Changing from mixed-sex to all-male provision in acutepsychiatric care: A case study of staff experiences

NEIL THOMAS1, JANE HUTTON2, PAUL ALLEN2, & DELE OLAJIDE2

1Mental Health Research Institute of Victoria and Department of Psychological Medicine, Monash

University, Melbourne, Australia, and 2South London & Maudsley NHS Trust, London, UK

AbstractBackground: British government policy advocates the availability of single-sex inpatient mental healthservices (Department of Health, 2003), but there is relatively little literature comparing single-sex andmixed-sex service provision and less still describing transitions between the two.Aims: To describe the experience of nursing staff on an acute psychiatric ward during the transitionfrom mixed-sex to all-male provision and the following 9 months and to suggest how this might havebeen improved.Method: All nursing staff working on the ward at the time of the change were asked to completequestionnaires 3 and 9 months later.Results: Response rates were 75% and 50% at 3 and 9 months respectively. Staff generally experiencedthe change negatively, with particular concerns about the ward environment becoming less therapeuticand more aggressive, and jobs becoming more stressful. These concerns did not diminish over time.Other concerns were related to the process and administrative consequences of change.Conclusions: The transition to single-sex provision can be a difficult one, and staff should be involvedas fully as possible in the process of change. Working with all-male populations can present particularchallenges and staff are likely to benefit from specific training and support to meet these.

Keywords: Inpatient services, services for men

Introduction

Mixed-sex provision has been widespread in UK psychiatric wards, stemming from attempts

to provide more normalized environments. However, with increasing community-based

provision, psychiatric hospitals have increasingly provided brief admissions covering very

acute episodes of illness. Thus, inpatients’ levels of disturbance are often very high and there

have been concerns about the vulnerability of women in mixed-sex wards to intimidation,

violence and sexual harassment (Cleary & Warren, 1998; Henderson & Reveley, 1996) and

suggestions that all-female wards may be more therapeutic (e.g., Mallon, 2001).

This has led to the UK government advocating more single-sex accommodation and

facilities (NHS Executive, 2000). In response to this, many NHS Trusts have returned to

the provision of single-sex wards. However, the literature does not unequivocally support

Correspondence: Dr Jane Hutton, Maudsley Psychology Centre, Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK.

Tel: þ44 (0)203 228 2194. Fax: þ44 (0)203 228 2473. E-mail: j.hutton@iop.kcl.ac.uk

Address where research was carried out: Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK.

Journal of Mental Health,

April 2009; 18(2): 129–136

ISSN 0963-8237 print/ISSN 1360-0567 online � Shadowfax Publishing and Informa Healthcare USA, Inc.

DOI: 10.1080/09638230701879201

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this. Henderson and Reveley (1996) caution against assuming that women will be safer on

single-sex wards on the basis that, in the wider community, most violence against women is

perpetrated by men. Instead, they suggest that the kinds of violent events which happen on

acute psychiatric wards should be considered and the perceived and actual safety of women

on mixed- and single-sex wards evaluated.

Several studies have investigated patients’ preferences for mixed- or single-sex provision.

Among 71 long-stay patients in single-sex accommodation, Hingley and Goodwin (1994)

found mixed views, with 62% men and 52% women preferring single-sex wards, but 82% and

62% respectively preferring the opportunity to socialize with both sexes within the hospital.

Amongst 258 patients on acute wards, Myers et al. (1990) found 63% would prefer

admission to a single-sex ward. Women, older patients and those already on such a ward

were more likely to do so. In Johnson et al.’s (2004) study of 50 female patients in mixed-sex

acute wards and an all-female crisis house, 80% preferred single-sex accommodation. Many

had been distressed and frightened by the disturbed behaviour of male patients while they

themselves were very unwell. In contrast, Thomas et al. (1992) found 57% of 150 patients

on mixed-sex acute wards preferred that setting and 24% had no preference. Some male

respondents (number not stated) said that women were less violent and had a calming effect

on the ward. Of more concern was some men’s wish to meet potential sexual or romantic

partners. A total of 27% of women said they would prefer a single-sex environment. Some

had been harassed and others felt nervous in male company. The 10 women in Cleary and

Warren’s (1998) study expressed a preference for mixed-sex wards.

The views of staff have been studied less. Cole et al. (2003) surveyed 109 staff on mixed

wards. There was much uncertainty about whether single-sex provision would improve

patients’ quality of life but some tendency to believe this would not be the case for men.

