qualitative research in psychology impact factor

Qualitative Research in Psychology - Impact Score, Ranking, SJR, h-index, Citescore, Rating, Publisher, ISSN, and Other Important Details

Published By: Taylor and Francis Ltd.

Abbreviation: Qual. Res. Psychol.

Impact Score The impact Score or journal impact score (JIS) is equivalent to Impact Factor. The impact factor (IF) or journal impact factor (JIF) of an academic journal is a scientometric index calculated by Clarivate that reflects the yearly mean number of citations of articles published in the last two years in a given journal, as indexed by Clarivate's Web of Science. On the other hand, Impact Score is based on Scopus data.

Important details, about qualitative research in psychology.

Qualitative Research in Psychology is a journal published by Taylor and Francis Ltd. . This journal covers the area[s] related to Psychology (miscellaneous), etc . The coverage history of this journal is as follows: 2004-2022. The rank of this journal is 794 . This journal's impact score, h-index, and SJR are 14.29, 48, and 2.631, respectively. The ISSN of this journal is/are as follows: 14780895, 14780887 . The best quartile of Qualitative Research in Psychology is Q1 . This journal has received a total of 1100 citations during the last three years (Preceding 2022).

Qualitative Research in Psychology Impact Score 2022-2023

The impact score (IS), also denoted as the Journal impact score (JIS), of an academic journal is a measure of the yearly average number of citations to recent articles published in that journal. It is based on Scopus data.

Prediction of Qualitative Research in Psychology Impact Score 2023

Impact Score 2022 of Qualitative Research in Psychology is 14.29 . If a similar upward trend continues, IS may increase in 2023 as well.

Impact Score Graph

Check below the impact score trends of qualitative research in psychology. this is based on scopus data., qualitative research in psychology h-index.

The h-index of Qualitative Research in Psychology is 48 . By definition of the h-index, this journal has at least 48 published articles with more than 48 citations.

What is h-index?

The h-index (also known as the Hirsch index or Hirsh index) is a scientometric parameter used to evaluate the scientific impact of the publications and journals. It is defined as the maximum value of h such that the given Journal has published at least h papers and each has at least h citations.

Qualitative Research in Psychology ISSN

The International Standard Serial Number (ISSN) of Qualitative Research in Psychology is/are as follows: 14780895, 14780887 .

The ISSN is a unique 8-digit identifier for a specific publication like Magazine or Journal. The ISSN is used in the postal system and in the publishing world to identify the articles that are published in journals, magazines, newsletters, etc. This is the number assigned to your article by the publisher, and it is the one you will use to reference your article within the library catalogues.

ISSN code (also called as "ISSN structure" or "ISSN syntax") can be expressed as follows: NNNN-NNNC Here, N is in the set {0,1,2,3...,9}, a digit character, and C is in {0,1,2,3,...,9,X}

Qualitative Research in Psychology Ranking and SCImago Journal Rank (SJR)

SCImago Journal Rank is an indicator, which measures the scientific influence of journals. It considers the number of citations received by a journal and the importance of the journals from where these citations come.

Qualitative Research in Psychology Publisher

The publisher of Qualitative Research in Psychology is Taylor and Francis Ltd. . The publishing house of this journal is located in the United Kingdom . Its coverage history is as follows: 2004-2022 .

Call For Papers (CFPs)

Please check the official website of this journal to find out the complete details and Call For Papers (CFPs).

Abbreviation

The International Organization for Standardization 4 (ISO 4) abbreviation of Qualitative Research in Psychology is Qual. Res. Psychol. . ISO 4 is an international standard which defines a uniform and consistent system for the abbreviation of serial publication titles, which are published regularly. The primary use of ISO 4 is to abbreviate or shorten the names of scientific journals using the technique of List of Title Word Abbreviations (LTWA).

As ISO 4 is an international standard, the abbreviation ('Qual. Res. Psychol.') can be used for citing, indexing, abstraction, and referencing purposes.

How to publish in Qualitative Research in Psychology

If your area of research or discipline is related to Psychology (miscellaneous), etc. , please check the journal's official website to understand the complete publication process.

Acceptance Rate

• Interest/demand of researchers/scientists for publishing in a specific journal/conference.
• The complexity of the peer review process and timeline.
• Time taken from draft submission to final publication.
• Number of submissions received and acceptance slots
• And Many More.

The simplest way to find out the acceptance rate or rejection rate of a Journal/Conference is to check with the journal's/conference's editorial team through emails or through the official website.

Frequently Asked Questions (FAQ)

What is the impact score of qualitative research in psychology.

The latest impact score of Qualitative Research in Psychology is 14.29. It is computed in the year 2023.

What is the h-index of Qualitative Research in Psychology?

The latest h-index of Qualitative Research in Psychology is 48. It is evaluated in the year 2023.

What is the SCImago Journal Rank (SJR) of Qualitative Research in Psychology?

The latest SCImago Journal Rank (SJR) of Qualitative Research in Psychology is 2.631. It is calculated in the year 2023.

What is the ranking of Qualitative Research in Psychology?

The latest ranking of Qualitative Research in Psychology is 794. This ranking is among 27955 Journals, Conferences, and Book Series. It is computed in the year 2023.

Who is the publisher of Qualitative Research in Psychology?

Qualitative Research in Psychology is published by Taylor and Francis Ltd.. The publication country of this journal is United Kingdom.

