes et al (2021) highlighted that if women in inpatient mental health services were to share their trauma histories they needed to feel safe, be given space, be in a trustful therapeutic relationship and be cared for by staff who are trained to adequately respond. Positive outcomes have been seen when staff listen to women and show that they care (van Daalen-Smith et al 2020). However, in practice, staff may not always be open to listening to women’s trauma histories.
In two studies of health professionals’ experiences of caring for female survivors of sexual violence in psychiatric inpatient units in Australia, O’Dwyer et al (2019a, 2019b) found that some staff believed that listening to women’s trauma histories was not part of their role and responded dismissively; that some were reluctant to work with women, believing they were more difficult to care for than men; and that implementing gender-sensitive care was challenging because of staff’s limited understanding of such care, pressures on services and the need to manage risk. These negative attitudes among staff towards working with women were confirmed by a scoping review of health professionals’ experiences of providing trauma-informed care in acute psychiatric inpatient settings (O’Dwyer et al 2021).
A systematic review of women’s experiences of inpatient mental health services – which also looked at staff’s experiences of providing care to female service users – found that women’s experiences had been fairly consistent between 1994 and 2019 (Scholes et al 2021). Inpatient mental health services could make women feel safe but also coerce them into taking medicines, induce fear and inadequately acknowledge histories of abuse (Scholes et al 2021).
As shown by Scholes et al (2021), women’s experiences of inpatient mental health services appear to have changed very little in the past 30 years, so it is important to continue to gather their views, the ultimate aim being to offer safe, gender-sensitive and trauma-informed services that meet women’s needs. In 2023, a service evaluation was conducted at Leicestershire Partnership NHS Trust’s mental health rehabilitation service to understand the experiences of female inpatients.
• Gender-sensitive and trauma-informed care implies safety, compassion, respect and avoidance of re-traumatisation
• Findings ways of facilitating interactions between female inpatients in mental health services may improve women’s experiences
• Where possible, ensuring that there are female staff available to support female inpatients in private spaces would help women feel comfortable and safe
• Some women receiving care in inpatient mental health settings may need more psychological support than others, notably if they have experienced interpersonal trauma
• Further exploration of women’s experiences is needed to determine to what extent the care offered in inpatient mental health rehabilitation services in the UK is gender-sensitive and trauma-informed
To understand women’s experiences of an inpatient mental health rehabilitation service, explore whether their specific needs were being met and gain their views on how their care could be improved.
The mental health rehabilitation service at Leicestershire Partnership NHS Trust has two inpatient units designed for people who have a severe and enduring mental illness and require a period of rehabilitation to reduce psychological distress and improve functioning, well-being and quality of life. One of the two units is mixed, offering 15 beds for women and 15 beds for men. It has separate female and male zones, each with private bedrooms, private toilet facilities, communal bathrooms, lounges and a kitchen. It also has a mixed-gender lounge and a mixed-gender garden. The other unit is for men only and provides eight beds.
All eligible women receiving inpatient care at the mixed-gender inpatient unit during the service evaluation period (n=14) were approached and informed about the service evaluation. To be eligible, women had to have mental capacity to consent to take part in an interview. Eight women declined and six women agreed to participate.
The six participants were aged between 29 years and 67 years and self-identified as cisgender. Two of them self-identified as being from an Asian ethnic background and four self-identified as being from a white ethnic background. At the time of the interview, they had been at the inpatient unit between one month and seven months.
Individual semi-structured interviews were used to explore participants’ experiences of the inpatient rehabilitation service. The interview schedule had been developed by one trainee and two qualified clinical psychologists (the authors of this article). The questions explored participants’ experiences of the service, whether their specific needs were being met, and their views regarding their care and how it could be improved. The interviews were conducted face to face by the trainee psychologist and audio recorded. At the end of their interview participants were offered additional support if required. The interviews were transcribed, after which the recordings were deleted.
Data analysis was undertaken by the trainee psychologist using the stages of thematic analysis outlined by Braun and Clarke (2012). Initial familiarisation with the data and the identification of patterns were followed by data-driven coding. Codes were sorted into broader themes and subthemes, which were later revisited to ensure they accurately represented participants’ narratives and the data set as a whole.
A critical realist epistemological position was adopted. Critical realism posits that reality can only be imperfectly understood and that subjectivity, including the influence of knowledge and experience, cannot be excluded (Madill et al 2000). The trainee psychologist had pre-existing knowledge of the service and pre-existing relationships with some of the participants. She used personal reflexivity in the form of peer debriefing in weekly supervision to consider how this could affect the data analysis and identify any potential biases.
