Participant characteristics
Fifty-nine patients completed the quantitative phase. Twelve patients (from those who completed the quantitative phase) and twelve staff were interviewed as part of the qualitative phase. Patients had a mean age of 37.7 (SD 10.9), and staff were slightly younger (34.2 ± 12.0). On average patients had been in the hospital nearly 3 years, and staff had working at the hospital for just over 9 years (Table 1). Staff roles varied but most participants were healthcare facilitators (n = 6, 50%). Primary mental health diagnosis also varied but paranoid schizophrenia was the most common and were mostly comorbid with other psychiatric conditions (e.g., personality disorders).
Table 1
Patient demographic characteristics (n = 24)
Characteristics | Patient N (%) | Staff N (%) |
Gender | | |
Male | 12 (100%) | 6 (50%) |
Female | 0 | 3 (25%) |
Prefer not to say | 0 | 3 (25%) |
Ethnicity | | |
White-British | 4 (33%) | 4 (33%) |
Asian-British | 0 | 2 (17%) |
Black or Black British - Caribbean | 2 (1%) | 0 |
Black or Black British – African | 2 (17%) | 1 (1%) |
Black or Black British - British | 1 (1%) | 0 |
Black or Black British – Other/Unspecified | 2 (2%) | 0 |
White - Irish | 1 (1%) | 1 (1%) |
Prefer not to say | 0 | 3 (25%) |
Ward level dependency | | |
Assertive Rehabilitation | 10 (83%) | 1 (1%) |
Increased support and assertive treatment | 2 (17%) | 2 (17%) |
Admissions | 0 | 5 (42%) |
Not available | 0 | 3 (25%) |
Primary diagnosis | | |
Paranoid schizophrenia | 5 (42%) | N/A |
Bipolar affective disorder | 2 (17%) | N/A |
Emotionally unstable personality disorder | 2 (17%) | N/A |
Schizotypal disorder | 1 (1%) | N/A |
Paranoid personality disorder | 1 (1%) | N/A |
Mental and behavioural disorders due to multiple drug use and substance misuse | 1 (1%) | N/A |
Role | | |
Healthcare facilitator | N/A | 6 (50%) |
Ward doctor | N/A | 2 (17%) |
Nurse | N/A | 1 (1%) |
Consultant psychiatrist | N/A | 1 (1%) |
Senior clinical manager | N/A | 1 (1%) |
Clinical nurse manager | N/A | 1 (1%) |
Previous use of Oxehealth before | | |
Yes | N/A | 2 (17%) |
No | N/A | 10 (83%) |
| Patient mean (SD) | Staff mean (SD) |
Length of stay (days) | 1052.8 (701.2) | N/A |
Length of service at Broadmoor Hospital (years) | N/A | 9.3 (11.1) |
Length of career in mental health (years) | N/A | 11.8 (11.6) |
Key: N/A no applicable |
<Insert Table 1: Patient demographic characteristics (n = 24)>
Main themes
There were seven main themes: detecting deterioration and improving health and safety, “Big Brother Syndrome”, privacy and dignity, knowledge and understanding, acceptance, barriers to use and practice issues and future changes needed (Fig. 2).
Detecting deterioration and improving health and safety
Both staff and patients agreed that the main purpose of Oxehealth was to look after the patients, improve safety and ultimately save lives. Staff especially mentioned that there was a need for Oxehealth and it was helpful to monitor the complex nature of patient’s mental and physical health (e.g., treatment-resistant patients, aggressive patients).