What is the abbreviation of Qualitative Research in Psychology?

This standard abbreviation of Qualitative Research in Psychology is Qual. Res. Psychol..

Is "Qualitative Research in Psychology" a Journal, Conference or Book Series?

Qualitative Research in Psychology is a journal published by Taylor and Francis Ltd..

What is the scope of Qualitative Research in Psychology?

• Psychology (miscellaneous)

For detailed scope of Qualitative Research in Psychology, check the official website of this journal.

What is the ISSN of Qualitative Research in Psychology?

The International Standard Serial Number (ISSN) of Qualitative Research in Psychology is/are as follows: 14780895, 14780887.

What is the best quartile for Qualitative Research in Psychology?

The best quartile for Qualitative Research in Psychology is Q1.

What is the coverage history of Qualitative Research in Psychology?

The coverage history of Qualitative Research in Psychology is as follows 2004-2022.

Credits and Sources

• Scimago Journal & Country Rank (SJR), https://www.scimagojr.com/
• Journal Impact Factor, https://clarivate.com/
• Issn.org, https://www.issn.org/
• Scopus, https://www.scopus.com/

Note: The impact score shown here is equivalent to the average number of times documents published in a journal/conference in the past two years have been cited in the current year (i.e., Cites / Doc. (2 years)). It is based on Scopus data and can be a little higher or different compared to the impact factor (IF) produced by Journal Citation Report. Please refer to the Web of Science data source to check the exact journal impact factor ™ (Thomson Reuters) metric.

Impact Score, SJR, h-Index, and Other Important metrics of These Journals, Conferences, and Book Series

Check complete list

Qualitative Research in Psychology Impact Score (IS) Trend

Top journals/conferences in psychology (miscellaneous).

Qualitative Psychology

Subject Area and Category

• Psychology (miscellaneous)

American Psychological Association

Publication type

23263598, 23263601

Information

How to publish in this journal

The set of journals have been ranked according to their SJR and divided into four equal groups, four quartiles. Q1 (green) comprises the quarter of the journals with the highest values, Q2 (yellow) the second highest values, Q3 (orange) the third highest values and Q4 (red) the lowest values.

The SJR is a size-independent prestige indicator that ranks journals by their 'average prestige per article'. It is based on the idea that 'all citations are not created equal'. SJR is a measure of scientific influence of journals that accounts for both the number of citations received by a journal and the importance or prestige of the journals where such citations come from It measures the scientific influence of the average article in a journal, it expresses how central to the global scientific discussion an average article of the journal is.

Evolution of the number of published documents. All types of documents are considered, including citable and non citable documents.

This indicator counts the number of citations received by documents from a journal and divides them by the total number of documents published in that journal. The chart shows the evolution of the average number of times documents published in a journal in the past two, three and four years have been cited in the current year. The two years line is equivalent to journal impact factor ™ (Thomson Reuters) metric.

Evolution of the total number of citations and journal's self-citations received by a journal's published documents during the three previous years. Journal Self-citation is defined as the number of citation from a journal citing article to articles published by the same journal.

Evolution of the number of total citation per document and external citation per document (i.e. journal self-citations removed) received by a journal's published documents during the three previous years. External citations are calculated by subtracting the number of self-citations from the total number of citations received by the journal’s documents.

International Collaboration accounts for the articles that have been produced by researchers from several countries. The chart shows the ratio of a journal's documents signed by researchers from more than one country; that is including more than one country address.

Not every article in a journal is considered primary research and therefore "citable", this chart shows the ratio of a journal's articles including substantial research (research articles, conference papers and reviews) in three year windows vs. those documents other than research articles, reviews and conference papers.

Ratio of a journal's items, grouped in three years windows, that have been cited at least once vs. those not cited during the following year.

Evolution of the percentage of female authors.

Evolution of the number of documents cited by public policy documents according to Overton database.

Evoution of the number of documents related to Sustainable Development Goals defined by United Nations. Available from 2018 onwards.

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Qualitative Research in Psychology Impact Factor & Key Scientometrics

Qualitative research in psychology overview, impact factor.

I. Basic Journal Info

Journal ISSN: 14780887, 14780895

Publisher: taylor & francis, history: 2004-ongoing, journal hompage: link, how to get published:, research categories, scope/description:.

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II. Science Citation Report (SCR)

Qualitative research in psychology scr impact factor, qualitative research in psychology scr journal ranking, qualitative research in psychology scimago sjr rank.

SCImago Journal Rank (SJR indicator) is a measure of scientific influence of scholarly journals that accounts for both the number of citations received by a journal and the importance or prestige of the journals where such citations come from.

Qualitative Research in Psychology Scopus 2-Year Impact Factor Trend

Qualitative research in psychology scopus 3-year impact factor trend, qualitative research in psychology scopus 4-year impact factor trend, qualitative research in psychology impact factor history.

