Implementation of Body Worn Camera: Practical and Ethical Considerations

Abstract

Body-worn cameras are increasingly being used as a violence prevention tool in inpatient mental health wards. However, there remains a limited understanding of this technology from an implementation perspective, such as protocols and best practice guidance if cameras are to be used in these settings. This study explores the perspectives of patients, mental health staff, and senior management to understand the practical and ethical issues related to the implementation of body-worn cameras. Semi-structured interviews (n = 64) with 24 patients, 25 staff from acute wards, six Mental Health Nursing Directors, and 9 community-based patients were conducted. Interviews were analysed using reflexive thematic analysis. Ethical approval was granted by the Health Research Authority. Findings from this study show that the implementation of BWC in healthcare settings requires careful consideration. The perspectives of patients and staff demonstrate the complex reality of implementation alongside the consideration of practical and ethical issues around implementation that are essential to ensures that wards recognise the need to assess their capacity to use the cameras in a way that is fair and consistent for all involved. The findings further highlight wider questions around power and autonomy in mental health care.

1. Introduction

A recent report has revealed that 14.3% of National Health Service (NHS) staff working within psychiatric settings in England have reported experiencing physical violence at work (NHS, 2022). Concerns about lack of safety and being subjected to violence also extend to patients (Jenkin et al., 2022) and these concerns are shared internationally (Iozzino et al., 2015). Hence, alongside existing violence reduction methods being deployed in inpatient psychiatric settings (Davison, 2005), digital surveillance technologies are seen as a relatively new approach in preventing or reducing aggression (Simpson, 2023). Central to this in England has been the introduction of body-worn cameras (BWC) (NHS, 2019). A BWC is a small video-camera device that can be attached to nurses’ clothing and activated by staff to provide audio and video recordings of interactions with or between patients. BWCs have been adopted by police forces internationally, with variable outcomes (Lum et al., 2020), and are now deployed in a range of healthcare and other public services (Wilson et al., 2023). The use of BWCs in mental health hospitals has been considered contentious across a range of stakeholders; issues raised include confidentiality and lack of awareness or consent amongst patients, many of whom are detained under mental health legislation (RCN, 2018); fears that BWCs may be considered a ‘quick fix’ for staff shortages and safety concerns (Baker & Pryjmachuk, 2016); or that the filming of patients, often in distress, may exacerbate power differentials, trigger previous traumatic experiences, criminalise mental illness, and impact negatively on therapeutic relationships and ward culture (NSUN, 2021; Rowan Olive, 2019; Wilson et al., 2023).

Despite the common application of BWCs in law enforcement and other public services (Ariel et al., 2019; Ho et al., 2017; Lum et al., 2020; Petersen et al., 2023; Wilson et al., 2023) evidence is lacking for their application in healthcare services (Wilson et al., 2021). Nonetheless, BWCs are being implemented in increasing numbers of emergency departments, ambulance services, and mental health units in England and Northern Ireland (RCN, 2023). While preliminary evaluations suggest that the use of such technology may be associated with a reduction in more serious incidents and the use of restrictive practices like tranquilising injections (Ellis et al., 2019; Hardy et al., 2017), results are contradictory and studies limited in number and quality. Research to date has also failed to address the suitability of this technology in such settings or the wider impact on patients’ care. Findings from a recent qualitative interview study with mental health patients and staff suggested violence and aggression was viewed as a complex and multi-faceted issue that requires attention to the systemic causes of violence and aggression over introducing BWCs (Wilson et al., 2023). Furthermore, concerns remain that surveillance technologies within these environments where people with mental illness or distress can be admitted, detained and treated can have serious and unintended consequences if not thoroughly considered and evaluated (Anastasi & Bambi, 2023; Simpson, 2023; Wilson et al., 2023).

The growing use of BWCs has raised several policy, ethical and practical concerns, as there is an absence of universal standards or guidelines for the application of their use in healthcare environments. While national bodies such as the Royal College of Nursing in the UK have recently provided guidance for the implementation of such technology (RCN, 2023), they conclude that the use of BWCs in health and care settings is a complex issue with no clear consensus and it is important to consider the potential benefits and drawbacks before making any decisions. Research has highlighted that there is limited understanding of how best to implement this technology (Wilson et al., 2021, 2023).

2. Methodology

The findings reported within this paper are part of a larger UK-based study on BWCs that explored the perspectives of patients, mental health staff, and senior management to identify the possible impacts of this technology in inpatient mental health settings. The first paper (Wilson et al., 2023) reported findings on people’s views about BWCs in relation to violence and aggression, and their experiences of BWCs being used. This second paper draws from a secondary analysis of the same interview data but reports on findings related to implementation and related ethical concerns.

2.1. Patient and public involvement

Patient and public involvement was a key component of this study. A Lived Experience Consultant (LEC) (Author #6) and a Lived Experience Research Assistant (LERA) (Author #5), both with personal knowledge of inpatient care, were key members of the research team. Both helped form and facilitate a Lived Experience Advisory Panel (LEAP) for this research, which consisted of eight people with diverse personal encounters with inpatient mental healthcare including some who had been on wards using BWCs. Most of those involved in the study had no strong feelings about the use of BWCs prior to study commencement, though others were strongly more or less favourable.

2.2. Study design

An exploratory qualitative approach was employed with semi-structured interviews conducted with staff and patients at five different NHS Trusts (Table 1), alongside online recruitment of service users via social media, and Directors of Mental Health Nursing via professional networks.

Table 1. Case sites.

Site A	Four hospital sites in London with 17 acute wards; staff not using body-worn cameras
Site B	Hospital in Southwest England with three acute wards; body-worn cameras in use only by staff in the health-based place of safety room
Site C	One hospital site in London with three acute wards; staff using body-worn cameras
Site D	Two hospital sites in Northeast England with six acute wards; staff using body-worn cameras
Site E	One hospital site in London with three acute wards; staff using body-worn cameras

2.3. Sample selection, eligibility, and recruitment

Convenience sampling was used to recruit staff and patients on wards. Researchers approached ward managers to distribute information sheets to staff, who shared that information with patients. Staff self-selected to participate in the study by liaising directly with the research team. After initial contact with the research team, patients were given a 24-h period to consider if they wanted to participate before being invited for an interview. The research team also circulated patient recruitment information via social media platform, Twitter. Due to high interest, quota sampling was used to ensure a diverse representation of patients was recruited from the community. An email inviting Directors of Mental Health Nursing to participate in the study was circulated via the National Mental Health Nurse Directors Forum. Directors self-selected to participate in the study by contacting the research team directly. Inclusion and exclusion criteria are outlined in Table 2.

