Addressing gender inequalities and improving women’s health at a female inpatient forensic mental health ward was achieved with this quality improvement change project
Women comprise less than one-fifth of service users in secure mental health settings, and many therapies and systems are geared towards males, leaving a deficit of care for women. This, the second of two related articles, explains how a nurse-led team used quality-improvement methodology to improve female equity, in terms of therapies and women’s health, on a medium-secure forensic mental health unit.
Citation: Hearn E (2023) Improving women’s health on a forensic mental health ward. Nursing Times [online]; 119: 12.
Author: Elizabeth Hearn is consultant nurse, East London NHS Foundation Trust.
Women with a serious mental illness (SMI) are up to six times more likely to be victims of sexual assault (Khalifeh et al, 2016; Miles et al, 2022), with 40% reported to be victims of rape or attempted rape (Khalifeh et al, 2015). Women who have experienced sexual abuse and rape are less likely to attend for cervical screening by up to 72% (Jo’s Cervical Cancer Trust, 2018).
Women with SMI, along with women in the prison system, are at a higher risk of dying from cancer than those in the general population – they have a 22% higher chance of a cancer diagnosis and higher rates of abnormal cervical screening (Manz et al, 2021). Cervical cancer is the most common type of cancer among female prisoners, which is thought to be due to risk factors such as early sexual activity, unprotected sex, lack of health education, multiple partners and trading sex for money and/or drugs (Binswanger et al, 2011), all of which also exist in the SMI population.
Access to, and attendance at, screening services are also contributory factors; 40% of outpatient appointments for female prisoners were cancelled or missed in 2017/2018, which is nearly double that of the general population (Davies et al, 2020).
At East London NHS Foundation Trust (ELFT), Bow Ward did not have a set pathway for female service users to have access to the population screening programme. It was not offered routinely or asked about for compliance. The unit GP did not offer cervical smear tests on site and referrals to the local hospital were not always accepted, due to perceived risk from the patients.
Many of the women were subject to Ministry of Justice restrictions when on leave, and leaving the ward meant wearing handcuffs and being escorted by several staff. One service user requested a smear test before the project but, on hearing the escort arrangements, declined to go, due to previous trauma around rape. This sparked conversations among the multidisciplinary team that they needed to provide a more holistic service and ensure service users could access the services they needed.
Background to the intervention
The patient notes of service users on the ward were reviewed to see how many were up to date with screening appointments. Several did not have dates listed on the system and there was no record of screening ever having been discussed. On the national system, it was found that, of 15 service users, only two screening reviews were up to date, three service users were not registered at all, and 10 were either overdue or had never had a test. All 15 were eligible for screening based on their age. This gave the ward a compliance rate of 13% for smear tests. Three of the patients were also eligible for mammograms, but none of them had ever been referred for this, giving the ward a compliance rating of 0%.
To understand the reasons for not engaging with population health better, the team completed a Pareto chart and identified factors hindering uptake. The main issues highlighted seemed to be:
- Lack of awareness that a test was due;
- Difficulty in accessing a test, once the issue had been raised;
- Addressing previous traumatic experiences from a trauma-informed psychological approach.
Timely screening interventions are a standard set out by Public Health England (2021) and the local trust, but this was not being met. A change was needed to provide a holistic service and improve health outcomes in this marginalised population.
This project was coproduced with service users, and one of the most powerful aspects was appointing a service user advocate. This service user had her own previous experience of needing medical intervention after a smear test, as well as a history of sexual violence and a mistrust of the system. Despite these experiences, she was able to speak out about the importance of the tests and reassure her peers.
Staff awareness of health needs
As there was no system to register female health history in the trust’s record system, the team piloted a paper form to record menstrual history, obstetrics, female genital mutilation and population health screening. After a successful pilot, it was introduced into the electronic record system. This form is now completed for all new admissions to Bow Ward and then at six-monthly intervals. This ensures all service users are regularly offered population health screenings.
By January 2023 100% of eligible patients had been offered smears and mammograms, with 46.67% and 66.67%, respectively, saying yes and taking the tests. The other patients have declined at this stage but will be re-offered in the future.
Availability of screening
The team worked with the local sexual health service, which agreed to provide onsite screening clinics. Due to service users’ complex needs, this was introduced slowly; sexual health workers spent time on the ward to educate and get to know service users, build trust, enable them to feel safe and allow the intimate procedure to go ahead when they felt they were ready.