• 2022 Impact Factor 14.288 10.784 8.326
• 2021 Impact Factor 3.138 2.805 3.25
• 2020 Impact Factor 1.287 1.407 1.764
• 2019 Impact Factor 1.966 1.79 2.407
• 2018 Impact Factor 1.902 2.459 3.152
• 2017 Impact Factor 2.02 2.434 2.125
• 2016 Impact Factor 1.891 1.765 1.741
• 2015 Impact Factor 1.396 1.175 1.416
• 2014 Impact Factor 0.5 NA NA
• 2013 Impact Factor 0.587 NA NA
• 2012 Impact Factor 0.932 NA NA
• 2011 Impact Factor 0.651 NA NA
• 2010 Impact Factor 0.6 NA NA
• 2009 Impact Factor 0.538 NA NA
• 2008 Impact Factor 3.053 NA NA
• 2007 Impact Factor 1.543 NA NA
• 2006 Impact Factor 1.758 NA NA
• 2005 Impact Factor 0.889 NA NA
• 2004 Impact Factor 0 NA NA
• 2003 Impact Factor NA NA NA
• 2002 Impact Factor NA NA NA
• 2001 Impact Factor NA NA NA
• 2000 Impact Factor NA NA NA

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Impact factor (IF) is a scientometric factor based on the yearly average number of citations on articles published by a particular journal in the last two years. A journal impact factor is frequently used as a proxy for the relative importance of a journal within its field. Find out more: What is a good impact factor?

III. Other Science Influence Indicators

Any impact factor or scientometric indicator alone will not give you the full picture of a science journal. There are also other factors such as H-Index, Self-Citation Ratio, SJR, SNIP, etc. Researchers may also consider the practical aspect of a journal such as publication fees, acceptance rate, review speed. ( Learn More )

Qualitative Research in Psychology H-Index

The h-index is an author-level metric that attempts to measure both the productivity and citation impact of the publications of a scientist or scholar. The index is based on the set of the scientist's most cited papers and the number of citations that they have received in other publications

Qualitative Research in Psychology H-Index History

scijournal.org is a platform dedicated to making the search and use of impact factors of science journals easier.

Scientometrics

Citing bodies, qualitative research in psychology.

• SpringerLink shop

Journal Metrics Reports 2022

Announcement of the latest impact factors from the journal citation reports.

Researchers consider a number of factors in deciding where to publish their research, such as journal reputation, readership and community, speed of publication, and citations. See how we share a whole range of information to help the research community decide which journal is the best home for their research as well as what the metrics can tell you about the performance of a journal and its articles.

Explore journal impact metrics

International Journal for the Advancement of Counselling

Impact Factor 1.5 (2022)

5 Year Impact Factor 1.7 (2022)

Cite Score 2.3 (2022)

H5 Index 20 (2021)

Social Media Mentions 120 (2022)

Downloads 175,018 (2022)

American Journal of Dance Therapy

Impact Factor 0.8 (2022)

5 Year Impact Factor 1.2 (2022)

Cite Score 2.2 (2022)

H5 Index 16 (2021)

Social Media Mentions 46 (2022)

Downloads 77,409 (2022)

Contemporary Family Therapy

Impact Factor 1.3 (2022)

5 Year Impact Factor 1.4 (2022)

Cite Score 2.4 (2022)

H5 Index 21 (2021)

Social Media Mentions 134 (2022)

Downloads 199,304 (2022)

Pastoral Psychology

5 Year Impact Factor 0.9 (2022)

Cite Score 1.6 (2022)

H5 Index 19 (2021)

Social Media Mentions 512 (2022)

Downloads 148,009 (2022)

Journal of Police and Criminal Psychology

Impact Factor 1.6 (2022)

5 Year Impact Factor 1.8 (2022)

Cite Score 3.0 (2022)

H5 Index 28 (2021)

Social Media Mentions 600 (2022)

Downloads 261,951 (2022)

Acta Analytica

Impact Factor 0.4 (2022)

5 Year Impact Factor 0.4 (2022)

Cite Score 1.0 (2022)

H5 Index 11 (2021)

Social Media Mentions 218 (2022)

Downloads 75,578 (2022)

Psychological Injury and Law

Impact Factor 3.1 (2022)

5 Year Impact Factor 2.6 (2022)

Cite Score 4.7 (2022)

Social Media Mentions 165 (2022)

Downloads 98,044 (2022)

Psychological Studies

H5 Index 15 (2021)

Social Media Mentions 195 (2022)

Downloads 145,050 (2022)

The Analysis of Verbal Behavior

Impact Factor 0.5 (2022)

5 Year Impact Factor 0.8 (2022)

Social Media Mentions 129 (2022)

Downloads 34,182 (2022)

Behavior Analysis in Practice

Impact Factor 2.2 (2022)

5 Year Impact Factor 2.2 (2022)

H5 Index 29 (2021)

Social Media Mentions 2,451 (2022)

Downloads 377,745 (2022)

Journal of Child & Adolescent Trauma

Cite Score 2.7 (2022)

H5 Index 25 (2021)

Social Media Mentions 1,088 (2022)

Downloads 212,550 (2022)

Evolutionary Psychological Science

Cite Score 3.2 (2022)

Social Media Mentions 11,144 (2022)

Downloads 182,996 (2022)

Journal of Cognitive Enhancement

5 Year Impact Factor 2.5 (2022)

Social Media Mentions 646 (2022)

Downloads 135,963 (2022)

Occupational Health Science

5 Year Impact Factor 3.1 (2022)

H5 Index 13 (2021)

Social Media Mentions 188 (2022)

Downloads 70,029 (2022)

Journal of Cultural Cognitive Science

Impact Factor 1.8 (2022)

5 Year Impact Factor 1.5 (2022)

Cite Score 2.9 (2022)