Table 2. Inclusion and exclusion criteria.

	Inclusion Criteria	Exclusion Criteria
Patients	Patients who have been an inpatient on an acute mental health ward for adults aged 18–65 within the last 5 years.	Patients lacking capacity to consent to take part in the research.
	Capacity to give informed consent and participate in a research interview.	Patients who have been an inpatient on Psychiatric Intensive Care Units (PICUs), forensic, rehab or specialist mental health wards.
		Children and adolescents under 18.
Staff	Staff who work on or manage an acute mental health ward for adults aged 18–65.	Staff working primarily on wards for children, adolescents, older adults, people with learning difficulties or forensic units.
	Capacity to give informed consent and participate in a research interview.

A total of 64 participants took part in the study: 24 patients and 25 staff members recruited from NHS sites, nine patients from Twitter, and six Mental Health Nursing Directors. No patients from Site E provided demographic information or consented to record their interview, thus interviewer notes were used to support analysis.

2.4. Procedure

Drawing on existing literature, semi-structured interview topic guides were developed in collaboration with an LEC (Author #3) and members of the LEAP. Guides consisted of key questions on topics related to the use of BWCs, including:

• What are your first thoughts and feelings about the topic of body worn cameras?

• How do or would having BWCs on wards impact you?

• What impact do you think BWCs might have on service users?

• Can you tell me a bit about the training and policies there are here around the use of BWCs?

• How can BWCs be used well on inpatient wards?

• For wards wanting to implement BWCs do you have any advice or things you think should be done differently?

These topic guides were used as a flexible tool to direct participants towards the key research questions. Panel members participated in practice interviews with the research team to refine the interview process. Interviews were conducted between May and November 2021 by members of the research team.

Participants were invited to take part in an interview with Author 1, 3, or 5 at a time and date that was convenient to them, either remotely to facilitate social distancing during the COVID-19 pandemic or within a private space on their ward. Interviews were scheduled for one hour with an additional 15 min before and after to obtain informed consent and answer any questions. Participation was voluntary and participants were free to withdraw at any time. Interviews were audio-recorded and saved to an encrypted server. To thank patients for their time, we offered a £10 voucher following the interview. Audio recordings were transcribed by an external company, and the research team checked the transcripts for accuracy and pseudonymised all participants. All transcripts were allocated a unique ID number and imported to NVivo (2020) for analysis. Interviews ranged from 25 min to 90 min in length.

2.5. Data analysis

We undertook reflexive thematic analysis following the phases and definitions outlined by Braun and Clarke (2021). Guided by the overarching study aim to explore the perspectives of and views on the use of BWCs, the interviewers (Authors 1, 3, and 5) read and re-read the interview transcripts to identify preliminary codes. Members of the research team with a range of lived and/or professional perspectives then reviewed the transcripts to verify potential codes (All Authors). Codes were defined as a single idea identifying what is of interest in the data. A line-by-line coding approach was used to ensure that data across the entire interview, not just questions related to implementation, was coded so as to not miss key points from interviews (see Appendix A for an example of coding). Following initial coding, related codes were sorted, grouped, and labelled as preliminary themes, which are central concepts that capture and summarise the core point of a meaningful pattern in the data. Themes were discussed and revised with the LEAP to ensure they were capturing something significant and relevant. To improve validity, transparency, and quality, we repeatedly reviewed the themes within the wider study group until a consensus was reached that a theoretically sufficient account had been created and no new concepts were being generated. Data extracts illustrate each theme and key analytic points (see supplementary materials for the COREQ checklist).

2.6. Ethics

Ethical approval was granted by the Health Research Authority (IRAS ID 266216) prior to data collection with a later amendment to move data collection online in response to COVID-19. Informed consent was collected from all participants.

3. Findings

Across the range of participants included in the study there was wide agreement that the implementation and use of BWCs in mental health services required careful consideration and consultation. The four themes (outlined in Figure 1) presented within this analysis provide an oversight of what this should look like.

Figure 1. Key themes.

3.1. Starting right: The why, who, what, where and when to use BWCs

While there were mixed feelings and thoughts around whether BWCs should be used within inpatient mental health settings, there was agreement that if they are going to be employed, it was important that policies and governance should be developed in a thoughtful and sensitive way given the complex nature and feelings expressed about the cameras. At the core of this was a necessity for Trusts to think through the how, why, what, where and when’s associated with the cameras’ use, and to build an open culture around them from the start of the implementation process.

If we get all of that right and people view it in the right way, in the correct way… you know, not as an antagonistic, a threatening tool, if you want…. then, it could be an interesting therapeutic tool. (Carol, Director)

3.1.1. Policies and procedures: Knowing why and how the cameras are being used

Across participant groups there was a consensus that if BWCs were going to be used it was instrumental that their use was surrounded by policies and procedures to ensure they were being used in the right way and for the right reasons. There was felt to be a lack of consistency across the country regarding why these cameras were used in Trusts, with some participants suggesting that a national directive was needed.

I think it’s not, “Will body cameras be rolled out nationally?” I think it’s more, “When?”, personally, so I think it’s really good to have a really good policy and structure in place for how these things are going to be, and will, be used… I think a national standard has to be set for the bare minimum of things that are to be expected, then local Trusts can add to it to make it a bit more unique for their own individual setting. (Alex, Patient, online recruitment)

At the core of the need for policies, procedures and protocols for the use of BWCs was the belief that everyone needs to be ‘on the same page’ about why the cameras were being used to ensure a consistent culture and understanding.

I’m just working really hard to make sure that we get the culture right and that we’re really clear with people and that we engage with our patients, our carers, our external stake holders, etc. And also, the police, to make sure that we explain why we’re doing it, so that the police don’t feel like it’s an extension of their body worn camera process, so this is for ourselves.” (Carol, Director)

I find that the bodycams are not worn all the time. They’re kept in the office, so when the incident breaks out it’s already started. (Destiny, patient, site C)

This desire for consistency was also seen as important to protect against misuse of the cameras and to ensure transparency of BWC use by having clear boundaries on the how, why, where and when to use the cameras.

