Racialisation in mental health care leads to cultures of silence.

A study published this month in the British Medical Journal Mental Health, and funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration – North Thames, has found experiences of racial discrimination exist within inpatient mental health settings. The research indicates that racialised behaviour and racial discrimination goes both ways between staff and patients and that this can lead to a lack of cultural and psychological safety in mental health wards, resulting in a negative culture in these settings. In this blog, Dr Hua, Dr Fenton and Dr Shakoor explain some of the key findings from the study and indicate what this means for inpatient mental health care.

Interviews were originally conducted with the patients (18–65 years: 40% female, 60% male) from four different geographically located NHS England mental health trusts between July and October 2017. Secondary qualitative data analysis was conducted in two phases: (1) reflexive thematic analysis and retroduction; (2) refinement of context–mechanism–outcome configurations to explore the generative mechanisms underpinning processes of racialisation and revision of the initial programme theory.

The study uncovered two themes that underscore how conditions in inpatient settings can reduce psychological safety: (1) absence of safe spaces to discuss racial discrimination which silenced and isolated patients; (2) strained communication and power imbalances which may explain why racial discrimination was experienced mutually by both patients and staff. This is important as it helps us to understand how patients experience their care, and in particular how racialisation and discrimination operate in inpatient settings.  The study also found that by failing to report and address racial discrimination, this perpetuates a “culture of silence” and prevents authentic patient feedback and staff-patient rapport. Getting authentic feedback from patients about their care is important to improve quality.

The research found that stereotypes of race/ethnicity persist in mental health wards and these impact both patients and staff, whether they are directly affected by racial discrimination or are in the position of stakeholders. The process of mutual racialisation warrants more investigation and may be based entirely on ungrounded prejudices, differing styles of communication and empathy between staff and patients. Non-reporting of racialisation and discrimination elicited emotions such as feeling othered, misunderstood, disempowered and fearful. NHS trusts could receive further training on the effects of racialisation on authentic patient feedback.

The study team have outlined why this research is important and what it contributes:

 Dr Phuong Hua from the Department of Psychiatry at Oxford and the Wolfson Institute of Population Health at Queen Mary, said:

“NHS trusts could be more aware of how racialisation prevents authentic patient feedback, hindering improvement in the quality of services, and can weaken rapport between staff and patients. I think it’s particularly important to further understand the processes of mutual racialisation and power imbalances in further studies about discrimination in mental health wards. The role of allies and bystanders in this issue are becoming increasingly important.”

Dr Sarah-Jane Fenton, Lecturer in Mental Health Policy for the Health Services Management Centre said:

“This research is useful in two ways – firstly the methods used advance our understanding of realist approaches to qualitative secondary data analysis; and secondly the model presented indicates how individuals experience of care and racism impacted their ability to give authentic feedback. Developing better understanding of such processes will facilitate more constructive conversations about racism and enable us to think of new ways to tackle poor experience and improve the quality of care in inpatient mental health settings. We now need larger-scale studies to further investigate racialisation in the staff-patient relationships and its impact”

Dr Sania Shakoor from the Wolfson Institute of Population Health at Queen Mary, said:

“Our research emphasises the need for safe spaces to discuss racialisation and help improve strained communication and power imbalances between staff and patients.”

Professor Kam Bhui, from Oxford University’s Department of Psychiatry, said:

“These findings are alarming. When people feel unsafe on wards due to racism, they are silenced. We must be courageous and ask questions because if we don’t it hurts patients and staff, and costs lives, money, and quality of life. This must change if we want to have a genuinely modern, inclusive, and effective mental health service.

 For further information about the findings please see the article in British Medical Journal Mental Health

Study team information:

Phuong Hua 1 ,2, Sania Sakoor 1, Sarah-Jane Fenton 3, Mark Freestone 1, Scott Weich 4, Kamaldeep Bhui 2

1 Wolfson Institute of Population Health, Queen Mary University of London, London, UK

2 Department of Psychiatry, University of Oxford, Oxford, UK

3 Health Services Management Centre, University of Birmingham, Birmingham, UK

4 The University of Sheffield, Sheffield, UK