Social Media Mentions 87 (2022)

Downloads 43,868 (2022)

Human Arenas

5 Year Impact Factor 1.0 (2022)

Cite Score 1.9 (2022)

H5 Index 12 (2021)

Social Media Mentions 237 (2022)

Downloads 133,520 (2022)

Behavior and Social Issues

5 Year Impact Factor 1.6 (2022)

Social Media Mentions 182 (2022)

Downloads 91,341 (2022)

Memory & Cognition

Impact Factor 2.4 (2022)

Cite Score 4.2 (2022)

H5 Index 33 (2021)

Social Media Mentions 3,076 (2022)

Downloads 1,120,963 (2022)

Journal of Child and Family Studies

Impact Factor 2.1 (2022)

5 Year Impact Factor 2.8 (2022)

Cite Score 4.1 (2022)

H5 Index 55 (2021)

Social Media Mentions 2,458 (2022)

Downloads 1,185,756 (2022)

Mindfulness

Impact Factor 3.6 (2022)

5 Year Impact Factor 4.7 (2022)

Cite Score 6.2 (2022)

H5 Index 64 (2021)

Social Media Mentions 4,077 (2022)

Downloads 1,284,632 (2022)

Attention, Perception, & Psychophysics

Impact Factor 1.7 (2022)

5 Year Impact Factor 2.0 (2022)

Cite Score 3.6 (2022)

H5 Index 39 (2021)

Downloads 1,334,241 (2022)

Journal of Youth and Adolescence

Impact Factor 4.9 (2022)

5 Year Impact Factor 5.7 (2022)

Cite Score 7.6 (2022)

H5 Index 68 (2021)

Social Media Mentions 6,499 (2022)

Downloads 1,363,488 (2022)

Impact Factor 3.8 (2022)

5 Year Impact Factor 4.6 (2022)

Cite Score 6.8 (2022)

H5 Index 59 (2021)

Social Media Mentions 17,441 (2022)

Downloads 1,441,825 (2022)

Archives of Sexual Behavior

5 Year Impact Factor 4.2 (2022)

Cite Score 5.3 (2022)

H5 Index 60 (2021)

Social Media Mentions 92,938 (2022)

Downloads 1,976,021 (2022)

Psychonomic Bulletin & Review

Impact Factor 3.5 (2022)

H5 Index 67 (2021)

Social Media Mentions 15,265 (2022)

Downloads 1,989,707 (2022)

Perspectives on Behavior Science

Impact Factor 2.0 (2022)

Cite Score 4.6 (2022)

H5 Index 23 (2021)

Social Media Mentions 832 (2022)

Downloads 120,722 (2022)

Social Justice Research

Impact Factor 2.3 (2022)

Cite Score 2.6 (2022)

H5 Index 17 (2021)

Social Media Mentions 811 (2022)

Downloads 137,009 (2022)

Journal of Behavioral Education

H5 Index 22 (2021)

Social Media Mentions 298 (2022)

Downloads 137,571 (2022)

Sexuality and Disability

Cite Score 2.5 (2022)

Social Media Mentions 314 (2022)

Downloads 145,500 (2022)

Journal of Adult Development

5 Year Impact Factor 2.3 (2022)

Cite Score 3.4 (2022)

Social Media Mentions 176 (2022)

Downloads 153,462 (2022)

Integrative Psychological and Behavioral Science

Impact Factor 1.2 (2022)

5 Year Impact Factor 1.1 (2022)

Social Media Mentions 877 (2022)

Downloads 173,047 (2022)

Journal of Rational-Emotive & Cognitive-Behavior Therapy

Cite Score 2.8 (2022)

Social Media Mentions 355 (2022)

Downloads 174,666 (2022)

Journal of Nonverbal Behavior

5 Year Impact Factor 2.9 (2022)

Cite Score 5.6 (2022)

Social Media Mentions 1,265 (2022)

Downloads 179,534 (2022)

Applied Psychophysiology and Biofeedback

Impact Factor 3.0 (2022)

Cite Score 5.2 (2022)

Social Media Mentions 4,510 (2022)

Downloads 191,715 (2022)

Journal of Psycholinguistic Research

Cite Score 3.3 (2022)

Social Media Mentions 374 (2022)

Downloads 196,158 (2022)

Journal of Developmental and Physical Disabilities

5 Year Impact Factor 1.9 (2022)

H5 Index 24 (2021)

Social Media Mentions 189 (2022)

Downloads 196,180 (2022)

Behavior Research Methods

Impact Factor 5.4 (2022)

5 Year Impact Factor 7.7 (2022)

Cite Score 11.2 (2022)

H5 Index 73 (2021)

Social Media Mentions 10,561 (2022)

Downloads 2,435,131 (2022)

Behavior Genetics

Impact Factor 2.6 (2022)

Social Media Mentions 6,500 (2022)

Downloads 230,801 (2022)

Child & Youth Care Forum

5 Year Impact Factor 2.1 (2022)

Social Media Mentions 751 (2022)

Downloads 252,650 (2022)

Psychometrika

5 Year Impact Factor 3.3 (2022)

H5 Index 27 (2021)

Social Media Mentions 928 (2022)

Downloads 263,953 (2022)

Education and Treatment of Children

Impact Factor 1.0 (2022)

Cite Score 1.5 (2022)

Downloads 29,079 (2022)