I think it was really helpful we have a very tight definition of when cameras can be used. You can’t just switch them on to – I don’t know – observe somebody eating, for instance. They’re there to be switched on in a situation which is escalating or which would have safeguarding implications or the patients asks for the cam to be turned on themselves. So that was part of our Data Protection Impact Assessment. (Sean, Director)

Having such clarity and transparency around why the cameras are being used was seen by patients as important for them to feel comfortable and safe about their use. Having visible policies and procedures explained provides assurance to the patient about why this equipment is being used and how, as well as ensuring accountability and transparency.

A key barrier to having consistency and creating a national approach was viewed by some staff and patients as related to the lack of evidence for the impact of BWCs. It was felt by some that there is a need for further and more independent in-depth research that places a focus on patient care to guide these policies.

I went on to ask some questions about, “And how do they improve quality of care?” and people couldn’t really answer that… I know I've seen in other areas people talk about, “It improves it because there are less assaults.” I'm not sure that’s improving the quality of patient care… I know some of the evaluations that one of the companies themselves did said that patients gave positive feedback… but equally they weren’t in favour, because there’s no impact for them. (Laura, Director)

3.1.2. Governance and data management

A considerable concern for many participants was related to the governance of the cameras’ use with many noting the need for reassurance regarding data management, e.g. where is the data saved, who sees it, what happens to the data? Given the sensitivity of filming people who are unwell and the ethical and human rights issues attached to these complex issues, it was clear that there need to be well thought-through, robust governance in place.

You just need to make sure that you’ve got really robust protocols in place and also the governance around it. Who has access to the images that have been downloaded, what’s the governance around storing of the images, you need a proper operational policy around it. I think you just need to make sure there’s a whole governance around body-worn cameras really. (Adam, Director)

Such governance was viewed as vital to ensure that patients and their carers would be assured of their safety and the safety of the data captured, especially in relation to who sees the images of them at their worst and unwell, and to feel assured that such data won’t be misused. Patients also noted the potential for misuse of footage by staff members, or that patients themselves may not obtain access to footage if requested.

What if it gets leaked? That could cause distress… We don’t know. they could be taking pictures of the patient and sending it to their friends and saying, ‘Look at the person I’m looking after, look how they sleep, look how they live.’ (Ayana, patient, site A)

Like no matter what is captured on camera there will be some reason why they can’t access the footage or there will be some reason why your interpretation is not a valid one of that experience. (Mary, patient, online recruitment)

Such fears also related to images appearing on social media or being used by government bodies involved in anti-terrorism, asylum applications or welfare benefits. This was a serious concern for many participants which highlighted the need to ensure that policies, procedures and protocols are in place before BWCs are implemented to ensure that Trusts are able to provide assurances concerning how data will be used and safeguarded to ensure the protection of vulnerable patients.

the problem is where does the footage go? Who holds the footage? How easily can you get access to the footage? What if you’ve got somebody else in the footage?… I guess, in my personal experience, having lots of meetings with police, as such, and obviously they have always had body cam footage on- And I get no access to that, even through freedom of information, even in court. I think it is still something that’s there. (Siobhan, patient, online recruitment)

3.2. Applying policy to practice

3.2.1. Staff training

There was wide agreement that staff needed to be trained in the use of the BWCs to ensure that policies and procedures were translated into practice on the wards. It was suggested that staff needed to be given training to understand when and how BWCs should be deployed and how they might be employed alongside other approaches such as de-escalation.

So it’s pointless having body-worn cameras if your staff haven’t been prepared, if they don’t help to de-escalate, if they don’t help to work with primary interventions to stop escalation. It won’t solve any of those problems. (Sean, Director)

I think training the staff is paramount, because they need to know how and when to use the cameras and also enlighten them on, maybe, the advantages that can come with this. Also, may be, to highlight that there could be disadvantages with some groups of patients. (Leslie, ward staff, site E)

Are they going to have to switch it off, take it off and leave it on the ward? Or can they carry on wearing it and go and record in a different environment, bearing in mind consent and other things having been dealt with for that other environment?… What do you do if, for example, in a team of 20, you have got only one person consenting to do it? When they wear it, what is going to happen when all the other people that don’t consent, are captured in the recordings. How would you address that? (Sharice, ward staff, site A)

The need for training was seen as necessary for staff as policies are often forgotten or left unread. The nature of training delivered appeared to be inconsistent with some staff receiving no or very limited training, compared to other trusts where there had been a range of training implemented for all staff members.

I was made aware they were going to be used, but not any formal training with regard to that… I got sent them [the policies] a while back they are not something I would use and there is lots of information… staff are hounded with information that actually, quite often we don’t take it in. (Frank, ward staff, site B)

Training, I only was shown how to sign out from the computer. (Joshua, ward staff, site E)

It was suggested that staff need to be trained not only in the technological aspects of BWCs, but also about their ethical use, decisions on when BWCs may or may not be used, the sensitivity of using cameras where they may be triggering for patients, and the appropriate techniques of communication across a range of situations when the camera may be switched on.

Make sure staff are trained not in the use of the camera – well, as in, they’re trained in the understanding and the application related in their use to the Human Rights Act. (Laura, Director)

I think that there needs to be mandatory human rights training for staff, and they need to understand that, unless the incident merits them turning the camera on, it does breach people’s human rights, and they can’t possibly know if it’s a proportionate use of a body-worn camera if they haven’t done human rights training. (Siobhan, patient, online recruitment)

Due to the nature of mental health wards and the requirement to provide a safe environment for patients, it was seen as important to train staff on the appropriate use of BWCs that considered the possible impacts that using them might have on engagement, therapeutic relationships, treatment and patients’ recovery.