Using the Health Research Authority decision tool (www.hra-decisiontools.org.uk/research) confirmed that this was a service evaluation, which meant that ethical approval from an NHS research ethics committee was not required. The service evaluation was approved by Leicestershire Partnership NHS Trust’s quality improvement programme in February 2023.
Women who had agreed to participate received an information sheet and were given the opportunity to ask questions before being asked to give verbal and written consent. They were informed that their confidentiality and anonymity would be protected, since their interview data would be assigned a unique participant number, and that their anonymised quotes would be used in an article for publication. Interview data were kept on a password-protected trust laptop.
Three themes and seven subthemes emerged from the analysis of data (Table 1).
Participants described their interactions with, and their experience of living alongside, the other women receiving inpatient care at the unit. Some described a pleasant atmosphere and a place where women could connect:
‘There’s a really friendly atmosphere I’d say.’ (Participant 1)
‘It’s very nice, warm and welcoming and everybody’s really nice to me.’ (Participant 2)
Some had witnessed negative interactions between women or had had negative interactions with other women:
‘They’re used to their way of dealing with things, so they either bully you or abuse you.’ (Participant 4)
Many participants described minimal interaction between women, one of the reasons being that everyone was focused on their own difficulties:
‘I don’t talk to the other residents that much… They’ve all got their own issues like I have.’ (Participant 6)
‘None of the people talk in here because they’re all depressed about being here.’ (Participant 3)
Some participants thought that age could be an issue in relation to interacting with the other women at the unit, whether they felt there were not enough women of the same age as them or whether they enjoyed interacting with younger women but found that there were not many of them:
‘I realise now that you do need your age group to mix with.’ (Participant 4)
‘It would be nice to have some more younger people, I get along well with younger people, there’s the young girl I am friendly with. But the rest, I don’t push them, and they don’t push me.’ (Participant 6)
Some participants wanted to connect with the other women and made suggestions about how this could be facilitated:
‘I think if we all sat in the female lounge and had a friendly chat with each other with the nurse, that would be a good idea to do that… It would help us get along better perhaps and get to know each other.’ (Participant 1)
Most participants felt that having the opportunity to interact with men was positive and highlighted that the unit’s layout enabled them to choose whether and when to interact with men, which they found helpful:
‘Yeah, I like that they’re separate but there’s a garden because then you can interact with the male patients too.’ (Participant 1)
‘There’s a good balance, there’s communal areas where you can talk to the men, which is nice.’ (Participant 5)
Some participants spoke about sharing a space and interacting with men as bringing a sense of normality to their lives:
‘Even though men and women are separated, they are allowed to interact in a healthy way. So when that happens it feels more normal. In other places you are just stuck with a load of women and it’s like, what happened to all the men?’ (Participant 2)
Some explained that feeling safe in their interactions with men was important and that staff’s presence in the shared areas made them feel safe:
‘[The staff] take care of you, like your safety, because sometimes there are people who are kind of like, do not get along with men and stuff like that.’ (Participant 2)
Some felt that the mixed-gender spaces were dominated by men:
‘I don’t really like the mixed lounge because the men seem to operate that area. It doesn’t seem suitable for both women and men. It’s mostly the men relaxing in there.’ (Participant 1)
Most participants described feeling comfortable approaching staff about their gender-specific health and care needs, for example regarding periods or the menopause, and feeling supported by staff regarding those needs:
‘I feel confident that if I had a problem, I could talk to somebody, I know there are enough nice members of staff that I would focus on.’ (Participant 5)
‘They make me feel comfortable and it feels like it’s nothing to be ashamed of. It’s your body and your body is a temple.’ (Participant 2)
‘Yeah, I have my period cup so like you know, they take care of my period cup, yes.’ (Participant 2)
‘If I need sanitary towels they arrange to take me to either Co-op or another shop.’ (Participant 4)
One participant stressed the importance of having female staff available to talk to about women’s issues such as periods:
‘I suppose one of the main things is because most of the staff team are female if you’re on your period you can be quite open and honest about it… I’m quite upfront about that kind of thing, I speak quite openly to men about women’s problems but I don’t think I should have to in a hospital environment, so it’s good that it’s female led.’ (Participant 5)
One participant felt that their health concerns were not being addressed:
‘They don’t listen to any of your health problems neither, they don’t do anything about it, like me they don’t care about my body.’ (Participant 3)
Some participants felt that they lacked privacy. One described feeling that their private space had been invaded when a male member of staff had entered the washroom when completing routine observation checks:
‘You know one time this man came in, I said I was in the washroom, he came inside and because I was not in the room, he opened the washroom door, erm so yeah, I told them to leave and he got out. So that’s why I need a little more privacy.’ (Participant 2)
