Originally published in: Emma Warnock-Parkes, Susan Young & Gisli

Gudjonsson (2010) Cultural sensitivity in forensic services: findings from

an audit of South London forensic inpatient services, The Journal of

Forensic Psychiatry & Psychology, 21:1, 156-166, DOI:

10.1080/14789940903202179

Cultural sensitivity in forensic services: findings from an audit of South London forensic inpatient services

Emma Warnock-Parkes a, Susan Young

b & Gisli

Gudjonsson b

a The Centre for Anxiety Disorders and Trauma, The Maudsley Hospital , London , UK

b Department of Forensic Mental Health Science, Institute of Psychiatry, London, UK Published online: 25 Sep 2009.

RESEARCH ARTICLE

Cultural sensitivity in forensic services: findings from an audit of South London forensic inpatient services Emma Warnock-Parkes

a*, Susan Young

b and Gisli Gudjonsson

b

aThe Centre for Anxiety Disorders and Trauma, The Maudsley Hospital, London, UK;

bDepartment of

Forensic Mental Health Science, Institute of Psychiatry, London, UK

(Received 8 August 2007; final version received 22 July 2009)

This paper summarises the key findings from an audit using the Cultural

Sensitivity Audit Tool for Mental Health Services (The Sainsbury Centre

for Mental Health, 2001) to evaluate the views of service-users and staff in

a South London Forensic Inpatient Service. Forty-one service-users and 47

members of staff working in the service took part in the audit. Staff

completed the tool as a questionnaire, and service-users were interviewed.

The majority of staff believed that black and minority ethnic patient groups

were over-represented in the service, and many attributed this to

misunderstandings of culture. Staff identified gaps in their training on race

and culture; none of the staff believed they had received all the training

required. Nevertheless, service-users highlighted culturally sensitive and

effective aspects of the service, and many believed their cultural needs were

understood. Given this disparity, the authors question whether the large

emphasis on the cultural sensitivity of services is something service-

providers are more concerned about than our service-users; and whether a

greater focus on service quality, of which cultural sensitivity is one aspect,

would be more helpful.

Introduction

The representation of black and minority ethnic groups in mental health services has

been documented to be significantly disproportionate to the ethnic profile of the

country at large (National Institute for Mental Health in England: NIMHE, 2003). The

area has become one of controversy: possibly due to the findings that people from

black and minority ethnic groups differ in the following respects from fellow white

service-users: they are more likely to be admitted to and over-represented in inpatient,

secure and prison settings (British Psychological Society, 1998; Department of

Corresponding author. Email: emma.warnock-parkes@slam.nhs.uk

DOI: 10.1080/14789940903202179 http://www.informaworld.com

Health, 1992, 1999a; Maden, Friendship, McClintock, & Rutter, 1999); more likely to

be compulsorily admitted and more than six times more likely to be sectioned

(Department of Health, 2000; Morgan et al., 2005); more likely to have an inpatient

diagnosis of schizophrenia (Bhugra et al., 1997); less likely to be registered with a

General Practitioner (Koffman, Fulop, & Pashley, 1997); less likely to be referred to

psychology services (BPS, 1998); less likely to be treated with psychotherapy or

antidepressants (McKenzie et al., 2001); and less likely to be prescribed newer

atypical antipsychotic medications (Wang, West, Tanielian, & Pincus, 2000).

However, a recent paper found no differences in the quality of prescribing between

black and white patients (Connolly & Taylor, 2008). It has been argued that some

documented differences in representation could be related to higher rates of psychosis

in certain ethnic groups (Bebbington et al., 1994), and it is observed that there might

be more exposure to risk factors that could lead to the development of mental illness

(Lewis, Croft-Jeffreys, & David, 1990). Although, as Singh and colleagues (Singh,

Greenwood, White, & Churchill, 2007) suggest, this area of research is ‘politically

charged and ethically contentious requiring a cautious and balanced approach to

research and interpretation of data’ (p. 103). Unfortunately, studies are often fraught

with methodological problems that limit their findings (Bhui et al., 2003).

Partly following such research, a number of governmental papers have been

published making recommendations for the treatment of black and minority ethnic

groups, including: the National Service Framework for mental health (Department of

Health, 1999b); a report titled Engaging and Changing (Patel, Winters, Bashford, &

Bingley, 2003) and Delivering Race Equality in Mental Health Care (DRE:

Department of Health, 2005). At a local level, the Race Relations [Amendment] Act

(Stationary Office, 2000) placed a general duty on all public authorities to eliminate

unlawful racial discrimination, promote equality of opportunity, and promote good

relations between people of different racial groups. In May 2002, the South London

and Maudsley (SLAM) NHS Trust published its first Race Equality Scheme as

required by the Race Relations Act (SLAM NHS Trust, 2002a). Six functions were

identified at this time: (1) clinical service provision; (2) employment; (3) patient and

public involvement; (4) education and training;

(5) research and development and (6) non-clinical support services.

