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Delivering security-focused healthcare

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Security, like safety, is the responsibility of all those caring for the mentally disordered and staff must work together to achieve this effectively to prevent them from harming themselves or others.

Security, like safety, is the responsibility of all those caring for the mentally disordered and staff must work together to achieve this effectively to prevent them from harming themselves or others.

Security strategies and measures need to become more systematic across the country, with the same standards for all high-, medium- and low-secure settings, and psychiatric intensive care units (PICU)

The purpose of security in psychiatric care is to provide a safe, secure environment for patients, staff and visitors, which facilitates appropriate treatment for patients while protecting the wider public.

Most patients in these environments do not consent to their detention - or are not capable of consent - so might try to escape or undermine security arrangements. They may attempt to do this by intimidating staff or other covert means. Some may wander off unaware of their actions due to their illness. Security is therefore fundamental to avoid such problems.

There is often a dilemma when it comes to balancing therapeutic relationships and maintaining a secure environment.

It is widely accepted that the level of security appropriate for an individual patient should match the risk posed to self, other patients, visitors, staff and the general public (Reed, 1997).

Security can be defined as the state of being or feeling secure, freedom from harm and danger but also doubt, anxiety and fear. The risk and level required must be assessed continuously by the RMOs with the help of the wider multidisciplinary team.

In healthcare, the security focus is on:

  • Ensuring safety against violent patients
  • Preventing overt or covert operations
  • Preventing patients from accessing staff?s personal information or other information unhelpful to a patient?s progress
  • Preventing access to substances/items regarded as contraband.

It is important to provide a consistent approach to security issues across an organisation so as to provide a safe working environment for both staff and patients. Security is not an end in itself, rather it creates a safe environment in which other therapeutic work can take place - work that it would be difficult to conduct outside a safe environment.

In the UK, there are three levels of secure care settings: high, medium and low security.

High security is necessary only for those patients who pose a grave and immediate danger to others if at large. It should be provided in secure hospitals with a full range of therapeutic and recreational facilities within the perimeter fence. Security arrangements should be capable of preventing even the most determined absconder.

Patients suited to medium security settings present a serious but less immediate danger to others and have the potential to abscond.

Low security is necessary for patients who present a less serious physical danger to others, and security measures are intended to impede rather than prevent absconsions, with greater reliance on staffing arrangements and less reliance on physical security measures.

In addition to these, there are PICUs, which provide short-term psychiatric intensive care. They are often located in or near open/general psychiatric wards/hospitals to provide support when some patients become difficult to manage. They are also a place of safety for those found by the police in public places who are deemed to have been mentally disturbed or have a mental illness. PICUs, in turn, refer those that they find difficult to manage or require long-term PIC to secure services

Security is a survival discipline with two components: the elimination and reduction of risks to an organisation; the safeguarding of people, utilities and peace of mind.

To achieve the ultimate secure care environment, three components must be provided: physical security; procedural security; and, relational/therapeutic security.

Physical security describes measures that prevent access to a facility or resource. It can be as simple as a locked door or as elaborate as multiple layers of armed guarded posts and includes control of items brought in or taken out of the secure perimeter.

Procedural security involves policies and procedures. These need to be clear to give people confidence in what they are doing and ensure they are all doing the same thing. Commonly used policy documents must be highlighted on training events.

Relational security relies entirely on staff developing constructive and professional working relationships with their colleagues and therapeutic relationships with the patients. There must be a commitment to the provision of therapeutic activity and the recognition of each patient?s individual needs.

Colleagues must be confident of each other's support in the event of a problem. Patients are not always in the wrong and there will be times when they raise valid points. However, a team must stick together and any differences addressed at forums away from the patients.

Relational security should be a continuous process, through which staff can highlight any security threats and support each other at work. This also calls for a specialist unit in higher security services to establish an intelligence centre where events are analysed and possible links established to prevent serious security breaches.

Awareness of the therapeutic importance of environmental, relational and procedural security is valuable in drafting safe treatment plans for patients and in the organisation and management of all secure mental health services.

Relational security is by far the most important element in the maintenance of the therapeutic progress of patients and in ensuring that the whole security system works.

Many staff struggle to strike the balance between maintaining therapeutic relationships and the safety and security of the environment due to the nature of the job. If it becomes necessary to restrain or seclude your patient for their safety and that of others, this may damage any relationships that have been formed. Others find themselves in situations where they have been manipulated to breach security and fear they may have compromised their jobs.

All aspects of security (searching, escorting, contraband, key safety, use of handcuffs, observation, patrolling and out-of-bounds areas, working relationships, etc) must be emphasised from the induction stages to ensure the staff understand what their responsibilities are before they enter these environments. It is also important that every secure environment has a designated security person who oversees security training and informs policy-making.

It is also important for security training to be standardised across the country to minimise confusion in definition, interpretation and implementation.

Types of security threats
Overt threats: escape, abscond, assault, group disorder/riot, hostage/siege, other threats to physical safety
Covert threats: smuggling/trafficking contraband, accessing sensitive information, bullying and intimidation, manipulation, conditioning, grooming, conning, splitting of staff

Reed J. (1997) The Need for Longer Term Psychiatric Care in Medium or Low Security. Criminal Behaviour and Mental Health 7 201-12.

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