Forty health professionals participated, including 20 nursing staff, 10 allied health professionals, seven medical staff and three consumer/peer support staff. Twenty-seven participants identified as female and thirteen as male. Thirty-one staff worked full-time and nine part-time. Participants had varying levels of experience working in their current role within the acute mental health service, ranging from three months to 29 years. The age of participants varied from 21 to 64 years of age with a mean of 42.5 years. Staff predominantly identified as being of Australian nationality (77.5%). Other staff identified as New Zealander, Maori, Chilean, Ghanaian, British, Greek, Indian, Italian and Singaporean.
Three main typologies were developed based on dominant themes within the dataset: Dismissing and denying; Acknowledging but unprepared; Empathising but despairing. Each of these typologies is described below with supporting quotes to illustrate them in more detail.
Dismissing and Denying
Some staff expressed negative attitudes towards female consumers who were believed to be more difficult to care for than male consumers. There was some reluctance from these staff to consider working on women only wards. George (Manager) illustrated this by recounting recent discussions with his colleagues: “You wouldn't get many who would want to work in a female only unit, because of the issues it causes, and women are, females generally are felt to be harder to look after…”. This negative bias toward female consumers extends further to those with a diagnosis of Borderline Personality Disorder. Camilla (Medical) described her Registrar telling her, "People with borderline, everyone sort of just runs away because they're so difficult to manage". This perspective was frustrating for Maryann (Allied Health). She expressed her irritation with colleagues’ negative attitudes, flippant comments and lack of understanding towards women with a diagnosis of Borderline Personality Disorder: "I guess where I see lack of respect is the ward's attitude to women who have a diagnosis of personality disorder. A woman with a personality disorder comes from most likely 99.9 percent of child sexual abuse”.
These negative attitudes towards female consumers resulted in staff not taking sexual assault disclosures seriously, minimising or blaming consumers. Elise (Allied Health) reported that female consumers were at times blamed for the perceived overexaggerated response to sexual violence. “It's one of the other unwell people who's done this to [a young woman] consumer because he's so unwell, immediately afterward, the staff was describing he had kind of humped her, and she reacted with rage at that, but then staff were kind of blaming her a bit, saying her reaction was over the top". Health professionals justified their dismissive, minimising or blaming responses using reasons which included lack of information on the incident of sexual violence, fear of retraumatising and time limitations of the care provision within a psychiatric inpatient unit. Compartmentalising incidents of sexual violence as historic, ‘confusing’ or expected due to the woman working in the sex industry permitted staff to ignore and reassure themselves that ‘it's not why she's here’ (Paul, Medical). Another reason for staff to justify their avoidance was expressed as a fear of “opening old wounds” by Jason (Allied Health) and a perception that it is better to “leave what happened in the past, in the past”, by Jane (Nurse). Kate (Allied Health) referred to the brevity of admission as a valid justification for this perception: “We're an inpatient unit, the average time is maybe a week that someone's here. So, to reopen old wounds and to explore that, I don't think it benefits them and is better for an outsourced service”.
Additionally, some staff shied away from asking about sexual violence as they didn’t see it as part of their role. This view was particularly prominent for male staff and it was seen as a more appropriate role for female nurses. Jason (Allied Health) stated “I guess my role isn't sort of specified towards that”. Ryan (Nurse) reported that providing care to survivors of sexual violence can be difficult for male staff “if someone has that sexual abuse history, they just see every male as being the perpetrator and being someone that's wanting to get them. That's always a challenge, it can always be confronting”. A male doctor, Paul, described nurses as the preferred staff for this role as they have more time to spend with patients than doctors. Nurses were considered to be intermediaries for disclosures of sexual violence from consumers who could then liaise with medical staff: “…the next best person would be the nurse, because nurses will spend way more time with them. I would say on average statistically the patients might like nurses better than doctors, so they might get a bit more history, and they'll flag it in their handover and it will be brought up to us as well” (Paul, Medical). Patrick (Medical) reinforced this perception of providing care to women who are survivors of sexual violence as a nurses’ role “I think general nursing staff who are more established are reasonably good”. Ruth, (Medical) pointed out the limitations of relying on nursing staff only to provide this care “the need for one-on-one staff we have to have nurses available to do that. One on one is pretty resource intense.”