Other participants felt that privacy issues were being managed appropriately and sensitively. For example, one participant described how female staff had helped her out of the bath, an incident that had been managed well but could have led to a breach of her privacy if it had been handled poorly:
‘I had an incident the other week where I was stuck in the bath, I couldn’t get out, I had to get five nurses to get me out with a hoist and they aren’t embarrassed, you know what I mean, they just take things in their stride.’ (Participant 6)
Some participants highlighted the benefits of being provided with opportunities to engage in self-care activities. These could range from looking after one’s body and physical appearance to developing a daily routine and taking time for self-reflection:
‘Having things like shaving cream, toothbrushes stuff like that, blow-dryers, so stuff like women would need to feel better about themselves, to feel good about themselves.’ (Participant 2)
‘They’ve made me a timetable now and erm I do different things every week with them so yeah. So yeah, I think that’s very supportive.’ (Participant 6)
‘I think this place has helped me, I am more relaxed and ready to listen more, so I have time to myself to organise myself and my brain.’ (Participant 2)
Most participants felt that they were being listened to and supported by staff:
‘If you’re feeling stressed at all, the nurses can calm you down. In different positions in the room at different periods of the day, they do different things when I’m stressed.’ (Participant 1)
‘There’s quite a full team around me, I feel supported.’ (Participant 5)
‘They listen to me if I do need to talk about anything.’ (Participant 6)
Many participants emphasised that staff made time for them, which helped them to feel cared for:
‘And the staff are nice, even if they are busy they can pay attention to you.’ (Participant 4)
‘They listen to you, they’ve got time for you in here. If you’ve got a problem, they will help sort it and they really are lovely people.’ (Participant 6)
One participant felt that she was not listened to or understood by staff, which reinforced her feeling that no one cared about her:
‘I just feel like no one cares. That’s what I have had to deal with my whole life anyway, people not caring.’ (Participant 3)
Some participants suggested ways in which service users’ experiences could be improved, such as taking a more person-centred approach and having more staff available:
‘Doctors to listen to you more, instead of just getting a high pay-pack and just going in your file, they should listen to people. Because not everyone’s case is the same.’ (Participant 3)
‘You know, there should be more staff to help, to psychologically help people, to listen to their needs.’ (Participant 2)
Some participants spoke about the restrictions they experienced as hospital inpatients, which they found frustrating and unfair:
‘When I first got here the doctors left me in here for three days and they didn’t let me have a cigarette, I was informal and then they put me on a section because I asked to go home.’ (Participant 3)
Some participants felt that processes were too slow, which could delay their discharge:
‘This place just leaves you in here for long periods of time. They should sort things a bit more quicker so they can make room for the next patients. Not take so long to sort things out and do things for people.’ (Participant 3)
One participant felt there was not enough contact with the wider team between ward rounds, which meant that changes occurred both too slowly and too abruptly, without enough opportunity to discuss and agree them in a timely manner:
‘But things tend to move really slowly because ward round is every two weeks, so I find that a problem, I get frustrated about the unknown and what’s coming next because things change so drastically from one fortnight to another.’ (Participant 5)
However, the same participant also felt that her need for more freedom had been recognised:
‘I like my doctor, he made me informal early on and he recognised my need for more freedom.’ (Participant 5)
Some participants described being spoken to as if they were a child, being treated with suspicion and being threatened with a cancellation of their leave from hospital. This revealed potentially uneven power dynamics between staff and service users:
‘I feel like you have to bow down to the staff all the time because they always say we’re having a go at them when we’re not. And I feel like they talk to you like a child. They just think they’ve got total control over me. “Ooh I’m stopping your leave, I’m stopping your leave”, that’s all they threaten you with.’ (Participant 3)
‘There has to be two people in the room and that always annoys me, you know it almost like well you’ve got your backup, what about my backup to prove what I’ve been saying.’ (Participant 5)
One participant felt that the way she was being treated, within the service and in society in general, was influenced by gendered views about men and women:
‘I do think that my attitude or attitude problem, as some call it, would be tolerated a lot more if I was a man. I do think the word “bossy” comes to mind [to] some people [when they] describe me, but I do think men get away with it, being called more “assertive” than “bossy” and I think with men it’s just expected more, this kind of hot head if you like. You know I generally feel that […] men get away with a lot more of that kind of behaviour than women.’ (Participant 5)
In the quotes above, participants use the term ‘informal’ to indicate that they were at the unit voluntarily.
Many participants in this service evaluation reported that there was little interaction between the women receiving inpatient care at the unit, for reasons including bullying behaviour from some of them, age differences, low mood and the fact that each person tended to focus on themselves. Some participants expressed a desire to interact more with the other women, which mirrors the findings of Kennedy and Fortune (2014). Finding ways of facilitating interaction between female inpatients in mental health services may improve women’s experiences.