Journal of Autism and Developmental Disorders

Impact Factor 3.9 (2022)

5 Year Impact Factor 4.5 (2022)

Cite Score 7.2 (2022)

H5 Index 82 (2021)

Social Media Mentions 35,135 (2022)

Downloads 3,699,758 (2022)

Learning & Behavior

Social Media Mentions 1,956 (2022)

Downloads 301,098 (2022)

Journal of Psychopathology and Behavioral Assessment

H5 Index 31 (2021)

Social Media Mentions 489 (2022)

Downloads 308,378 (2022)

Child and Adolescent Social Work Journal

Social Media Mentions 643 (2022)

Downloads 314,881 (2022)

School Mental Health

5 Year Impact Factor 3.2 (2022)

H5 Index 30 (2021)

Social Media Mentions 931 (2022)

Downloads 315,166 (2022)

Journal of Occupational Rehabilitation

Impact Factor 3.3 (2022)

Cite Score 5.4 (2022)

Social Media Mentions 1,675 (2022)

Downloads 367,159 (2022)

Review Journal of Autism and Developmental Disorders

5 Year Impact Factor 3.6 (2022)

Cite Score 6.7 (2022)

Social Media Mentions 2,075 (2022)

Downloads 390,758 (2022)

Sexuality Research and Social Policy

5 Year Impact Factor 3.0 (2022)

Cite Score 3.7 (2022)

Social Media Mentions 6,457 (2022)

Downloads 393,715 (2022)

Clinical Social Work Journal

Impact Factor 2.8 (2022)

Social Media Mentions 937 (2022)

Downloads 394,152 (2022)

Psicologia: Reflexão e Crítica

Impact Factor 1.4 (2022)

H5 Index 18 (2021)

Social Media Mentions 221 (2022)

Downloads 397,497 (2022)

Motivation and Emotion

Impact Factor 4.8 (2022)

5 Year Impact Factor 4.1 (2022)

Cite Score 4.9 (2022)

H5 Index 34 (2021)

Social Media Mentions 2,980 (2022)

Downloads 446,592 (2022)

Clinical Child and Family Psychology Review

Impact Factor 6.9 (2022)

5 Year Impact Factor 8.0 (2022)

Cite Score 10.1 (2022)

H5 Index 38 (2021)

Social Media Mentions 1,746 (2022)

Downloads 492,425 (2022)

Psychological Research

5 Year Impact Factor 2.4 (2022)

Cite Score 5.0 (2022)

H5 Index 35 (2021)

Social Media Mentions 2,529 (2022)

Downloads 512,168 (2022)

Cognitive Therapy and Research

H5 Index 37 (2021)

Social Media Mentions 1,870 (2022)

Downloads 524,567 (2022)

Child Psychiatry & Human Development

Impact Factor 2.9 (2022)

Social Media Mentions 2,189 (2022)

Downloads 580,707 (2022)

Journal of Business and Psychology

5 Year Impact Factor 7.1 (2022)

Cite Score 10.3 (2022)

H5 Index 47 (2021)

Social Media Mentions 2,067 (2022)

Downloads 591,991 (2022)

Cognitive, Affective, & Behavioral Neuroscience

Downloads 632,689 (2022)

Research on Child and Adolescent Psychopathology

5 Year Impact Factor 4.3 (2022)

H5 Index 50 (2021)

Social Media Mentions 4,955 (2022)

Downloads 726,131 (2022)

Cognitive Research: Principles and Implications

Impact Factor 4.1 (2022)

Social Media Mentions 5,793 (2022)

Downloads 890,208 (2022)

The Psychological Record

5 Year Impact Factor 1.3 (2022)

Downloads 91,850 (2022)

International Journal of Cognitive Therapy

Cite Score 3.1 (2022)

Social Media Mentions 419 (2022)

Downloads 99,607 (2022)

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• Systematic Review
• Open access
• Published: 30 May 2024

The effectiveness of interventions for offending behaviours in adults with autism spectrum disorders (ASD): a systematic PRISMA review

• Jody Salter 1 , 2 &
• Sarah Blainey 1 , 3  

BMC Psychology volume  12 , Article number:  316 ( 2024 ) Cite this article

134 Accesses

1 Altmetric

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Previous research has suggested that the core features of autism spectrum disorders (ASD) may contribute to offending behaviours and increased vulnerability within the Criminal Justice System. To date, there is a paucity of evidence assessing the effectiveness of interventions for offending behaviour in adults with ASD but without co-occurring intellectual disability (ID) across a broad range of forensic settings. The lack of robust evidence is concerning, as limited effectiveness may contribute to an increased likelihood of prolonged incarceration, particularly in the most restrictive settings. A PRISMA systematic review was conducted with a narrative synthesis to: (a) evaluate the evidence of the effectiveness of interventions aimed at reducing recidivism, (b) assess whether the core features of ASD impact the effectiveness of these interventions, and (c) identify additional factors that may affect the effectiveness of interventions within this population. Seven studies involving ten male participants were identified. The findings suggest that interventions for offending behaviours in adults with ASD without intellectual disability (ID) are largely inadequate, and that core ASD features need to be considered. Additionally, a complex interplay of risk factors potentially impacting intervention effectiveness was suggested. Limitations include heterogeneity across intervention types, measures of effectiveness, and what constitutes effectiveness. Despite the limited number of studies and data quality, the review aligns with a growing body of literature highlighting vulnerability and a need for evidence-based interventions for people with ASD. The review also discusses the broader implications of ineffective interventions.