This division and avoidance was also reportedly evident at a leadership and an organisational level. Kaye (Allied Health) described, "When we start talking about making definite decisions that affect everybody, the men are really engaged but when it's considered almost secret woman's business, they're nowhere to be found. They're not interested in the safety of their units, they're not really interested in family violence”. Furthermore, Matthew (Manager) expressed the view that desensitising consumers who had survived trauma was more important than ensuring their sense of safety and security on the ward: “There was discussions about making one ward female only. No, because the world's not like that, so it's a fake sense of security… If you put them on a female ward then it's gonna be a fake environment, because the world is not segregated. It's about learning to manage. I know, trauma, and all that, but if we can learn to desensitise in the right way, that would help”. These perceptions highlight the lack of understanding and reluctance of some health professionals to address women’s experiences of sexual violence.
Acknowledging but unprepared
This theme describes the experience of many health professionals who recognised the prevalence and impact of sexual violence but felt unprepared to respond accordingly. Chris (Nurse) illustrates this understanding through his comment "I think it [sexual violence] is a very common thing that's for sure. A lot of our consumers who have borderline personalities tend to have a history of sexual assault, physical assault, mental even, so there have been numerous cases in the past". These staff also had good insight into how consumers may be feeling during their inpatient stay, as illustrated by Josie’s (Allied Health) comment: “Essentially, it's about not feeling safe and not being able to predict what might happen next, and a vulnerability about not necessarily having the capacity to make oneself safe”. Incidents of sexual violence were reported by several healthcare professionals to have occurred on the psychiatric inpatient wards. These incidents, understandably, re-traumatised and negatively impacted a consumer’s recovery and ability to engage in treatment. This fear of harm while in the inpatient unit was real and a lived experience for female consumers as highlighted by Caroline's (Nurse) comment: “A male exposed himself to her [consumer] and was offering sexual favours and was blowing her kisses from a bedroom and whatnot and he was taken out of the unit. It was a trigger for her because she had had an experience in the past where she was sexually abused. She struggled with her progression of her treatment here because it had brought up so much for her and she was really afraid and frightened. It was really hard to nurse her after that exposure and that experience”.
In particular, many junior doctors and new graduate nursing and allied health professionals recognised that they might not have the skills to ask about histories of sexual violence and respond to disclosures. This was clearly reported by Camilla (Medical) “We were never taught it in Med[ical] School, even in orientation. Here it would be useful to have a rundown of how to approach it. I ask the question quickly and then kind of move on”. Elise (Allied Health) was frequently approached by junior medical staff asking for help to discuss trauma and sexual violence: “I think a lot of staff here try hard to do their best. A lot of staff openly say they don't quite know what to do. I've had doctors say to me they don't know how to ask”. Amanda (Nurse) declared her lack of knowledge in this area and desire to know more: “I would like to know if there's more that can be done. I guess for me, it's a case of ‘I don't know what I don't know’. But I think there must be more things that we could do but I don't know what they are”. Furthermore, Ray (Allied Health) described his feelings of fear and inadequacy due to his lack of experience and limited time in his role: “There are days when we don't really feel prepared. There are days when I question whether or not I am ready or able, or capable of providing good service to [survivors of sexual violence]”. Senior staff expressed concern as to how this affected appropriate follow-up, referrals, and care for female consumers within the inpatient unit: “Well, everything is quite new to [graduate staff] so they're not sure what to expect when I've asked them questions about their role and why things aren't done, you know, this way for example. ‘We didn't know’. And that's understandable, but I'm just worried about how that then flows on and what they think about their roles and how that then influences our consumers” (Madeline, Allied Health).
A level of confidence was noted by some senior female nursing staff in listening to women's histories of sexual violence; however, this was often where their skills and confidence ended: “I guess I suppose just being very, very conscious and very aware of it. If women want to talk to me about it, I'm more than happy to listen” (Caroline, Nurse). Referrals to external agencies or to experienced allied health staff were perceived as the only avenues for care from this point for nursing staff. Olive (Nurse) describes: “Again, I don't know that we feel, or me particularly, or when people come to me to discuss it that we actually feel that we're [in] the best position to talk about what's happened in the past. We'll happily discuss it, but how do we work around it or with it? There's often referrals to other agencies or our social worker”. However, senior male nurse Keith admits that seniority does not necessarily bring confidence or skills in caring for women who are survivors of sexual violence “I don't feel that I would be the best person to deal with difficult and very distressing issues for some people. I probably wouldn't feel equipped or all that comfortable to deal with quite serious issues”.