Many participants reported that being able to interact with male inpatients if and when they wanted was positive. This reinforces the idea that gender-segregated wards are beneficial for women, ensuring that they feel emotionally and physically safe (Morton et al 2022) but that having the possibility to interact with men is also beneficial.
Most participants felt that their gender-specific health and care needs were adequately met and felt comfortable talking to staff about them. One participant highlighted the importance of the availability of female staff to discuss those needs. Participants had mixed views regarding whether their privacy was respected. One described feeling comfortable being helped out of the bath by female staff; another described feeling that her private space had been invaded by a male member of staff. Where possible, ensuring that there are female staff available to support female inpatients in private spaces would help women feel comfortable and safe.
Participants discussed aspects of their care that were not necessarily specific to them as women but were still important as part of their experiences of the inpatient rehabilitation service. Some described being provided with opportunities to engage in self-care activities that made them feel better about themselves. Determining and addressing each woman’s individual self-care needs can increase their self-esteem and support their recovery.
All participants identified that being listened to and cared for by staff was important and most felt that their needs in that respect were being addressed. These statements contradict findings that have shown that women in similar settings felt unheard, unimportant, ignored and not treated with empathy (Kennedy and Fortune 2014, van Daalen-Smith et al 2020). However, one participant did feel unsupported and not listened to, which exacerbated her long-standing sentiment that no one cared about her. This reflected the findings of O’Dwyer et al (2019a) from their interviews with healthcare professionals caring for female survivors of sexual violence in Australian psychiatric inpatient units, where some women felt dismissed when seeking support. Some women receiving care in inpatient mental health settings may need more psychological support than others, notably if they have experienced interpersonal trauma. This reinforces the findings of Scholes et al (2021), who highlighted the importance for women of having therapeutic relationships with professionals who are trained to help them open-up about their experiences of trauma and respond appropriately.
Some participants in this service evaluation described experiencing restrictions and feeling frustrated or ‘trapped’ by ward policies and slow processes delaying discharge. However, what they described was not commensurate with the negative experiences discussed in the literature, such as physical restraint (Scholes et al 2022) and feelings of being coerced into taking medicines (van Daalen-Smith et al 2020, Scholes et al 2021), which have been shown by researchers to have existed in inpatient mental health services for many years. It would be interesting to explore whether these differences in women’s experience of care were consistent across inpatient mental health rehabilitation services, including in women who receive care on a mental health section, which would suggest a major change in the way women are supported in these services.
Some participants felt that they were being spoken ‘down to’ by staff, which points to uneven power dynamics. One participant felt that the way she was treated was gendered and that her behaviour would have been considered more acceptable had she been a man. Although boundaries are needed to ensure everyone’s safety, it appears important to consider how they are implemented to reduce power imbalances and prevent a breakdown in the relationship between staff and service users.
The sample was small and three of the six participants had only been in the unit for one month. Some participants were interviewed by a professional who was working with them clinically, which may have biased their answers. More than half of the women who had been approached had declined to take part and those who took part may have had more positive experiences of the service – however, participants described negative as well as positive experiences. No service user had been involved in the development of the interview schedule, which may not have adequately reflected what is important to them.
The findings of this service evaluation are not generalisable beyond the setting where it was undertaken, where they will inform future service improvements. Similar evaluations in other services would be needed to provide broader insight into the care women receive in inpatient mental health rehabilitation services in the UK. More research in this area would also help understand the experiences of women of different ages and from a wider range of ethnic backgrounds.
This service evaluation of the experiences of women receiving inpatient mental healthcare at one rehabilitation unit found that, overall, participants’ experiences were positive. Most women interviewed felt listened to by staff, felt that their health and care needs were being addressed, and appreciated being offered opportunities for self-care and for safe interactions with male inpatients. Areas for improvement included facilitating more interaction between female service users; being mindful of their privacy needs; and implementing boundaries and ward policies in ways that minimise power imbalances.
One participant’s experiences were negative, which may show that some women receiving care in inpatient mental health settings may need more support than others, notably if they have experienced interpersonal trauma. Further exploration of women’s experiences is needed to determine to what extent the care offered in inpatient mental health rehabilitation services in the UK is gender-sensitive and trauma-informed.
04 July 2024 / Vol 27 issue 4
Survey evaluates quality of patient information at end of treatment
A patient experience survey was undertaken by the South West...
Effectiveness of a neutropenic sepsis clinical pathway
This article reports the findings of a re-audit across a...
Developing a clinic to meet patients’ pre-operative needs
This article describes a practice development project at a...
Emergency assessment bay for cancer patients
The annual Quality in Care (QiC) Excellence in Oncology...
Benefits of attending nurse-led pre-chemotherapy group sessions
Before the start of chemotherapy, cancer patients and their...