Ward doctors built a relationship with a nearby mammogram clinic. Due to system complications around GP registration for long-term inpatients, they had to create a new referral system to avoid service users being excluded. They used easily accessible groups, such as bingo, to raise awareness and improve knowledge.
Normalised female health
The hospital shop did not display period products as it thought this might upset male service users. This made the women feel ashamed and reluctant to ask for the items they needed. The team campaigned and the shop not only displayed period products but also introduced a new line of feminine hygiene products. The team also obtained funding for free period products to be provided on the ward.
Many therapy groups were geared towards men, and female service users did not always feel safe to attend. The team developed its own therapy programme and asked service users what they wanted groups to focus on. Topics including physical health, self-soothe, sexual health, body image and sleep hygiene were chosen. Service users said this became a safe, cofacilitated, supportive space.
Education on women’s health needs
Even when screening became available, uptake was still initially low due to a lack of motivation/awareness of the importance of it and fear around the procedure. The team ran education groups to debunk myths and discuss the process. It also used fun activities – such as playing games and decorating fairy cakes for Breast Cancer Awareness and International Women’s Day – to normalise female health and make the conversations accessible to everyone.
The service user advocate explained the impact of the changes:
“I went for a smear test and had to have three-quarters of my cervix cut away due to cancer. I was unable to have a follow-up smear test when in custody as they weren’t doing them. I then came to Bow Ward and […] could have my smear test. Now I’m cancer free and can have regular tests. I went to the community meeting and shared my story […] and the importance of having a smear test, and that it can change [and save] your life. Now they’re making arrangements for all the ladies on the ward to be able to have smear tests on a regular basis.”
Inpatient physical health care has been improved, with access to cervical and breast screening established and better awareness of menopause and other female health concerns. A range of psychological interventions are offered, as well as specific gender-focused groups that tackle a wide range of topics.
This project was led by nursing staff and a multidisciplinary team, but coproduced with service users, who attended weekly quality-improvement meetings. A multi-service approach was taken to the project, which included staff from the sexual health outreach service and the unit GP.
Women in secure settings and with SMI have more risks to their health, but fewer intervention opportunities. The team normalised female health and created new screening pathways. It built trust with service users by being trauma aware, offering focused psychological group sessions, using games and psychoeducation, and having a service user advocate who shared her own experiences. Women were not rushed and could take up screening in their own time or decline if they were not ready. Plans have been put in place to scale up this work across other parts of the trust.
- Women with mental ill health are 18% less likely to participate in breast screening and 20-38% less likely to participate in cervical screening than the general population
- Approximately 18% of secure mental health beds in the UK are for women
- Secure mental health settings are traditionally geared towards male service users and their needs
Binswanger IA et al (2011) Risk factors for cervical cancer in criminal justice settings. Journal of Women’s Health; 20: 12, 1839-1845.
Cadman L et al (2012) Barriers to cervical screening in women who have experienced sexual abuse: an exploratory study. BMJ Sexual and Reproductive Health; 38: 4, 214-220.
Davies M et al (2020) Locked out? Prisoners’ Use of Hospital Care. Nuffield Trust.
Jo’s Cervical Cancer Trust (2018) Three quarters of sexual violence survivors feel unable to go for potentially life-saving test. jostrust.org.uk, 31 August (accessed 7 November 2023).
Khalifeh H et al (2016) Recent physical and sexual violence against adults with severe mental illness: a systematic review and meta-analysis. International Review of Psychiatry. 28:5; 433-451.
Khalifeh H et al (2015) Domestic and sexual violence against patients with severe mental illness. Psychological Medicine; 45: 4, 875-886.
Manz CR et al (2021) Disparities in cancer prevalence, incidence, and mortality for incarcerated and formerly incarcerated patients: a scoping review. Cancer Medicine; 10: 20, 7277-7288.
Miles L et al (2022) Mental illness as a vulnerability for sexual assault: a retrospective study of 7,455 sexual assault forensic medical examinations. Journal of Forensic Nursing; 18: 3, 131-138.
Public Health England (2021) NHS population screening: improving access for people with severe mental illness. gov.uk, 23 September (accessed 7 November 2023).
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