When the RES was published, clinical service provision and employment were

prioritised as the first part of this work. Thus, in order to examine the clinical

service provision and evaluate the effectiveness of the South London Southwark

Forensic Service in meeting the needs of ethnic minority service-users, this service

conducted an audit of the cultural knowledge and practice adopted within the

service, from both a staff and service-user perspective. The aims of this audit were

to assess the views of staff and service-users on the ethnic diversity, accessibility

and cultural sensitivity of the service.

Method The service

At the time of the audit, the Southwark Forensic Inpatient Service (‘the service’)

included two units for male mentally disordered offenders and patients who are

difficult to manage in general psychiatric settings. One was a 29-bedded inpatient

forensic service providing care and treatment in conditions of medium security, and

the second was a 15-bedded open Forensic Rehabilitation Unit.

Participants

Participants were 41 patients and 47 members of staff working in the service.

Participation in the audit was voluntary.

Exclusions included service-users who were too unwell to participate (i.e., actively

psychotic as assessed by nursing staff) and individuals with moderate learning

disabilities who could not comprehend the questions. Unfortunately, due to a lack of

funding, interpreters could not be provided to aid completion of the questionnaires, so

individuals without an adequate understanding of English were excluded.

Measures

The Cultural Sensitivity Audit Tool for Mental Health Services (The Sainsbury

Centre for Mental Health, 2001) was devised for independent use by mental health

services to identify areas of good practice and those for improvement. It places

particular emphasis on the experiences of the people using and working in services.

The tool consists of two interview schedules:-

The Staff Interview Schedule consisting of 67 questions split into six domains: (1)

demographics; (2) communication; (3) the availability of staff to work with clients;

(4) knowledge and views of cultural and ethnic issues;

(5) training regarding cultural issues and (6) the cultural appropriateness of day

centres, hospital wards and residential settings. For this audit, the latter section was

applied to the mental health hospital ward.

The Service-User Interview Schedule consisting of 71 questions split into seven

domains: (1) demographics; (2) accessibility of services; (3) language and

interpreters; (4) general service use issues; (5) availability of appropriate staff; (6)

availability of ethnically specific services and (7) service-users’ views on the cultural

appropriateness of mental health services.

The tool has been reviewed by Mckenzie (2002) who noted that there was

insufficient information on the tool’s development and there were no data presented

on the reliability and validity of the tool. A review of the literature does not reveal

evidence of any subsequent validation with regard to this tool. However, in spite of

the lack of validity, and absence of other instruments that address specific issues of

cultural sensitivity in mental health services, this current study represents a

preliminary attempt to audit issues relevant to cultural sensitivity in forensic services.

Procedure

Copies of the Staff Interview Schedule, together with a consent form and information

sheet, were internally distributed to all staff employed in the service. These were then

returned anonymously in internal envelopes to a researcher.

The Service-User Interview Schedule was administered by a researcher as a semi-

structured interview. All individuals who met the inclusion criteria were approached

and invited to participate. Each participant was required to provide written informed

consent before completing the interview. Interviews took approximately 30 minutes to

complete, and were conducted in clinic rooms on the units.

Data were analysed using descriptive statistics or qualitative thematic analysis. For

the latter analysis, instructions were devised on how respondents’ qualitative

comments were organised into themes and a second researcher was asked to analyse

the data using these instructions. Overall, there was a high level of agreement between

the two researchers, and any discrepancies were discussed and the comment was

subsequently allocated to a theme once an agreement had been made.

Results

Due to the volume of results the key outcomes are briefly summarised (the full audit

is available on request from the authors). As some participants chose not to respond to

particular questions, there are a number of missing responses. Missing data are noted

where relevant throughout the results. Percentages are calculated on the total number

of participants, unless otherwise stated.

Characteristics of staff and service-user respondents

A total of 47 staff, representing all members of the multidisciplinary team, and 41 all

male service-users, completed the audit. Table 1 shows the characteristics of

respondents.

Staff perceptions Ethnicity and representation of service-users

The majority of staff (28, 60%; missing data – two) thought that black and minority

ethnic patient groups were over-represented in the service compared to the local area.

Of that group most (20, 71%) believed, this

Table 1. The demographic characteristics of staff and service-user respondents (number and percentage).

Staff respondents, Service-user

respondents,

n = 47 (%) n = 41 (%)

Gender

Male 20 (43) 41 (100)

Female 27 (57) 0 (0)

Ethnicity subgroups

White background 27 (57) 15 (37)

African/Caribbean 15 (32) 19 (46)

Mixed race 3 (6) 5 (12)

Indian/Asian 2 (4) 1 (2)

Black other 0 (0) 1 (2)

Religion

Christian 33 (70) 27 (66)

Atheist/no religion 10 (21) 9 (22)

Muslim 1 (2) 2 (5)

Hindu 1 (2) 1 (2)

Other 2 (4) 2 (5)

reflected a misunderstanding of culture and ethnicity, and the ways in which people

express themselves.

