Implications for practice and research

• Patients expect to be cared for and kept safe by nurses. They feel physically safer when male nurses are present and feel vulnerable among fellow patients.

• Nurses need to be sensitive to the experience of hospitalisation and need to provide physical and emotional safety for all inpatients through close engagement with them.

• Further research is needed to explore the factors that promote feelings of being safe and recovery in acute inpatient units.

Context

The experience of psychiatric inpatient hospitalisation has received increasing scrutiny over recent years. Risk to self or others is usually the core reason for admission to hospital; as such, nurses are required to maintain safety for patients. However, patients have mixed feelings (often negative) about their hospitalisation. Trauma experienced during hospitalisation has been termed ‘sanctuary harm’ to recognise the impact of the experience.1 It is important to provide a therapeutic environment to foster recovery and decrease the likelihood of patients absconding, an event which has associated negative effects.

Findings

Participants wanted to feel safe in hospital and felt vulnerable when there were few male staff and when they were unsure of other patients. From the participants’ perspective it was the nurses’ role to keep patients safe, and to protect them from people outside who they wanted to get away from. Participants saw other patients as different to themselves and this increased their anxiety. Perceptions of threat experienced by patients were heightened when having to share rooms with other patients.

Commentary

This study confirms and extends existing work about the nature of the inpatient experience for people with a mental illness. The perception that male nurses were required to maintain physical safety for patients stems from the view that physical strength is required to deal with aggression. In this study, gendered discourses explain perceptions by participants that female nurses provided emotional support while male nurses provided physical protection and control of the environment. In other studies, which have drawn on mental health geography to explore the experiences of being a patient, the psychiatric inpatient ward is perceived as both a safe and unsafe place. Good relationships with staff, as well as familiarity with the environment and other patients, facilitate a feeling of safety on the ward. Conversely, observing restraint or seclusion and being unfamiliar with staff-exacerbated fear.2 ,3 Participants’ perceptions that being in hospital protected them from ‘others on the outside’ is in contrast to findings suggesting that acute inpatient psychiatric units are permeable institutions due to factors such as the use of mobile phones with texting and social networking, such as Facebook.4 Nurses need to be aware of the potential negative effects that receiving upsetting emails or texts can have on people already in a vulnerable state.

The findings from this study also appear to support a conceptual notion of hospitality where the nurse is the host and the patient is the guest or stranger. The role of the host is to protect and provide for the guest, and create an environment that is empathic and nurturing. Perhaps this is a useful way for clinicians to view patients—as guests who are not familiar to them and who are likely to experience strangeness in the environment around them and those within it. Understanding the perspective of the patient can increase clinical engagement strategies and create a therapeutic milieu.