Also, I think, it’s, kind of, making sure that staff are trained about why they’re wearing them and appropriate use, you know? Are there times when they should be switched off? If you’re helping someone with personal care, say, is it appropriate to have your body camera switched on then? If you’re having quite a meaningful one to one conversation with someone, should that be recorded? So, there are things that need to be considered to make sure that that level of privacy and dignity and trust can be maintained and that if it is being used it is only being used in a way that’s least intrusive, I guess. (Craig, ward staff, site A)

3.2.2. The need for a continual feedback loop to address challenges

Due to the nature of staffing on mental health wards with shortages and the use of temporary staff frequently reported, it was recognised by staff that there was a need to have a continued training approach as opposed to a one-off session during induction to ensure changes in personnel, practice, and shift patterns are part of the implementation process.

So gradually it would be phased in. So we all get to wear it, and then you’ll agree to a date and a shift and you try it out on weekends, week days, public holidays. Well, we do earlies, lates and nights. Try it out in advance, give people plenty of notice. “This is what’s going to happen. And it’s only going to last 8 hours.” Then ask for feedback on one shift. And then try again, on a different shift, different day. (John, ward staff, site A)

The need for feedback from staff was seen as vital for continued improvement and implementation needs. Having leadership to keep track of issues and create solutions was seen by one trust as central to the success of the cameras as it allowed them to pick up on a range of issues and to problem solve across the technical side as well as the culture of the ward and concerns from both staff and patients.

You have to see through some of the ongoing difficulties… You would need to have that clear, management structure, openness about what’s happening, why we’re doing it and clarity of the procedures. Also, the review points within that, they would have to be clear review points for when we review this, what’s happening, when are we going to use it, what for, and also, really promoting it as a technology which will be, not only used ethically and safely, but also has disadvantages. (Thomas, ward staff, site A)

Overall, it was acknowledged that implementation takes time and that is important to ensure that this ‘starting right’ phase has leadership and management in place to see it through in an ethical and appropriate way, and that explanations for their use needs to go beyond the technological.

Let’s say the whole ward is going to be wearing body cameras… you have to do it well in advance and put a programme in saying, ‘There’s a reason why we’re going to do this project and why they’re coming in… It could take up to 6 months because it’s something you have to be very careful with. You’re dealing with safety of everyone. Data, imaging, and if there’s a bad experience, as you know, bad news travels fast. (John, ward staff, site A)

3.2.3. Informing patients

At the heart of implementation was the need to inform patients about the use of BWCs when they are admitted to the ward to ensure they know how, why and when cameras are being used as well as their rights.

On admission you can say, “We have cameras on the ward, staff are wearing body cameras, we just want to let you know.” It becomes part of the admission process, so they get that information, depending on if they have capacity. But I think if we are going to use it one-to-one with the patients involved, it is to say to them, “Listen, I have my camera. I am going to put it on.” As we go it becomes part of us. They can say, “Yes, they wear body cameras. This is the reason why they are wearing it, and I agree to it because it makes me feel safe.” (Kwame, ward staff, site C)

Part of the importance of informing patients was to add transparency to the use of BWCs as well as to hold staff to account for using them correctly. Being open and honest about the use of BWCs, having transparency regarding policies and governance as well as having open communication with patients was seen as important to implementing best practice for Trusts.

If somebody asks me, ‘Am I being recorded?’ So, I do take that moment to explain to them that, ‘You’re not being recorded all the time. It’s only when there is a situation that needs us to be recording, according to the Trust policies, we turn them on. So, you’re not being recorded all the time. So, please do not worry.’ (Leslie, ward staff, site E)

Communication around this was seen as essential, with a range of methods of informing patients used including posters, community meetings and leaflets in admissions packs.

We’ve got lots of posters around, in communal areas. We have lots and lots of conversations about the cameras as well. I think we’re very open as well. When people do ask questions, we’re very open: "This is where the footage will be stored. This is who can view the footage," which are really, really important questions. Because I know if I was being recorded when I was unwell, I would want to know who’s seeing the footage, what they’re doing with the footage, how it’s being kept and that. I think carers are involved, as well, in having the conversations with relatives, and that, actually, we do use body-worn cameras on the wards and they may be activated if we need to. (David, ward staff, site D)

There appeared to be an inconsistent approach to how wards communicated this information, with many patients on wards using BWCs saying that they had not received any information and were often unaware of their rights in relation to BWCs. One participant (PU101) said they were not given any information or explanation about the use of BWCs or informed about the BWC policies or procedures, and while she had seen them worn on a staff member’s uniform she wasn’t totally sure if that is what it was.

There’s no posters in here explaining about why staff are wearing body cams and what they might be used for. And maybe yes, there should be some posters in the main corridors so patients can – they can just have a read. (Destiny, patient, site C)

This highlighted the need for there be continued information surrounding the use of BWCs on wards to ensure that patients remain informed throughout a time where their health and capacity may fluctuate.

I mean for me the most important thing is making sure that patients are aware as quickly as possible… that conversation about why it is happening is done as quickly as possible… When patients come onto the ward their insight isn’t great a lot of the time. They’re not going to be able to take in a lot of information. So there are issues around capacity and understanding which really need to be carefully considered. (Craig, ward staff, site A)

It was just a ratty poster on the back of a door. So, it wasn’t really like it was forefront of, yes, this is why we do it, and everything like that. It wasn’t really that clear. There was posters that were on the bedroom doors and it was just a brief description of it. I can’t actually remember too much about what it said. But yes, I don’t think it was enough where you were spoken through what it was, or anything like that. (Alice, patient, site D)

Overall, patients were asking for more information, continued refreshing of information across their stay, and different mediums to ensure that everyone was informed irrespective of their literacy, capacity, or health.

You must explain why. You can’t say, “Well there’s a body camera there and you’re going to get recorded.” People want to know why. “What’s going to happen me? What will you do with it?” Those questions come up. It’s good, but you need to let them know in a clear signage why it’s being done. Then, once they understand that things change. Once you explain something to someone and tell them why it’s happened, what needs to be done, they understand and they’re much better towards you. (John, ward staff, site A)

3.3. The logistics of using BWCs on the ward

3.3.1. Exploring the feasibility of using BWCs

When exploring the use of BWCs on mental health wards there were a range of logistical issues identified that were deemed important to consider. At the core of this was the need to understand the technical infrastructure inclusive of good systems and IT support to support the data management plans and policies underpinning BWC implementation.