“I think it's actually really important that Broadmoor, and especially because of the complex nature of the patients and the treatment-resistant patients, how aggressive and unwell patients are and it's a lot more difficult to take physical health, vital signs monitoring at Broadmoor, so I think it's completely appropriate here, but it needs to be explained properly to patients and staff.” (Staff 11)
Participants described Oxehealth as a balance between savings lives and watching the patients, but with their “human rights” impacted. For example, some patients reported feeling reassured having Oxehealth in that someone would intervene if their health was worsening and that made them feel safer, and more relaxed. However, a few patients felt despite the intention to improve patient safety, they still did not want Oxehealth and were not happy, specifically the invasion of privacy. Moreover, some staff and patients reported that the technology was not as accurate as it could be and needed improvement to detect deteriorating physical health. For example, a few patients described how a person had died in their beds despite having Oxehealth, and had not detected the patient deterioration or prevented their death. Similarly, one staff member also recalled the patient death but that Oxehealth had helped explain what had happened.
“Well going back to that… I remember that night the alarm bell went off so I’m not sure whether that was something that Oxehealth triggered or whether that was part of the plan of Oxehealth to raise the alarm by setting off the alarm bell I’m not sure if that’s part of the plan obviously I’m not privy to what happened so but somebody died so…was it successful or did it not work but somebody died at the end of the day so if it’s there to prevent death and somebody dies then that means it failed.” (Patient 7)
“A patient died in their room where Oxehealth was, and I think it actually provided some timelines closer to the time when the patient is suspected to have passed away rather than…..and it ruled out any assumptions that what happened what went wrong” (Staff 4)
“I think he died in the area where there is a blind spot, rest in peace. So maybe if the Oxehealth could have a way of monitoring that blind spot if it was possible a bit better than it actually can or does and then that allows staff then to react, which could then save a patient’s life, react quicker maybe which could then save a patient’s life. Because I think that by the time they was made aware of him not being where he should be the time had really gone by and it was too late.” (Patient 42)
There was disagreement across patients, and staff about the use, need of both invasive (physical checks every 15 minute) and non-invasive (Oxehealth) patient monitoring. Most staff felt that Oxehealth could not replace the physical checks, and the Oxehealth was an addition intervention to help staff maintain patient safety.
“It's [Oxehealth] not a substitute to doing the general observation or the eyesight observations and stuff like it's an additional technology that you can use to help you to assure yourself that the patient is physically well.” (Staff 4)
Most patients reported not having a choice in which method staff used to watch them. Most patients preferred non-invasive monitoring to physical checks despite the thought of staff watching them because the physical checks, every 15 minutes, were described as annoying and negatively impacted their sleep at night. For example, patients reported staff making noise and shinning lights through the windows to make sure the patients are still breathing.
“I’ll wake up sometimes, they shine it in your eyes so you wake up, like if your watching TV and they’re disturbing you all the time shining it in” (Patient 117)
Similarly, some female staff members reported feeling more comfortable with Oxehealth than the physical checks because they felt safer not needing to go into patient’s rooms, particularly with more aggressive and psychotic patients. In contrast, a few patients indicated they were not as bothered about the physical checks because staff were respectful. In contrast, some patients were not happy with “being watched” all the time, describing it as “Big Brother Syndrome”.
“I still feel alright, but now I know. At first, I said to my friend, they don’t see me in my room. They can’t see me. Now I know that they can see me, sometimes I pray and these are private things, they might have seen me pray a couple of times maybe” (Patient, 93)
“It’s the cameras in it, it’s all watching somebody. Like I always get changed in my bathroom and I always make sure I’m not in my room, I’m quite conscious about that.” (Patient 117)
This invoked paranoia and anxiety from the patients, particularly when they first came into the hospital. Staff also agreed.
“We need not to forget that our patients have a mental illness, and again, some of these paranoias and suspicions relate to being watched, you know” (Staff 4, Nurse)
Other patients accepted that they were in bad situation where connection with others was limited, specifically in seclusion. However, Oxehealth provided some patients with comfort and human connection (e.g. through the camera). Some staff also reported that they understood patient’s feelings. It had led to rebellious behaviour in the past, with some patients physically blocking the cameras with wet paper. Patients more than staff could not understand why staff were still doing the physical checks if they had Oxehealth. Moreover, some patients likened Oxehealth to CCTV, whereas others could see the distinction between Oxehealth and CCTV, especially staff.
