Johnson et al¹ provide a comprehensive and illuminating review of the evidence and key issues in relation to acute and crisis mental health care. As they suggest, psychiatric inpatient care is most often un­­popular – with both patients and many staff – and can be traumatizing, re-traumatizing and coercive.

Huge tensions exist around keeping se­­verely mentally distressed people safe whilst trying to build and sustain engaging, accepting, therapeutic relationships and milieu, often within health care sys­­tems and organizations that are inadequately funded and woefully understaffed.

Those staff that commit their time and energies to providing inpatient care often do so with great skill and humanity. A cross-national comparative case study² reported positive practice within acute in­­patient wards, with evidence of safe, respectful, compassionate care. Patients were aware of efforts taken to keep them safe, but did not feel routinely involved in care planning or risk management decisions. Research on increasing therapeutic contact time, shared decision making in risk assessment, and using recovery-focused tools could further promote personalized care planning.

The ever-present issue of boredom on psychiatric wards is also highlighted in Johnson et al’s paper. Freely available initiatives such as Star Wards (www.starwards.org.uk) provide multiple creative suggestions for increasing interactions on busy mental health wards, and can create opportunities for staff and patients to engage in conversations and collaboration to design and implement constructive activities.

There is a pressing need for research to investigate the organizational factors that need to be put in place to support more interactive, productive environments in acute mental health care³. Whether such solutions are possible within restrictive and risk-averse contexts remains to be seen. Activities to be considered, in addition to relief of boredom, include encouraging engagement, appraising the ability to undertake activities of daily living, preparing for discharge, and supporting tentative steps towards recovery.

It may be unlikely that all these needs can be adequately met in the typically short time spent on a ward, whilst also consid­ering the varying demographic and dia­g­nostic profiles. This applies in particular to the development of the necessary skills and confidence to build and maintain re­covery while engaging with an often threat­ening outside world. ­Multidisciplinary ap­­­­proaches involving occupational therapists and peer workers may offer a way forward.

Johnson et al¹ highlight evidence supporting the use of Six Core Strategies and Safewards to reduce conflict and the use of containment measures on inpatient wards. A recent review acknowledged the increased evidence base for the efficacy of Safewards on acute wards in various countries⁴. More research is required to evaluate adaptations in psychiatric intensive care units, secure mental health services, emergency departments, and wards for other age groups. However, the staff shortages and considerable pressures faced by those working in mental health care also create considerable barriers for those implementing interventions⁵ and undertaking related research⁶.

A narrative review of the literature⁷ found a relatively small body of research on the use of closed circuits television (CCTV) to increase security for patients and staff in acute psychiatric units, but recognized the trade-off with privacy. CCTV increased sub­jective feelings of safety amongst patient and staff, but there was no evidence that it increased objective security or reduced vi­olence.

CCTV and, more recently, infrared cameras have also been used to conduct close ob­servations and monitoring of vital signs in patients, including in seclusion. Such tech­nology can be less invasive for patients, reduce sleep disruption when making checks, and can be preferred by some patients as it avoids staff entering a person’s private space. This may reduce triggers for conflict and aggression, and subsequent psychological harm associated with containment measures. Video monitoring can also allow over-stimulated patients to be left alone, while enabling staff to carry out their observations.

On the other hand, the use of electronic surveillance can be seen as distancing and dehumanizing. Studies suggest that the main factor in comforting patients and re­­ducing trauma during an episode of se­clu­sion or restraint is contact and commu­nication with staff⁸. Symptoms of fear, dis­­­­trust or delusions can be worsened in some patients, and there are concerns that CCTV might increase paranoid thoughts or trigger distressing memories of prior abuse involving videos. Video cameras might di­rectly contribute to an atmosphere of de­tachment, control and fear, which could promote occurrence of the very events that surveillance is supposed to reduce. Video­ing patients, especially in distress, can fuel feelings of shame and touches the right to privacy.

These concerns and the need for more re­search are important, as the increasing availability and affordability of digital technol­ogies has seen body worn cameras (BWC) being introduced to inpatient units, in emer­gency departments and for paramedics in ambulances. BWCs are small devices that can be worn on clothing, which record sights and sounds in the vicinity of the wearer. Men­tal health staff are being asked to wear BWCs and to switch them on during inci­dents, or sometimes at the request of a pa­tient. It is hoped that the use of BWCs will defuse situations, reduce aggression, and increase accountability and evidence-gathering around serious incidents. How­ever, a recent systematic review of the liter­ature identified only two low-quality eval­uations of BWC use in mental health wards, with mixed results though some indication of reductions in more serious incidents⁹.

In conclusion, addressing the activity and engagement needs of patients on busy pressured wards can be regarded today as a priority, whereas the idea of using electronic surveillance in acute mental health settings is not supported at the moment by convincing research evidence and is generating significant concerns.