You need to have an internet system that can handle the uploading of footage. You need to have the ward manager support, you need to have them on-board. In terms of the camera company, you need to make sure that they are offering something that is suitable for the service that you’re using, that you’re going to be using them for. (Sarah, ward staff, site D)

In addition, the day-to-day management of cameras was seen to create potential issues, with charging and storage having been found to be problematic on busy wards.

One of the things is maintaining the cameras, and one thing we already have a problem is making sure they’re all kept on charge. That’s already an issue. Because I think we’ve only got three, and they’re not always put on charge, and then when you need them, you don’t have them. That’s only a trial. So, if everyone had one on the ward, I think that would be a bit difficult. (Jason, ward staff, site B)

Furthermore, both staff and patient participants noted the necessity of having hardware that was durable and hardy. This was in part related to the need to withstand infection control procedures as well as when being used in situations such as restraint. Several participants noted that safety equipment and keys often get pulled off during incidents thus the cameras would need to be secure and safe if someone was to take it off a member of staff.

I mean, if they are expensive pieces of equipment, they’d have to be shock-resistant, waterproof and everything. They’d have to take quite a bit of punishment, these cameras. (Gray, patient, site A)

It might get ripped off so needs to be secure. (Trevor, patient, site B).

This reinforced the need for a feedback loop and the need to have continued refinement and improvements. This was observed in one Trust where issues related to the usability and safety of the BWCs when used on the wards came to light and could be discussed with the manufacturer. Without these real-time feedback loops, improvements cannot be made to ensure safety for both staff and patients.

The body-worn cameras, initially, we had magnet. But sometimes it used to come off if there’s a string and stuff. But now we have, like, strong clips so we put it on the decking and there’s a strong clip. You put it into your polo shirt. So, we clip it on. It doesn’t come off. Yes, it’s really tight, so it doesn’t come off unless you physically take it out. (SU303)

3.3.2. Understanding the impact on resources

Given the need for durable hardware and good IT infrastructure there was concern for some participants that the implementation and use of such technology would be costly with implications for resources. This was particularly salient when considering their use with people being violent and the potential for damage to the hardware during possible conflicts.

I think that would be difficult on this ward, especially. I think, for one, we’d probably have a lot of broken cameras, so there’s a cost element there. (Malcolm, ward staff, site D)

Other staff noted that the nature of the workforce, where there are bank staff, changing shift patterns and staff moving between wards, created a logistical risk of losing the cameras which comes with a financial cost and reduced availability of the resource on the ward as a result.

The only problem is even though we try, we keep losing cameras. You know, with the wards, we always get bank staff all the time. If there’s someone who just walks out, maybe they’ve come to your ward on that one occasion, they will never come back again. They go out, they forget, with the camera on their shirt, they go out, they will never come back and they lose it, that’s the most annoying thing. Like, we bought six cameras on our station, but I came in today, there’s one camera missing. It’s just annoying. (Ibrahim, ward staff, site E)

The impact on resources was seen as a concern for some participants where there was a lack of evidence as to the effectiveness of the BWCs.

We might be investing millions and millions of pounds to save 10 incidents a year. I just don’t know; I really don’t know. (Sean, Director)

Most staff interviewed saw the use of BWCs as having little direct impact on their daily routines. Others highlighted the need for the devices to be simple and easy to use to ensure that their deployment did not add considerably to their workload.

I love gadgets and technology, but the problem I have is I have not got enough time to start fiddling with things, I will just put it aside. But if it is straightforward, I am a big fan. (Kwame, ward staff, site C)

If I am just wearing it in the same way that I am wearing my badge, and then I take it off at the end of my shift, and then I don’t have to do anything additional. If I had to then take time out of my working day… I imagine people won’t be too big a fan of that… Then from a coercive perspective, again, workload. If I am already feeling overwhelmed with my workload, in particular on an acute ward where it is a fast-paced environment, and a lot of the time people already feel that there is not enough staffing to do the basics that they need to do, are they going to see this as another job on top of what they have already got to do? Yes. (Sharice, ward staff, site A)

Those working in senior or leadership roles who had the responsibility to review recordings spoke of the impact on their time. While some saw the value in saving time on investigations by having camera footage available, others mentioned the additional time and cost of having to review the footage as well as governance and management aspects which involve both costs and benefits.

The only workload that it increases is mine as the manager, because I am the one who’s reviewing the footage. So, but although it increases, I find it really useful to get a picture of what’s been happening on the ward, and really look and see what people have experienced during incidents so that I can better support my staff. So, now when there has been an incident I can review the severity of it and see exactly who was involved so I know where I can give emotional support to. (Rose, ward staff, site E)

Such workloads were not felt across all staff or across Trusts, with some Trusts noting they would need to review all footage, while others intended to only review footage related to an incident. As a result, the nature of staffing costs for management of footage was dependent on the nature and use of the footage.

It’s a full-time job for somebody… so it is a significant undertaking. (Sean, Director)

I don’t think at ward level that would be so much of an issue… it would be used for higher up above. (Jason, ward staff, site B)

Ultimately, the footage needs to be viewed, but at the same time, I don’t expect every bit of footage to be watched. So, what I’ve said, what I’m trying to get the matrons into the way of thinking is when you have a Datix [incident report] you’ve got to then complete the local investigation and any lessons learnt… It is a workload, and you can’t get away from that. I think it’s really difficult just now we’re under pressures that I’ve never seen in my career. It’s immense, the pressures. (Harry, ward staff, site D)

3.4. Consultation

While implementation often focused on policies, logistics and resources, a central element concerned consultation with staff and patients. This was felt as salient as the introduction of BWCs is a complex and emotive topic with real implications for those using BWCs or being filmed by them. Therefore, it was seen as important to consult with staff and patients to fully understand the concerns and challenges of using BWCs on wards before deciding whether to use them.

I would definitely be recommending focus groups before you even think about rolling them out, to give people a platform to talk about their views, and to understand the reasoning behind the cameras, because there is a lot of stigma associated with cameras anyway. (Sharice, ward staff, site B)

Definitely have the conversations with patients and staff and explain the use of them and explain why they’re being used, and get a sense of how people feel about it, which is exactly what we did here and it worked really, really well. (David, ward staff, site C)

3.4.1. Consulting with staff members

It was felt vital that staff were involved in consultations about introducing BWCs to help understand any challenges or issues that need consideration or that may threaten their implementation. It could also help identify issues to be included in any subsequent training and help gauge levels of ‘buy-in’.