A limitation of all the above studies is that not all participants had experienced both

single- and mixed-sex provision. A few studies have examined the effects of transitions from

the former to the latter in Germany. Gebhardt and Steinert (1999) surveyed 162 staff and 18

patients on 4 inpatient units changing from predominantly single-sex provision, with more

disturbed patients placed together, to mixed-sex provision with no segregation by level of

disturbance. Overall levels of aggression decreased and peacefulness, order and patient

autonomy increased. Spiessl et al. (2001) found that 75% of 318 inpatients surveyed would

prefer mixed-sex provision. Men and younger patients were particularly likely to do so. After

wards became mixed, this preference became stronger, particularly for female patients.

Among staff, Krumm et al. (2006) used focus groups to evaluate perceptions of a

transition to mixed-sex provision. Generally, this was seen as positive, leading to a calmer

atmosphere, with both genders showing more appropriate behaviour and women

encouraging men to socialize. No need was perceived for women to be protected through

single-sex provision; normalization, through mixed-sex provision, was prioritized.

It is difficult to generalize from these studies, which were conducted with longer-staying

patients in a different system and culture, to the UK. They also examined the opposite

transition to that described here. As far as we are aware, this is the first study describing the

transition from mixed- to single-sex provision which is taking place in many NHS settings.

Method

A survey methodology was used to investigate the experiences of nurses on an acute

psychiatric ward in Inner London, following reconfiguration of services from mixed- to

single-sex wards. Historically, wards were aligned to community mental health teams

covering geographical catchment areas. Following reconfiguration, this model was replaced

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by a borough-wide bed management, so that all five wards related to all 10 community

teams. The ward under study became all-male.

All nursing staff were surveyed 3 and 9 months after the change, using a questionnaire

with a number of open response questions asking about the process of change, and changes

in the role of nursing staff, the ward atmosphere, and the perceived experiences of patients.

Content analysis of themes from the first questionnaire was used to develop a list of

representative statements, which was included in the second questionnaire to assess the

proportion of participants agreeing with each statement.

Both questionnaires also included two 5-point forced choice items, assessing participants’

opinions on how their job satisfaction and job-related stress had changed (‘‘Compared with

when [the ward] was mixed-sex, do you feel your job . . . is now . . . much more/a little more/

about the same/a little less/much less . . . satisfying/stressful’’) and an item enquiring how

they felt the change had been for male patients (‘‘almost entirely positive/mostly positive/no

real difference/mostly negative/almost entirely negative’’).

Only staff who had worked on the ward prior to the change were included. The sample

size thus defined was 20. Questionnaires were returned anonymously.

Questionnaires, rather than focus groups, were used because the pressures on ward staff

were such that it would have been difficult to bring together a sufficiently large group. We

wanted to offer all staff, including those working nights and those with responsibilities

preventing them from attending outside of working hours, equal opportunities to

participate. We also thought staff would be more able to express any views not consistent

with those of the majority via anonymous questionnaires.

Records of staff sick leave and calls to the emergency team for incidents of violence for the

first three months after the change were also scrutinized.

Results

Fifteen participants responded at 3 months, and 10 at 9 months, giving response rates of

75% and 50% respectively. Of the total sample, 55% were male and 40% White British.

Seventy per cent were staff nurses and 15% each were senior nurses and nursing assistants.

At 3 months, 53% of respondents were male and the same proportion White British; 67%

were staff nurses, 20% more senior nurses and 13% nursing assistants. At 9 months, 60%

were male, 40% White British and 70, 10 and 20% respectively were staff nurses, more

senior nurses and nursing assistants. Thus, respondents were similar in gender, ethnicity

and seniority to non-respondents, although White British staff were somewhat over-

represented at the first time point.

The lower response rate at 9 months may have been due to the fact that fewer resources

were available at that time to encourage staff to complete the questionnaire. There was also

anecdotal evidence suggesting it may have been related to a sense of hopelessness and a

belief that expressing ones views would not change anything.

Responses at 3 months were used to compile a list of 27 representative statements. Table I

lists these statements, grouped by theme, together with number of respondents making

comments related to the statement at 3 months and number of respondents endorsing the

statement at 9 months. Each theme is discussed further below.

Change in therapeutic atmosphere

After 3 months, 12 respondents and, after 9 months, all 10 respondents commented that

they felt the ward atmosphere had deteriorated. There were considerable concerns about

Changing to single-sex provision in acute psychiatry 131

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increased aggression and conflict, with associated risks to both staff and patients. It was also

commented that the ward atmosphere had become less therapeutic and more unnatural,

with patients interacting less with one another and with staff and competing for power on

the ward. There was some evidence that there was, indeed, an increase in aggression on

the ward, from the records of calls to the emergency team for incidents of violence. There

were 16 in the 3 months following the change to single-sex provision, compared to two in

the equivalent period of the previous year. However, after 3 months, two respondents

commented that the ward was calmer or less tense.