Cultural appropriateness of the service

The majority of staff (40, 85%; missing – four) believed that the food available on the

unit fulfilled cultural and religious requirements of the service-users. Only a third of

staff (15, 32%; missing data – eight) stated that culturally appropriate personal care

products were available in the service.

The majority of keyworker staff (10 of the 13 keyworkers that commented – 77%)

reported that service-users were rarely given the option of having a keyworker of the

same ethnicity, although the same percentage of staff stated that a culturally

appropriate member of staff is usually available on the ward, if required.

Just under half of staff respondents (20, 43%; missing data – three) stated that the

team in which they work had attempted to improve its cultural sensitivity and

examples were given relating to: staff development (e.g., training), clinical practice

(e.g., care plans), diverse recruitment, ward-based factors and events (e.g., organising

culturally appropriate social events) and displaying culturally relevant literature on the

wards.

Communication

Less than half of the staff (22 respondents; 47%; missing data – four) reported to have

access to written information for service-users available in different languages.

However, approximately half of staff respondents (24, 51%) had required interpreter

services in the past.

Staff knowledge, skills and training

A majority of staff (28, 60%; missing data – 4) were aware of external services for

people from black and minority ethnic communities and half of these staff (14, 50%

of the 24 staff) members had referred service-users onto such services.

Just less than half of the staff respondents (23, 49%) stated that they had a

moderate-to-high level of knowledge of the Trust’s anti-discrimination policies. A

majority of staff (34, 73%) stated that they had some knowledge and skills but that

these were ‘not adequate’, indicating they lacked confidence in their knowledge and

skills. Only one-quarter of staff (12; 26%) stated that their knowledge and skills were

‘adequate’. Half of staff respondents (23, 49%; missing data – three) stated they had

attended ‘no training’ regarding ethnic and cultural issues.

Service-user perceptions of the service Impact of ethnicity on diagnosis and treatment

A majority of service-users (31; 80%; missing data – two) stated that they did not

think the treatment they received was different from other people because of their

ethnicity and/or gender. Furthermore, just over half of service-users (21, 51%) stated

that there would not have been any differences in their treatment and diagnosis if they

had been in contact with a member of staff who better understood their experiences as

a member of a particular ethnic group. Most service-users (29; 71%; missing data –

one) believed that staff understood their cultural needs, with 13 (32%) reporting that

these needs were understood ‘very well’, and 16 (40%) ‘fairly well’.

The cultural appropriateness of the service

A majority of service-users stated that they had appropriate places to worship if

required (29, 71%; missing data – five), and were happy with the levels of privacy

they received on the unit (34, 83%; missing data – three). Only half of service-users

(20, 49%; missing – eight) stated that culturally appropriate personal care products

were available.

The majority of service-users (29, 71%), did not express a preference for a

keyworker of the same ethnic background.

A majority of service-users (29, 71%; missing data – one) were unaware of local

services provided specifically for people from black and minority ethnic backgrounds,

and only six service-users could identify any local community services by name.

Communication

A majority of service-users (17, 41%) stated that they preferred to talk about mental

health issues in English, and a majority of service-users (33, 80%) reported to

understand ‘everything’ or ‘most’ of what the staff said to them.

Discussion

The majority of staff respondents (60%) believed that black and minority ethnic

groups were over-represented in the service compared with the local area. As a crude

method of exploring the representation of ethnic groups in the service compared to

local demographics, comparison with the 2001 census data (see Gardener &

Connolly, 2005) and the ethnicity data for the London Borough of Southwark (SLAM

NHS Trust, 2002b) suggests that a greater proportion of the patient respondents to this

audit were from African-Caribbean and mixed race backgrounds than reside in the

local community. This apparent over-representation of black and minority ethnic

groups in this service is consistent with previous research and audits in inpatient and

secure settings (BPS, 1998; Browne, 1995; Department of Health, 1999a; Southwark

Community Health Council, 1999). Staff attributed this over-representation to

misunderstandings of culture and ethnicity, and the ways in which people express

themselves, which is consistent with the published literature (Bhugra, 2002;

McGoldrick & Giordano, 1996).

Strikingly, a majority of service-users did not think the treatment they received

was affected by their ethnicity, or that their treatment would have been different if

they had contact with staff who better understood their experiences as a member of a

particular ethnic group. Indeed, the majority of service-users did not express a

preference to have an ethnically matched keyworker. This is interesting given that the

ethnic profile of staff respondents was somewhat more white-dominated than that of

the service-users (this finding is reflective of the diversity of Southwark NHS

employees more generally: SLAM NHS Trust, 2002a). Furthermore, a high

proportion of service-users (71%) believed that staff understood their cultural needs.