We need to get the clinicians and the staff really telling us, and truthfully and being really honest. And I’d be really interested – well, I’ve had conversations with some staff about what their viewpoint is. (Carol, Director)

During interviews for this study, some staff expressed their worry about the cameras being used as a tool to monitor staff behaviour. This highlighted the importance of consultation and listening to staff concerns.

In the perfect world there would’ve been lots of staff engagement. People will know that there’d be really clear procedures written down, that people would feel comfortable with using them. That they would understand when they were going to be used. They would understand about the data, that they would be able to have conversations in a non-threatening or antagonistic way with patients and carers about their use in the services and why they use them. (Carol, Director)

An important part of these conversations and consultations were to acknowledge the feedback and perspectives of staff, including to accept if implementation was not the right choice for staff and the trust.

Over a period of time, everyone has the chance to go on these team meetings… You’re going to have all this, so you need to get the feedback from everyone. I’d do that before we decide is it really worth it? Because if the majority have said no, well there’s no point, you might as well just stop the project. (Natalee, ward staff, site C)

3.4.2. Consulting with patients

A key reason identified for consulting with patients was to acknowledge the needs that different patients have and to ensure that any implementation or use of this technology would be sensitive to such needs and concerns. This was particularly so when considering patients’ mental health diagnoses and mental state, such as those who are autistic, experiencing psychosis, or with a history of trauma, who all may be impacted negatively by the presence of cameras. Both patients and staff expressed concerns that BWCs may act as a ‘trigger’ or make someone more distressed. Therefore, such risks to patients’ wellbeing need to be paramount when considering their use.

I think the staff would have to be so careful of how to use it as a helpful thing rather than… I think it would be quite distressing for patients at times. I think the first few weeks when I was there, it would have been really trippy. (Destiny, patient, ward C)

Meltdowns aren’t under my control… taken in isolation, the film of me melting down looks an awful lot like aggression to a regular person that doesn’t know anything about autism, or even a professional that doesn’t know anything about autism. So, I would look bad in that case, if I was filmed. (Florin, patient, online recruitment).

If you’re psychotic and you’re paranoid, it doesn’t take much for something to trigger you and you may become aggressive. Normally that person could be really, really, quiet. I just feel that that’s using body cameras inappropriately. I don’t think it’s fair. (Katie, patient, online recruitment)

Regarding the acceptability and appropriate use of BWCs, there was consensus amongst many patients interviewed about where they would feel comfortable with cameras being used, e.g. communal areas, and where they should not be used, e.g. in private spaces such as bedrooms and bathrooms.

I don’t think they should be used in bedrooms and bathrooms, no. But I do believe that there are situations where people are on one-to-one, and this is not the bathroom situation, but this is the bedroom. (Lero, patient, site A)

When people are getting dressed and undressed, that’s not appropriate because of dignity. (Katie, patient, online recruitment)

While these aspects were widely agreed it was acknowledged that such boundaries were not easy to adhere to as incidents could happen in private spaces. It was therefore felt that there should be a policy of not using BWCs in private spaces (e.g. bathrooms and bedrooms) unless it was ‘really necessary’ (Florence, patient, site C) and for there to be clear guidelines and protocols for staff when making such decisions.

This was a belief shared by many staff interviewed who felt that to ensure privacy and dignity for patients there needed to be limits around the use of cameras and flexibility to not use them when they might cause distress to an individual or where staff could not preserve their dignity and recording would seem unethical.

We have a lot of on-ward patients who strip a lot and stuff like that. It’s more for their dignity and things like that that we’re a little bit like, "Hmm." Especially on the female ward we find that that tends to happen a lot more, whereas some male acute wards we’ve got cameras on, not body-worn ones but cameras, and there are a lot less dignity issues. On the female wards it’s a little bit harder to get over that. (Nala, ward staff, site A)

Privacy and dignity need to be maintained. I think CQC would be very clear about making sure you don’t record in a bedroom. I would probably never agree with recording in bedrooms, to be honest, I think it’s probably… I think we need to get a chaperoning service for that, I don’t think it would be appropriate to use it from that perspective. (Adam, Director)

Discussion

In this paper, we have illustrated that mental health service managers, ward staff and patients have a range of views and important suggestions when considering and planning the deployment of BWCs on mental health wards. This is before we even consider whether BWCs have any beneficial impacts on patient care or staff and patient safety (Anastasi & Bambi, 2023; Wilson et al., 2023).

Regarding the practical considerations, patients and staff request policies and procedures that allow for clear paths forward for implementation and transparency around data management. Without such policies, concerns about the potential misuse of the cameras and the video footage were expressed. To complement robust policies, effective and continuous training is also required, including for temporary ward staff. Training should include consideration of the potential impact on therapeutic relationships and ward milieu alongside perhaps more straight-forward technological elements. However, even if valuable, such detailed training could be considered a burden as it would require additional staff time when it is already difficult to release staff for training due to staffing shortages. Other concerns relate to the durability and cost of the equipment and potential waste due to lack of use or misplacement. Overall, consideration of multiple intersecting practical issues is essential to avoid wasting time and money and to ensure consistency in the use of BWCs before they are implemented.

The findings also demonstrate the need for wider ethical considerations, as the use of BWCs is an emotive topic where both patients and staff may have concerns about how cameras and footage are used. The perspectives reported here show that respect and consideration for the dignity and rights of patients, needs to be maintained through information, consultation, and inclusion in the decision-making of all those involved. Coffey et al. (2019) has identified how mental health inpatients recognise and appreciate efforts taken by staff to keep them safe but feel excluded from discussions and decisions about the methods employed. Maintaining dignity is important for patients’ care and recovery (Chambers et al. 2014). Bee et al. (2015) found barriers to people’s involvement in their own care included issues related to a lack of information provided. When there is a lack of accessible information and discussion about the use of BWCs it raises questions around meaningful patient involvement in the provision of their care, which is at odds with attempts to improve inpatient mental health care (NHSE, 2023).