Change in role of staff

Nine months after the transition, all participants agreed that the role of staff had become

more custodial. Eight also found there was less time to spend with patients therapeutically,

and nine reported that it was more difficult to engage patients. Although some positive

experiences were reported 3 months post-change – e.g., finding opportunities to work with

Table I. Representative comments post-change, with number of respondents making similar (and, in brackets,

opposite) comments at three months and number of respondents endorsing them at nine months.

3 months 9 months

Therapeutic atmosphere

8. There is now more aggression and conflict on the ward 7 10

11. The ward is less therapeutic 6 9

13. Patients and staff are now at significantly greater risk of being assaulted 1 8

5. I am still concerned that an all-male environment is unnatural 3 7

16. Patients are less supportive of each other 1 7

24. Patients interact with each other less 6 5

1. The ward is calmer than when it was mixed sex 1 (4) 3

17. The ward is just as therapeutic as before (4) 2

3. The ward atmosphere is not significantly different from when it was mixed sex 1 1

Role of staff

19. The role of staff has become more custodial 2 10

21. My job is more stressful now 4 9

22. It is harder to motivate patients to engage in ward activities 3 9

20. Staff have less time to spend therapeutically with patients since the change 2 8

25. The role of nursing staff is not significantly different on an all-male ward 1 (1) 5

23. There have been opportunities to work in new ways with patients 2 2

8. We are now better able to meet the needs of male patients (2) 2

Process of change

12. Staff really supported each other in adapting to the change 9 10

26. The ward needed more preparation for becoming all male than it received 10 9

2. Staff were not sufficiently involved in the decision to create single sex wards 10 8

6. Staff did not have enough support in coping with the change to all male 3 8

15. The ward has adapted successfully to becoming all male 3 8

27. I feel proud of the way the team has handled the change to mixed sex 2 8

14. I remain unhappy that the ward has changed to single-sex 6 6

Changes accompanying the change to single sex service provision

18. The change resulted in there being noticeably less space on the ward 5 10

4. There is now more pressure to move patients on quickly 2 9

9. It is much more difficult to liaise with community services now the ward

covers a wider area

4 8

10. Paperwork has increased noticeably 5 8

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male patients in new ways, or feeling better able to meet male needs – few respondents

endorsed these at 9-month follow up.

Process of change

Comments on the process of change covered two themes. After 3 months, 12 respondents

reported feeling unprepared for the change, unsupported and uninvolved in the decision-

making process. These concerns were less prominent after 9 months. Consultation meetings

had been organised for staff before the change, but these were held when the decision to

switch to single-sex wards had already been made. There were also comments on the lack of

information or training on the specific needs of male patients which might have helped staff

to approach the change proactively. More positively, after 3 months, 14 respondents

remarked on the ward’s capacity to adapt successfully, on the importance of mutual support

and strong leadership within the ward or a general sense of pride in how the ward had coped

with the change. After 9 months, three respondents mentioned a new therapeutic Men’s

Group on the ward as a helpful development.

Changes accompanying the change to single sex service provision

In providing care for only male patients, the ward lost its geographically-defined catchment

area. This resulted in the loss of a close working relationship with one community mental

health team, with which the ward shared some (medical and psychology) staff. Ward staff

now had to liaise with several community teams and across multiple service interfaces. At 3

and 9 months respectively, four and two participants mentioned the increased burden of

liaison and paperwork.

Staff stress

After 3 months, 12 respondents were finding their jobs more stressful (8 ‘‘a little’’ and 4

‘‘much’’). One was finding it ‘‘about the same’’ and one each a little less and much less

stressful. At 9-month follow-up, all respondents reported their jobs were more stressful (7 ‘‘a

little’’ and 3 ‘‘much’’). Also, number of days of sick leave (excluding two members of staff

on long-term sick leave) increased by a factor of 2.65 in the 3 months after the change,

relative to the previous 3 months.

Job satisfaction

Responses were more varied for job satisfaction. After 3 months, seven respondents were

finding their jobs less satisfying (4 ‘‘a little’’ and 3 ‘‘much’’), seven about the same and

one a little more satisfying. After 9 months, five respondents reported their jobs as less

satisfying (4 ‘‘a little’’ and 1 ‘‘much’’), four ‘‘about the same’’, and one ‘‘a little more

satisfying’’.