Thus, the majority of service-users did not report experiencing the differential

treatment that has been reported for black and minority ethnic groups in inpatient

mental health services (BPS, 1998; Mckenzie et al., 2001; Wang et al., 2000).

In terms of the cultural appropriateness of the service, the overall majority of

service-users commented that appropriate services were provided in terms of levels of

privacy, food and places to worship. The availability of culturally appropriate

personal care products was the only area that was highlighted as needing attention.

These findings prompt an

interesting question: are we as staff putting too much emphasis on services being

culturally sensitive when the service is successfully meeting the majority of the needs

of our service-users? Indeed, in a recent paper, Singh (2007) acknowledges the

importance of being culturally sensitive, but warns about the dangers of treating

patients as groups rather than individuals, observing that this is what racists

themselves do, and highlighting that cultural factors are only a part of a patient’s

formulation and care plan.

Despite a majority of service-users concluding that the service on the whole met

their cultural needs overall, the staff lacked confidence in their knowledge and skills

with regards to race and culture, and none of the staff believed they had received all

the training they required. It would also seem from the results that although

interpreters had been used, staff had not attended training on using interpreters. Of

note, published literature discusses the limitations of accurately assessing, diagnosing

and treating people with mental health problems without a detailed understanding of

their cultural background (Bell, Halligan, & Ellis, 2003; Leeser & O’Donohue, 1999;

Rhi, 2001). However, evidence of the effectiveness of training on service delivery is

still needed (Bhui, Warfa, Edonya, McKenzie, & Bhugra, 2007). Further, given that

this was not a problem for our service-users, perhaps staff can overestimate the level

of knowledge and skills that is required to provide a service that meets a variety of

cultural and ethnic needs. Of relevance, in a paper looking at lessons from public

inquiries on institutional racism, Singh (2007) makes reference to the limitations of

relying on training as a key recommendation in dealing with inequality of treatment in

the NHS.

In terms of information about services, the lack of information available in

different languages was highlighted in this audit, as has been the case in past service

evaluations (Fassil, 1996). The majority of staff did report knowledge of local service

provision for black and minority ethnic communities, despite the majority of service-

users being unaware of these services. The importance of forging links with

community groups outside of inpatient services for ‘effective change to be made

inside’ is highlighted by the National Institute for Mental Health in England (NIMHE,

2003: 63). However, no service-users mentioned this as being a limitation of the

service.

The study has a number of limitations. First, no record was made of the number of

staff or service-users who did not complete the questionnaires. Therefore, there may

be a response bias in favour of people who wished to express their views; especially

since two white female members of staff, who would not have matched most of the

service-users, conducted the interviews. Second, as service-users were interviewed by

a researcher, it is possible that they were more favourable in their responses than they

might have been if completing a questionnaire anonymously. This potential bias and

imbalance of power would have been better addressed if service-users had conducted

the interviews themselves; the authors recommend this to be considered in future

similar studies. Third, due to resource issues, the interview was completed by staff as

a self-administered questionnaire, which may have contributed to missing data.

Alternatively, this might indicate that staff were reluctant to be forthcoming about

themselves and their views. Fourth, in spite of the audit-evaluating aspects of culture

and ethnicity in the service, financial resources were not available to use an interpreter

to complete the service-user interviews. Thus, only service-users proficient in English

were able to participate which could have biased the findings. Fifth, the measure used

has no published reliability and validity data (McKenzie, 2002). The way questions

were worded could also have focused on highlighting areas of cultural insensitivity,

rather than encouraging expression of cultural sensitivity. Finally, we did not

breakdown responses by ethnicity and so it is hard to say which ethnic groups

responded in which direction.

Conclusions

The findings of the study reveal ethnic diversity within the service. With such

diversity comes a variety of needs, and services have a responsibility to meet these

needs. Interestingly, the audit appears to have found that service-users on the whole

are happy with the cultural appropriateness of the service they receive. The

assumption of a cultural sensitivity audit tool is that there are important cultural issues

and needs not being adequately addressed in health services. This study actually

suggests that this may not be the case: that most service-users in this service do not

receive differential treatment as a result of their ethnic background. This leads to an

interesting question: are we placing too much emphasis on cultural sensitivity, when

this is something that our service-users do not necessarily see as a problem? As Singh

argues

‘By focusing inappropriately on culture and ethnicity at the expense of sound clinical

judgement, we risk offering poorer rather than better care to patients from minority

ethnic groups’ (2007: p. 364).

Acknowledgements

The authors thank all the staff and participants from all the units involved. We would also like

to thank the reviewers of the paper for their helpful comments and suggestions on improving

it.

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