Privacy and dignity
All participants described having a lack of privacy and dignity since installing Oxehealth technology. Most patients were more bothered by the camera than Oxehealth itself (checking they are breathing), and felt it was an invasion of privacy and violation of dignity.
“…the other day with another patient on another ward… he didn’t like it [Oxehealth] at all, he thought it was his dignity was getting invaded and his privacy was getting invaded and I’ve heard a lot of other patients like when I was on [ward name] I heard other patients saying they didn’t like it in the room and it’s not fair they are being watched on cameras and that so I’ve had a lot of negative response from it.” (Patient 117)
Some patients had adjusted their behaviour because of the camera including sleeping under the covers, getting changed in the bathroom and masturbating in the shower. One patient felt that staff were looking at him naked and felt embarrassed.
“Er, if they see you naked they apologise but that’s not really maintaining privacy is it.” (Patient 2)
Most staff reported that they understood why patients felt they had no privacy, and they did their best to maintain it. For example, staff reported knocking on the door before entering, trying to reassure the patients that the camera is not recording them all the time, and giving patients the opportunity to ask questions. Most patients described feeling comfortable talking to staff if they needed to but some often kept any issues to themselves. This two-way social interaction was apparent across all participant in some way. For example, several patients reported lack of trust between patients and staff, but staff also suggested this was something to acknowledge and a barrier to staff using Oxehealth.
“It's all about reassurance and information. When we build that trust up and they start to trust us a bit more, but that comes with time and then, you know, they accept more of the reassurance about it” (Staff 2, Nurse)
A few patients reported that there was an imbalanced power dynamic that made them feel like victims, and sometimes there was a power struggle between staff and patients, but this was not just about Oxehealth. Staff views differed on whether privacy had been breached or not. For example, a healthcare facilitator felt Oxehealth did not breach ethics because staff did not abuse Oxehealth, whereas another healthcare facilitator felt there were ethical issues in watching patients. However, staff felt the benefits of Oxehealth in detecting deteriorating health outweighed the ethical issues.
“There are a few points in terms of ethics in terms of the continuous recording, as well as patient privacy and also who has access to that information because I guess we are sharing information” (Staff 8, Healthcare facilitator)
Knowledge and understanding
Most patients knew that Oxehealth monitored patient’s vital signs, but they all described inaccuracies about how Oxehealth works and misunderstandings about the reason for the camera and how it is used. For example, some patients felt that Oxehealth measures blood pressure and pulse, and others thought staff could not see them on the camera; both were inaccurate descriptions.
“I don’t know. I think it’s something to do with lasers” (Patient 93)
Some staff and patients described incidents where patient misunderstanding had resulted in disruption by patients including blocking the camera with wet tissues, particularly when first coming into the hospital. Notably, patients indicated that Oxehealth had not been explained to patients properly or in a consistent manner. Some patients described being told about Oxehealth during group discussion, whereas others had a one-on-one with a patient rep, and others reported being self-taught.
“Not really, no one’s really explained to me how it works I learnt just myself by talking to some patients and that.” (Patient 117)
Similarly, the formats of explanation also differed across the patients (e.g., leaflets, chat, and presentation). Some staff also did not know how it worked and what their role was in using Oxehealth. For example, a few staff members, especially bank staff, reported confusion over the procedural use of Oxehealth. In contrast, other staff felt confident in using Oxehealth, but Oxehealth itself made them feel confident and more assured about their own physical observations of the patient’s health and safety.
“it's quite reassuring for me as a junior doctor to know that people's heart rate is not elevated, especially if you're worried about some infection. Or that their respiratory rates particularly high, if you're worried about breathlessness or anything like that. So I think it's very helpful and reassuring from that point of view.” (Staff 11, Ward Doctor)
Most staff reported liking Oxehealth and saw it as an extra measure that reassured them when it was difficult to check on patient safety from physical checks alone. However, most staff indicated it should not replace physical checks with Oxehealth alone.