Suggestions for robust policies coupled with the use of staff discretion for deciding on the appropriate use of BWCs are outlined in the findings as potential ways forward for the implementation of the cameras. With this approach, there is a risk that patients are excluded from the decision-making process regarding their care as they do not appear to be involved in drawing the boundaries around the use of the cameras. This can further enforce the power differentials between staff using the cameras and patients who are being recorded as it leaves the power of when and where to record in the hands of staff and policymakers. Wilson et al. (2023) have argued that the use of BWCs could lead to the ‘blaming’ of individuals for incidents on wards rather than giving recognition to the wider structural issues at play. O'Shea et al. (2019) research is relevant here as they explore the hierarchy of power that can exist in healthcare and conclude that professionals, even with the modern-day growth of patient and public involvement (PPI), continue to dominate developments and decision-making within healthcare with professionals seen as holding greater legitimacy. Given the sensitivity of this topic, there is an urgent need for much greater co-production in future research and the development of policies, procedures and guidance for the use of BWCs, with service users’ views being given primacy. This paper makes a small contribution towards that.

There is a need for far greater consideration of the potential uses of BWCs and other digital technologies beyond reducing aggression, and for a more nuanced discussion of potential benefits and other, often serious concerns. It may also be useful to consider BWCs alongside or instead of other methods employed that may also produce mixed views. Creating safe spaces where patients, family members, staff and service managers can share and explore these issues is imperative. Advancements in such technologies are happening at incredible speed and it is easy to jump onto either the ‘for’ or ‘against’ position without engaging with consideration of some of the complexities of the issues involved.

Limitations

This study provides some insights into the key considerations for the implementation of BWCS in acute mental health services, however there are limitations to these findings. Firstly, while the findings of this study outline key strategies for the implementation of BWCs in mental health settings, these findings sit within the wider context of participants discussing the wider systemic issues facing staff and patients on wards as well as the wider concerns that remain around the use of BWCs on wards. These findings represent the perspectives of patients and staff on the topic of if, or when, BWCs are implemented on wards (given the acceleration of their use across England) thus represent how this could be done well rather than necessarily an endorsement of using BWCs.

Secondly, it is important to highlight that the introduction of BWCs to date appears to have been largely within the specific context of state-provided mental health services in England, which limits the generalisability of such findings to other countries in which healthcare is delivered differently. Lastly, the qualitive methodology used provides an exploratory insight into these implementation considerations. There is a need for future research to conduct evaluations that can explore whether such approaches towards implementation can be carried out in real-life, and if so, what impact these have on the use and impact of BWCs on staff and patients.

Conclusion

Overall, these findings show that the implementation of BWC in healthcare settings requires careful consideration. The perspectives of patients and staff demonstrate the complex reality of implementation. Considering the practical issues around implementation is essential to ensure that wards recognise the need to assess their capacity to use the cameras in a way that is fair and consistent for all involved. Equally, the ethical considerations need to be well thought through to ensure the dignity and respect of patients is upheld. Without deep consideration of ethical implications, there is the potential to further reduce patients’ involvement in their own care and create even greater distance between patients and staff.

This study highlights the need to devote adequate time and thought ahead of implementing the cameras. Using the multiple interconnected practical and ethical considerations that are outlined in the findings as a guide allows for such in-depth considerations. However, after consideration of the practical implications, the ethical considerations highlight wider questions around power and autonomy in mental health care. The findings demonstrate the complexity that comes with implementing the cameras and the potentially harmful consequences of reducing dignity and respect for patients. In mental health settings where autonomy, respect and dignity of patients are already contentious issues, adding interventions such as BWCs which could potentially reduce these basic human rights requires deep reflection on the approaches being taken and the direction in which mental health care is heading.

Authors contributions

Una Foye: Conceptualisation, Methodology, Formal analysis, Investigation, Writing (original draft; review & editing), Visualisation, Project admin, Funding acquisition

Ciara Regan: Formal analysis, Writing (original draft; review & editing), Visualisation, Project admin.

Keiran Wilson: Conceptualisation, Methodology, Formal analysis, Investigation, Writing (original draft; review & editing), Visualisation

Rubbia Ali: Formal analysis, Writing (original draft; review & editing), Visualisation, Project admin.

Madeleine Chadwick: Conceptualisation, Methodology, Formal analysis, Investigation,

Ellen Thomas: Conceptualisation, Methodology, Formal analysis, Writing (review & editing), Funding acquisition

Sahil Dodhia: Formal analysis, Writing (review & editing),

Jenny Allen-Lynn: Formal analysis, Writing (review & editing),

Jude Allen-Lynn: Formal analysis, Writing (review & editing),

Geoff Brennan: Conceptualisation, Writing (Review & editing), Funding acquisition

Professor Alan Simpson: Conceptualisation, Methodology, Writing (Review & editing), Project admin, Funding acquisition, Supervision

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the sensitive nature of this study, participants were assured the interviews would remain confidential and would not be shared.

Data not available/the data that has been used is confidential.

Additional information

Funding

Funding was provided by both The Maudsley Charity and the Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care Research Challenge Fund 2019. Funders were independent of the research and did not impact findings.

Appendix A.

Example of coding

Coded extracts related to code ‘staff consultation’

<Files\\Staff Interviews\\Directors\\Carol> - § 5 references coded [4.43% Coverage]

Reference 1 − 0.97% Coverage

And also, what I’m really keen on, is listening to staff. Because I think there are certain—I’m so sorry, we’ve got building work next-door. So, just as the dog finishes, the building work starts, I apologise. Is that to listen to staff, to hear what their expectation are, do you understand what I mean? What they think it’s for.

References 2 to 3 − 1.25% Coverage

So, we kind of got a few onto our governance structure and we’ve got all of that. But then, to hear from staff about when do they—so we’re led by what they would like. Do you understand what I mean? And when they think it should be used, and then we can have this conversation that kind of questions, well would you really use it for then? Or is there something else we could be doing? What about, you know, your de-escalation.

Reference 4 − 1.03% Coverage

So, we need to get the clinicians and the staff really telling us, and truthfully and being really honest. And I’d be really interested—well, I’ve had conversations with some staff about what their viewpoint is, and you know, some of it is a bit punitive and it’s about protecting me, and yes, in parts it is. But in part, it’s something else, as well.