Staff perception of patients’ views of the change

At 9-month follow up, six respondents regarded the change as ‘‘mostly negative’’ for

patients, three ‘‘no real difference’’ and one ‘‘mostly positive’’. Three respondents expressed

cynicism about the rationale for the change, or a belief that the interests of male patients had

been ignored in favour of those of females.

Changing to single-sex provision in acute psychiatry 133

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Discussion

The aims of this study were to describe the experience of nursing staff on an acute

psychiatric ward during and following the transition from mixed-sex to all-male provision

and to suggest how this might have been improved.

In general, this experience was negative. All respondents reported that their job stress had

increased 9 months after the transition and half reported that their job satisfaction had

decreased. Many expressed concerns that the ward had become a more dangerous and less

therapeutic place for patients. There was no evidence that these concerns had diminished by

9 months after the transition. Thus, they did not appear to be a transient reaction to the

change.

A major concern was the impact of male-only provision on ward atmosphere, in

particular, with regard to increasing aggression. Staff feared this would lead to the loss of the

strong biopsychosocial approach to care in which they had previously taken great pride, as a

result of needing to adopt a more interventionist role, heavily reliant on medication

management, control and restraint and referral to the psychiatric intensive care unit. The

available data suggest that there had, indeed, been an increase in violent incidents. This is

consistent with Gebhardt & Steinert’s (1999) findings of decreased aggression and improved

ward atmosphere after the converse change. It suggests that changing from mixed-sex to

single-sex provision should not be seen as providing a simple increase in patient safety as

some sources of risk, particularly violence between male patients, may increase as others are

diminished. This creates new challenges for services, in ensuring patient safety whilst

maintaining a therapeutic environment.

Another area of concern surrounded the process of change. Many respondents

experienced it as something in which they had no involvement. There is evidence (e.g.,

Greenglass & Burke, 2000) that nurses find service restructuring stressful and anger-

provoking and it seems likely that perceived lack of involvement would exacerbate this.

Greater autonomy has been associated with higher job satisfaction and lower absenteeism

(Song et al., 1997) and a desire to be more involved in decision-making has been cited by

nurses as a reason for leaving the profession (Ames et al., 1992).

All respondents viewed their jobs as becoming more stressful and half reported less job

satisfaction 3 months following the change. This was also evident at 9-month follow up,

suggesting it was not a transient response to the change, and that staff found working in an

all-male environment more challenging. Staff who were more dissatisfied may have been

more likely to participate in the study. However, it is also possible they were less likely to

participate, due to a belief that expressing their views was unlikely to change anything.

This study has several limitations. Its scope was limited to one ward, the sample size was

small, no service user perspective was included and there was no attempt to investigate the

transition to all-female provision. Some of the issues raised were related to the ward’s

previous strong tradition of biopsychosocially-oriented care. Others were related to changes

which do not necessarily, but may well accompany the change to single-sex provision. For

example, it is very likely that such a change will result in a ward covering a wider

geographical area and thus relating to a larger number of teams.

These findings are consistent with an audit of UK NHS acute mental health services

(Ryan et al., 2004), which found pronounced recruitment difficulties for nursing staff on all-

male wards, when compared with all-female and mixed-sex wards. This suggests the

importance of considering the specific needs of staff working in all-male wards. It has been

argued that ‘‘to reduce gender disparities in mental health treatment, gender-sensitive

services are essential’’ (World Health Organization, 2005). Men differ from women in their

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help-seeking approaches and are more reluctant to seek help for emotional problems and to

use mental health services (Galdas, Cheater & Marshall, 2005; Moller-Leimkuhler, 2002;

Kennedy, 2001). Their needs differ from those of women with similar diagnoses

(Thornicroft et al., 2002) and they may benefit from male-specific therapy (Dickstein

et al., 1991; Rees, Jones, & Scott, 1995).

Further work is needed to develop our knowledge of the specific needs of male patients

and how they can best be met on acute psychiatric wards, and to use this knowledge to

inform the training of nurses in this setting, so that they can become more skilled and more

confident in this challenging and specialized area of work. This study also demonstrates the

need to recognize staff anxieties around the transition from working in a mixed to single sex

ward and to involve staff in the planning and implementation stages in order to retain morale

and job satisfaction.

Acknowledgement

The authors acknowledge and wholeheartedly thank Padraıc McLoughlin for his

contribution to the study.

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