Peer Review reports

Introduction

Autism spectrum disorders (ASD) represent a group of complex and highly heterogeneous neurodevelopmental disorders. A diagnosis of ASD is based on the presence of two core features: impairments in social communication and interaction (SCI), and restrictive and repetitive behaviours (RRBs) [ 1 ].

Phenotypic manifestations of the core features often present with varying degrees of social disengagement, difficulties in establishing and sustaining relationships, social naivety, lack of eye contact, and difficulties in interpreting facial expressions [ 2 ]. RRBs manifest as intense and highly restrictive special interests, a strong inclination for environmental consistency [ 3 ], cognitive rigidity, and hyper-or hypo sensory responses to the environment [ 4 ].

Additional factors modulate and influence these core features, including the extent of sensory and motor impairments, language and cognitive abilities, adaptive functioning, gender and the presence of co-occurring psychiatric disorders [ 5 , 6 , 7 ]. The increasing recognition of ASD has resulted in significantly higher diagnosis rates across all age groups [ 8 ], which are currently estimated to be 1 in 57 in England [ 9 ]. Consequently, this increase in diagnoses has led to a greater representation of individuals with ASD within the criminal justice system (CJS).

ASD in the criminal justice system

An increasing body of research has highlighted the significant vulnerability experienced by individuals with ASD while navigating the CJS. This vulnerability becomes evident throughout multiple stages of the criminal justice process, ranging from initial encounters with police [ 10 ] through to police interviews [ 11 ], to court room proceedings [ 12 ] and prison services [ 13 ]. This heightened vulnerability is exacerbated by the reported general lack of understanding of ASD within the CJS, among both professionals and the general public [ 13 , 14 , 15 , 16 ].

Individuals with ASD and co-occurring intellectual disability (ID) are often identified and diverted from the criminal justice system (CJS). This is due to a recognition of their reduced culpability, a result of impairments in both intellectual and adaptive functioning [ 15 ]. In contrast, individuals with ASD but without co-occurring ID, the population on which this review focuses, exhibit significant deficits in adaptive functioning despite their intellectual capabilities. This difference is often referred to as the IQ functioning gap and is unique to individuals with ASD [ 17 ]. Despite impairments in adaptive functioning, this population is considered intellectually capable. Therefore, they are generally perceived as culpable and sufficiently competent to navigate the complexities of the CJS and receive a fair trial. This contrast raises further questions concerning culpability ranging from criminal responsibility to the appropriateness of sentencing.

Following conviction, when an offence has met the custody threshold, offenders with ASD are typically diverted to the community or prison. Alternatively, if detained under the Mental Health Act 1983 (the legislative framework governing mental healthcare and treatment in England and Wales), they may be detained in a secure hospital environment (classified as low, medium, or high security).

Estimating the prevalence of ASD within the UK prison population is difficult because of a lack of routine assessment; nonetheless, ASD is estimated to range between 1% and 4.4% [ 5 ]. Research has shown a disproportionately high prevalence of ASD in secure hospital settings (6.5%), exceeding the estimate for the general population [ 18 ].

Qualitative studies examining the experiences of prisoners with ASD without co-occurring ID have highlighted their increased vulnerability to bullying, exploitation, and social anxiety in prison [ 13 ]. In addition, research aimed at evaluating the prevalence of the broader autistic phenotype among a prison population, as well as comparing their mental health characteristics to those without, revealed a significant risk of self-harm and suicide in individuals presenting with autistic traits. Within this cohort, of the 240 prisoners assessed, 46 displayed significant autistic traits, with 12 meeting the diagnostic criteria for ASD. Notably, only two of these individuals had been previously recognised by the prison as having ASD. This finding highlights the under recognition of ASD and emphasises the heightened vulnerability of this population to a range of mental health risks within the prison environment [ 5 ].

Although it may be logical to assume that a secure hospital setting may better meet the treatment needs of people with ASD than a prison setting, current evidence suggests otherwise. Concerns have been raised, including the high likelihood of long-term seclusion in people with ASD compared to those without ASD [ 19 ] and significantly longer than average stays within secure hospital settings [ 20 ].

Despite several initiatives aimed at improving the recognition of ASD within the prison population [ 21 ], a recent UK government report on ‘neurodiversity’ [ 22 ], a term encompassing various conditions that fall into the broader category of neurodevelopmental disorders (NDDs) including ASD, highlighted three notable areas of concern. These included a greater likelihood of neurodivergent individuals being held on remand, inappropriately pleading guilty, and judges often failing to recognise a defendant’s neurodivergence as a mitigating factor when sentencing. These findings demonstrate that much work is needed to address the challenges faced by individuals with ASD and neurodivergent conditions in the CJS.

ASD and risk of offending

While there is insufficient evidence to suggest that individuals with ASD are at greater risk of engaging in offending behaviours [ 23 ], it has been suggested that the core features of ASD may contribute to the risk of offending behaviours [ 24 , 25 ]. Risk factors for offending behaviour in the general population are associated with the cumulative influence of various factors, including alcohol and drug abuse, low socioeconomic status, mental disorders, adversity, child abuse, and traumatic brain injury [ 26 , 27 , 28 ]. Less is known about the risk factors for offending behaviour within the ASD population, with the exception of co-occurring psychiatric disorders, such as personality disorders and psychosis [ 5 ].