“it's not a substitute to doing the general observation or the eyesight observations and stuff like it's an additional technology that you can use to help you to assure yourself that the patient is physically well” (Staff 4, Senior Clinical Manager)
Acceptance (patient only)
Most patients had come to accept that Oxehealth was here to stay, and that nothing they say would make a difference in getting rid of it. This view was emphasised when asked about if they had a choice on the decision to keep Oxehealth or not. Some still had a problem with Oxehealth and would not want it if they had a choice. However, others could still see a place for it and felt it kept patients safe. Time seemed to be a consideration as to the reason why some patients were or were not bothered about Oxehealth as some described learning to live with it since it was introduced. Whereas those who complained about its use were more likely to have had less time in the hospital. However, most demonstrated indifference about Oxehealth. Some patients described forgetting it is there, not paying attention anymore, and being unphased at being monitored.
“…I don’t mind it, it don’t bother me I don’t really think about it, it don’t come into my thoughts…it’s just there, part of my room.” (Patient 117)
“Well if I thought it was going to save people’s lives I would want it but if it was just for surveillance then I would say take it away, everyone has a right to their privacy. You know.” (Patient 22)
Barriers to use and practical issues (staff only)
Staff described several barriers and practical issues to using Oxehealth in the correct manner. For example, most staff reported technological glitches, which included poor Wi-Fi, signal issues, and not being able to view live coverage for a long period or a good reading of patient activity. Similarly, some staff indicated that there were security concerns over using the IPad to monitor Oxehealth including using the IPad as a weapon, and patients accessing the Oxehealth data on the IPad (e.g. code on the back of the IPad). Reported barriers to staff using Oxehealth were varied and more relating to personal and interpersonal factors. For example, some staff described the reliance of staff ability to use technology, not being able to understand current resources, and not being trained enough as barriers to staff using staff, and/or using it correctly.
“Lack of understanding of it like me! Perhaps there might be a lack of trust in it compared to like the more familiar traditional ways of measuring the outcomes.” (Staff 2, Consultant Psychiatrist)
Future changes needed
This last theme was connected to improving areas discussed in the previous themes, or sub-themes. Overall, most staff still feel physical checks are still needed regardless of the benefits of Oxehealth. Staff members suggested that reasons for this included having increased reassurance in knowing the patient was safe, that Oxehealth is not always accurate, and staff would not welcome that swapping to Oxehealth alone. One staff member argued that Oxehealth was not a substitute but only an addition to visual checks and observations. Another staff member suggested having checks every 30 minutes as standard rather every 15 minutes. Related to this, a few staff members, and one patient mentioned that better accuracy in detecting deterioration was needed because Oxehealth did not always detect deterioration.
“Sometimes it doesn't always pick up readings, even when people are still. And I’ve noticed that myself when I’ve tried to check it.” (Staff 11, Ward doctor)
Better education about Oxehealth was reported as needed for both staff and patients. Most staff described needing training in what Oxehealth does and does not do; expectations of staff, particularly bank staff, and what staff need to do to monitor patients. Subsequently, this was reported to likely improve the patients’ knowledge about Oxehealth and that it would
have a positive impact on the patient’s education. Additionally, the need for more support but from the Oxehealth company directly, was mentioned by a few staff members. Staff mentioned this would be helpful to “sort out the technology” and having more IT support on hand. One patient felt that discussing the benefits of Oxehealth with patients might help patients understand why there is a camera in their room. Another patient wanted Oxehealth in the bathroom, as they described it as the only place that could not detect deteriorating physical health and they would therefore feel safer.
“There should be more sensors in the room, you know like, Oxehealth technology will only get better over the years but they should be one of the bathrooms” (Patient 60)
<Insert Fig. 2: Thematic map>