Reference 5 − 1.18% Coverage

I don’t even know if it’s the right message, to be honest with you, is to get your foundations right, to get your structure right, to get your organisational culture on that ward right. Or right—that’s kind of like, to start those conversations before you even start rolling it out. And to engage, engage, engage with internal and external stake holders.

<Files\\Staff Interviews\\N1\\John> - § 1 reference coded [2.29% Coverage]

Reference 1 − 2.29% Coverage

So everyone would have to go on like a team course, where you get everyone together. So over a period of time, everyone has the chance to go on these team meetings. Explain their concerns. You know, because some people will be concerned. They will have oppos- You’re going to have all this, so you need to get the feedback from everyone. You know. Is it a good thing, bad thing, you know.

I’d do that before we decide is it really worth it? Because if the majority have said no, well there’s no point, you might as well just stop the project. But if they all say- Say three-quarters say yes. Then you look at it- And you start looking at the legal aspects, personal safety.

So it would be a gradual introduction to it, so they’re all aware of it. You wouldn’t put a date on it. You need to say, “This is what we’re going to do. There’s no date yet,” until everyone’s happy that we are going to do these things. There is, like I said, safeguarding measures, to do with personal data and everything else. So you need to explain to people why.

<Files\\Staff Interviews\\N1\\Thomas> - § 2 references coded [4.30% Coverage]

References 1 to 2 − 4.30% Coverage

Respondent: That’s interesting. Most of it is practice when you come to introduce them. I think there has got to be lots of- We should definitely involve service users in the groups, and have agreements that they will be used, and used by certain staff. I think, it may be that we, initially, have everybody agrees certain times they are on and certain times they are off, or whatever. I do think that a majority, and it doesn’t have to be everybody, because I think, if you get everybody it’s not going to work. The majority of staff should agree that.

Service user groups, and it wouldn’t necessarily be the staff, the patients on the ward at that time, because on our acute wards they are, on average, there for 30–40 days. Every group is different. So, if you get agreement from one group, it doesn’t mean the next group of service users agree. Maybe, from an inpatient-we have a service user and carer advisory group. They would be able to advise on those processes, to make sure there is best practice involved. So, they would be involved in those processes.

This service users and carers advisory group would be able to have that input, so carers are in that process as well. You need a majority of staff; you don’t need everybody because you won’t get everybody. You need that as well, and it would be led- It has to be led in best practice by a willing consultant, ward manager and senior management team, to support that process. I think, any change, something like this is big.

Extract from interview with ‘carol’ with ‘staff consultation’ coded segment highlighted

Interviewer: What would that look like for you, in terms of what situations might the cameras be used? Who might be wearing them? What particular—is it only in certain places? Kind of, in the perfect world?

Respondent: In the perfect world there would have been, and of course, it’s not going to go like this, I know this. But—and it’s not going to go like that, I’m not stupid. But if even we can achieve you know, 75% of it, I think we would’ve done really, really well.

Is that, in the perfect world, you know, there would’ve been lots of staff engagement. People will know that there’d be really clear procedures written down, that people would feel comfortable with using them. That they would understand when they were going to be used. They would understand about the data, that they would be able to have conversations in a non-threatening or antagonistic way with patients and carers about their use in the services and why they use them, etc. There would be quite clear signage, all of that.

So, it would be a therapeutic tool, if you want. Because I think that’s what we need to say, it’s a therapeutic tool. And when it would be used is—and this sounds very idealistic, and I know that it’s probably not going to work like that, there will be on occasions when it’s used in a different way.

And also, what I’m really keen on, is listening to staff. Because I think there are certain. Is that to listen to staff, to hear what their expectation are, do you understand what I mean? What they think it’s for.

So, we kind of got a few onto our governance structure and we’ve got all of that. But then, to hear from staff about when do they—so we’re led by what they would like. Do you understand what I mean? And when they think it should be used, and then we can have this conversation that kind of questions, well would you really use it for then? Or is there something else we could be doing? What about, you know, your de-escalation.

Because it’s all tied in with our management of violence and aggression and the whole de-escalation, etc. So, hopefully, ultimately, it would be really great if we get our safe wards built into this, so that it becomes like a process.

So, it’s not just straight to the body worn cameras, that the clinicians are looking at. Somebody’s becoming distressed, they’re becoming angry, so let’s look at safe wards, what can we do? Let’s look at our de-escalation skills and if it’s worse, then we go to the—does this all make sense?

So, we need to get the clinicians and the staff really telling us, and truthfully and being really honest. And I’d be really interested—well, I’ve had conversations with some staff about what their viewpoint is, and you know, some of it is a bit punitive and it’s about protecting me, and yes, in parts it is. But in part, it’s something else, as well.

And the kind of instance, I suppose it could be used for times that if we do have—and as I said, they’re not that frequent, but when carers are abusive, become verbally aggressive, etc. Then, I think there may be a place for them, just to kindly say, “I’m going to start recording.” You know, give them fair warning, all that kind of thing.

But also, this is why we’re trialling it on the PICU, is when there are real violence incidents, because what is helpful, is when we’re doing our review of those kinds of situations, is I think footage will be really helpful.

So, for me it’s about how we learn from that situation. Yes, it’s got a place in a criminal justice system, if you want. But also, it is about how we use that footage so that we learn, so that we review our practice, and we learn from it in a culture that isn’t full of blame.

But having said that, I also recognise that in some instances, there may be a, for example, the trust is very active in taking police action if staff are assaulted by patients or if they damage trust property. So, footage would be helpful for that because it supports, but also, I see the footage as kind of like a learning tool.

…

Interviewer: And my final question is, what would your key message around the topic of body worn cameras from your expertise and experience and thoughts and all that sort of stuff, that’s been swilling around? What would your key message be, that you think should come through in this kind of research?

Respondent: My key message is—I think it’s difficult because we haven’t done it yet, do you understand what I mean?

So, where I am at the moment is, my key message—I don’t even know if it’s the right message, to be honest with you, is to get your foundations right, to get your structure right, to get your organisational culture on that ward right. Or right—that’s kind of like, to start those conversations before you even start rolling it out. And to engage, engage, engage with internal and external stake holders.