Research suggests that individuals diagnosed with ASD early in life face barriers to services throughout their lifespan, resulting in unmet education, health, and therapeutic needs [ 29 , 30 ]. Research suggests that certain demographic groups, such as women [ 31 , 32 ], individuals from ethnic minorities, and those from lower socioeconomic backgrounds [ 9 , 33 ], are far more likely to be underdiagnosed. This in turn increases the risk of unmet needs [ 34 , 35 ]. These factors may contribute as variables that collectively increase the overall cumulative risk of engaging in offending behaviours.

Forensic interventions

Interventions for offending behaviour often use cognitive-behavioural techniques to reduce recidivism, with an emphasis on perspective-taking, self-and relationship management, and problem solving. In the United Kingdom, the Ministry of Justice requires a sufficient evidence base for the accreditation of forensic interventions. This accreditation aims to promote high-quality programs in prisons and community settings to reduce recidivism [ 36 ].

Cognitive behavioural therapy (CBT) is widely recognised as one of the most effective interventions for offending behaviours [ 37 ]. There is evidence that CBT reduces recidivism by 20–30% in the general offending population [ 38 , 39 ]. However, there is little evidence to support the effectiveness of such interventions for offending behaviour in forensic secure settings, often yielding inconsistent findings [ 40 ].

Beyond forensic settings, evidence suggests that adapted CBT is effective for individuals with ASD [ 41 , 42 ]. These adjustments are necessary due to the core features of ASD and challenges in areas such as perspective taking and cognitive rigidity, both of which are conducive to successful therapeutic outcomes in this population [ 43 ]. Additionally, evidence supports the use of social skills training [ 44 ] and group-based social skills interventions in adults with ASD [ 41 ] However, there is no consensus regarding the specific adaptations most beneficial for individuals with ASD.

Furthermore, the lack of appropriate outcome measures has been reported to be a barrier to determining the effectiveness of interventions within secure forensic hospital settings [ 45 , 46 , 47 ]. Despite the evidence for CBT use within the general offender population and for individuals with ASD outside forensic settings, there are reports that the implementation of these interventions is not effective for individuals detained within secure hospital settings [ 19 , 48 , 49 ].

The increasing recognition of the vulnerability of individuals with ASD within the CJS highlights the urgent need for a systematic evaluation of the effectiveness of interventions for offending behaviours in adults with ASD. While previous research has examined interventions for individuals with ASD and co-occurring ID [ 49 ], a significant research gap remains regarding the effectiveness of forensic interventions for individuals with ASD but without co-occurring ID [ 14 ].

This systematic review aims to address this gap by conducting a comprehensive evaluation of intervention effectiveness in an ASD population without co-occurring ID.

Research aims

This systematic review is guided by the following research objectives:

To systematically review and evaluate the effectiveness of interventions for offending behaviours in adults with ASD without co-occurring ID, as reported in the literature;

To ascertain whether the core features of ASD impact the effectiveness of the identified interventions; and.

To identify additional risk factors that may impact the effectiveness of interventions in this population.

Inclusion criteria

Each potentially eligible study was screened based on the inclusion and exclusion criteria described in the PICO framework below [ 50 ].

Population.

Participants included adults aged 18 years and older diagnosed with ASD, as defined by the authors in the literature. Studies involving participants with co-occurring ASD and ID and those that did not differentiate between these two populations were excluded.

Intervention & Outcomes.

Our review aimed to identify studies that objectively and/or subjectively measured the effectiveness of therapeutic or pharmacological interventions for reducing recidivism in individuals with ASD exhibiting offending behaviours. These included interventions delivered in all categories, namely, prisons, probation supervision, and secure hospitals.

Study Design and Comparison.

All primary research studies were included, regardless of publication date or country of origin. Studies that were peer-reviewed (e.g., grey literature and conference abstracts), systematic reviews, and those not published in English were excluded. An inclusion-exclusion criterion related to the type of comparison conducted in individual studies was not imposed.

Search strategy

The search was conducted on the 27th of March 2021 across five databases, covering a broad timeframe and utilising international terminology. The databases included:

Embase (1974 to 2021).

Ovid MEDLINE(R) and Epub ahead of print, In-process, In data-review and other Non-Indexed Citations.

Ovid MEDLINE(R) Daily.

Global Health (1973 to March 2021).

APA PsychInfo (1806 to February 2021).

Furthermore, a web-based search using Google Scholar was conducted with the same search terms. The first 15 pages of results were manually reviewed; however, no additional studies meeting the inclusion criteria were found. Additionally, the reference lists and citations of relevant reviews were manually checked, but this did not yield any further eligible studies.

Data selection and extraction

The data selection and extraction processes consisted of two stages:

During Stage 1, potential eligible studies were screened based on their titles and abstracts against the predefined inclusion and exclusion criteria. Owing to the limited number of results, the screening process was performed manually and repeated one week later to increase accuracy.

Stage 2 involved a comprehensive review of the full texts of the selected studies to confirm their alignment with the inclusion criteria. Relevant data were extracted and organised into spreadsheets using Microsoft Excel.