Empathising but despairing
This theme encapsulates responses of several health professionals who understood the bidirectionality of sexual violence and mental illness and the individual responses from consumers. They expressed frustration towards colleagues and the mental health system for not responding sensitively or appropriately. Lucy (Nurse) described the individual experiences of sexual violence and the need for all staff to have an awareness of the possible impacts on victim-survivors. “It [the impact of sexual violence] is completely subjective to the client. Just because you don't feel that that is extreme, that's your opinion. It is not how you approach in a hospital, or in any other setting. Especially with sexual assault. I think some people still need to get the grasp of that”. In addition, staff who understood the aetiology of Borderline Personality Disorder recognised the high prevalence of trauma and sexual violence these women have likely experienced. James (Manager) recognised that sexual violence is ‘a complex topic’ and that a staff member’s personal bias may influence the consumer's decision to make a report: “Often guilt is associated with the assault or abuse, working through that with the consumer, trying to be supportive of whatever decision they make; whether they want to report it or not. Trying to have their best interests in mind, but also respecting their choices regardless of what they may be and setting your own opinions aside and trying to remain supportive but neutral”.
Empathising and believing women’s disclosures was more important to some staff members than others. These healthcare professionals were often frustrated with their colleagues who questioned the veracity of a disclosure of sexual violence due to psychosis or lack of evidence. Lucy (Nurse) empathetically discussed her understanding of psychotic symptoms as grounded in lived experience: “I suppose instead of just pushing that aside as, ‘Oh, it's just the psychosis’. You're right, they are psychotic, but the memories of their experience from before is still real”. Similarly, Angela (Allied Health) took the stance of believing the woman’s disclosure: “Possibly [an allegation of sexual violence is] not true, but why did we believe it's not true until we find out. I find that common here”. Lauren (Nurse) explained this is an issue they frequently face within the unit and try to address through training and challenging perspectives: “We'll often get people, and they will report ‘I've been assaulted on the unit’. Sometimes it's difficult for staff, they'll think, ‘Oh, is it just part of a delusion or something like that?’ That's a pretty big challenge, and a big part of the training as well. Where I try to emphasise that it [truthfulness] doesn't matter”. Madeline (Allied Health) described her strategy of acknowledging that their role is not to question but to create a safe and trusting environment for women to make disclosures: "Unfortunately, I still get responses like, ‘We're not sure if it's true’, or ‘It's part of her illness’. So really just making sure that it's not our job to investigate whether something is true or not but more so to make sure that the person feels safe and has the option to disclose if they wanted to".
Staff were at times critical of the treatment recommended and provided to women. Some health professionals expressed their despair that certain retraumatising practices were still being carried out within the organisation. They had difficulty making decisions, asserting their opinions or having to ‘follow certain rules' feeling it was incongruous with their personal beliefs and clinical judgement. Brooke (Nurse) illustrated this with a distressing example: “My old nurse in charge, when the female nurses were off, organised male staff and male security staff to hold down and give a female consumer IM [intra muscular] injections. And that's not on, so, that will be followed up by management because that's just appalling behaviour and that shouldn't be happening here. And it happened again last month. I'm horrified by the whole scenario. We've just traumatised a patient”. Encouragingly some staff felt confident enough to raise their concerns with management; however, this is not always the case. A barrier to assertively raising their concerns was a lack of confidence to speak up and disagree with more dominant colleagues as noted by Charlotte (Manager): “I think sometimes it's about confidence, that sometimes a colleague is a lot stronger in verbalizing what they think should go on, or even sometimes if I [the manager] go in, I notice that people withdraw. They'll wait for that authority, for people to decide for them. We're really trying to change this”. In these instances, staff sought out and relied on management to assert their authority rather than feeling that they could be assertive or raise their concern themselves.
The main findings are summarised below in Table 1. The typology of dismissing and denying consisted predominantly of male staff who expressed fearfulness and ambivalence towards female consumers. The typology of acknowledging but unprepared consisted of male and female staff who expressed anxiety and a lack of confidence in response to providing care to survivors of sexual violence. The third typology, empathising but despairing, denotes health professionals’ frustration with their colleagues and a sense of powerlessness with leadership and the health system.