Johnson 等人¹对与急性和危机精神卫生保健相关的证据和关键问题进行了全面而富有启发性的回顾。正如他们所建议的那样，精神病住院治疗通常不受欢迎——无论是患者还是许多工作人员——并且可能会造成创伤、再创伤和胁迫。

Huge tensions exist around keeping se­­verely mentally distressed people safe whilst trying to build and sustain engaging, accepting, therapeutic relationships and milieu, often within health care sys­­tems and organizations that are inadequately funded and woefully understaffed.

Those staff that commit their time and energies to providing inpatient care often do so with great skill and humanity. A cross-national comparative case study² reported positive practice within acute in­­patient wards, with evidence of safe, respectful, compassionate care. Patients were aware of efforts taken to keep them safe, but did not feel routinely involved in care planning or risk management decisions. Research on increasing therapeutic contact time, shared decision making in risk assessment, and using recovery-focused tools could further promote personalized care planning.

The ever-present issue of boredom on psychiatric wards is also highlighted in Johnson et al’s paper. Freely available initiatives such as Star Wards (www.starwards.org.uk) provide multiple creative suggestions for increasing interactions on busy mental health wards, and can create opportunities for staff and patients to engage in conversations and collaboration to design and implement constructive activities.

There is a pressing need for research to investigate the organizational factors that need to be put in place to support more interactive, productive environments in acute mental health care³. Whether such solutions are possible within restrictive and risk-averse contexts remains to be seen. Activities to be considered, in addition to relief of boredom, include encouraging engagement, appraising the ability to undertake activities of daily living, preparing for discharge, and supporting tentative steps towards recovery.

It may be unlikely that all these needs can be adequately met in the typically short time spent on a ward, whilst also consid­ering the varying demographic and dia­g­nostic profiles. This applies in particular to the development of the necessary skills and confidence to build and maintain re­covery while engaging with an often threat­ening outside world. ­Multidisciplinary ap­­­­proaches involving occupational therapists and peer workers may offer a way forward.

Johnson 等人¹强调了支持使用六项核心策略和安全措施来减少冲突以及在住院病房中使用遏制措施的证据。最近的一项审查承认，Safewards在不同国家/地区的急诊病房疗效的证据基础有所增加⁴。需要更多的研究来评估精神科重症监护病房、确保心理健康服务、急诊科和其他年龄组病房的适应情况。然而，精神卫生保健工作者面临的人员短缺和巨大压力也为实施干预措施⁵和开展相关研究^{6的人员造成了相当大的障碍}.

对文献⁷的叙述性回顾发现，关于使用闭路电视 (CCTV) 来提高急性精神科病房患者和工作人员的安全性的研究相对较少，但也认识到了与隐私的权衡。闭路电视增加了患者和工作人员的主观安全感，但没有证据表明它增加了客观的安全感或减少了暴力。

闭路电视和最近的红外摄像机也被用于对患者的生命体征进行密切观察和监测，包括隐居状态。这种技术对患者的侵入性较小，可以减少检查时的睡眠中断，并且可能会受到一些患者的青睐，因为它可以避免工作人员进入个人的私人空间。这可能会减少引发冲突和侵略的诱因，以及随后与遏制措施相关的心理伤害。视频监控还可以让过度刺激的患者独处，同时使工作人员能够进行观察。

另一方面，使用电子监控可以被视为疏远和非人性化。研究表明，在隔离或约束期间安慰患者和减少创伤的主要因素是与工作人员的接触和沟通⁸。一些患者的恐惧、不信任或妄想症状可能会恶化，并且有人担心闭路电视可能会增加偏执的想法或引发对涉及视频的先前虐待的痛苦记忆。摄像机可能会直接助长一种超然、控制和恐惧的气氛，这可能会促进监视本应减少的事件的发生。录像病人，尤其是处于困境中的病人，会加剧羞耻感并触及隐私权。

这些担忧和对更多研究的需求很重要，因为随着数字技术的日益普及和经济实惠，随身携带的摄像机 (BWC) 已被引入住院病房、急诊科和救护车的护理人员。BWC 是可以穿在衣服上的小型设备，可以记录佩戴者附近的景象和声音。精神卫生工作人员被要求佩戴 BWC，并在事件发生时或有时应患者的要求打开它们。希望生物武器公约的使用能够缓和局势，减少攻击性，并加强对严重事件的问责和证据收集。然而，最近一项对文献的系统回顾发现，只有两项关于 BWC 在心理健康病房中使用的低质量评估，⁹ .

总之，在繁忙的压力病房中解决患者的活动和参与需求今天可以被视为优先事项，而在急性心理健康环境中使用电子监控的想法目前没有得到令人信服的研究证据的支持，并且引起了重大关注.