PRISMA flow diagram of searches of databases and registers only

Consistent with the primary aim of this systematic review, the first outcome measure is the effectiveness of the identified forensic interventions, measured by a reduction in recidivism. While reducing recidivism is the principal goal of forensic interventions, it is often viewed as a proxy measure that may not fully capture the complexity of offending behaviours, particularly in cases of crossover crime [ 46 , 51 ]. To address this limitation, additional relevant measures contributing to reduced recidivism were collected to allow for a preliminary assessment of intervention effectiveness. These additional measures included variables such as a reduction in security levels within institutional settings (i.e., medium to low security) or significant positive changes compared to baseline measurements recorded before and after the intervention.

The second aim of this review was to examine whether the core features of ASD present barriers to the rehabilitation process. To achieve this objective, data concerning the interactions between impairments in social communication and interaction (SCI) and restrictive and repetitive behaviours (RRBs) in relation to interventions within individual studies, as described by clinicians were collected and analysed.

Thirdly, this review aimed to identify additional risk factors described within findings that may influence the effectiveness of the interventions. The aim of the analysis is to provide a more comprehensive understanding of collective risk factors and their interactions with intervention effectiveness assessed through narrative synthesis. In addition, the data collected included the study design, author, and country of origin. When reported, participant demographics, such as age, gender, offence, ethnicity, and socioeconomic status, were reported. The intervention data included the type of intervention used, setting, duration, and frequency, only when available.

Study risk of bias assessment

The Mixed Methods Appraisal Tool (MMAT) [ 52 ] is a comprehensive tool for critically evaluating various research methods. The methodological quality of each study and the potential risk of bias were assessed using the MMAT. The results of this assessment are presented in tabular form (Table  2 , ‘MMAT Quality Appraisal’, appendix).

Synthesis method

A narrative synthesis [ 53 ] was used for this review as a meta-analysis was not appropriate because of the significant heterogeneity between studies. The synthesis process began with a preliminary analysis, in which the data were extracted and presented in tabular form to provide a summary of the findings and to identify potential patterns within the data. A guided conceptual framework was constructed based on the narrative synthesis of the primary data. This framework aimed to assess both the similarities and differences between the included studies while exploring emerging thematic elements.

Study selection

The initial database search returned 2,551 results after removing duplicates, as shown in Fig.  1 of the PRISMA flow diagram, which depicts the flow of information at each stage of the systematic review search. Subsequent screening included an initial assessment of the titles and a subsequent assessment of the abstracts, which led to the exclusion of an additional 2,530 articles. To ensure accuracy, abstract screening was repeated one week later. Subsequent full-text eligibility screening excluded 14 additional studies. The reasons for exclusion included the following: (a) participants under 18 years of age ( n  = 4), (b) lacked differentiation between the ID and ASD populations ( n  = 4), (c) were differentiated but not described in the context of the results ( n  = 2), (d) measurement of interventions for self-harm and suicide among offenders with ASD rather than for offending behaviour ( n  = 1), and (e) removal of commentary papers ( n  = 3). Consequently, the final number of included studies from the initial database search was seven ( n  = 7).

Study characteristics

Among the seven studies identified, three were case reports ( n  = 3), two were qualitative studies ( n  = 2), and two were quantitative case series ( n  = 2). These studies jointly assessed the effectiveness of the various interventions. The total sample size of all the studies was limited to 10; all the participants were men, and demographic information was limited. It is worth noting that despite the use of international terminology in the search criteria, all seven articles described studies conducted exclusively in southern England, United Kingdom (UK). In these studies, all participants, apart from one were held in secure hospital units under the provisions of the Mental Health Act 1983. The most prevalent types of offending behaviours observed were sexual offences ( n  = 4), followed by manslaughter ( n  = 3), and arson ( n  = 3).

Table  1 ‘Summary of Findings’ provides a summary of each study included in the systematic review. The summary includes author information, available participant demographics, offence type, setting, detainment status (i.e., under the mental health act), intervention approach, study findings, intervention effectiveness, measurement used to assess effectiveness, and whether there was evidence to suggest that the core features of ASD impacted the effectiveness of forensic intervention(s). These are separated by impairments in social communication and interaction (SCI) and restrictive and repetitive behaviours (RRBs).

Risk of bias in studies

The methodological quality of the studies was assessed using the MMAT [ 52 ] (Table  2 , ‘MMAT Quality Appraisal’, appendix). Each of the three case reports received a 3-star rating, indicating a moderate risk of bias and meeting 75% of the qualitative MMAT criteria [ 54 , 55 , 56 ].

The two quantitative case series were found to be at a higher risk of bias due to difficulties in distinguishing the treatment groups, recruitment difficulties, lack of a control group, and incomplete outcome data for the ASD group without co-occurring ID. They received a 2-star rating, meeting 50% of the MMAT quantitative criteria [ 58 ].

The second quantitative study [ 57 ], raised concerns about the validity and reliability of outcome measures, which were originally designed for the ID population but applied to the ASD group without co-occurring ID. This study also received a 2-star rating and met 50% of the MMAT’s quantitative criteria.

The remaining qualitative studies received a 3-star rating, meeting 75% of the MMAT criteria. The first evaluated intervention effectiveness from the perspective of the clinicians who delivered the therapeutic program [ 59 ]. The second assessed offenders’ views via self-report, which carry a potential risk of response bias [ 60 ].

Selection bias was observed in studies that combined ID and ASD populations. Overall, it was difficult to establish a causal relationship between the interventions and outcomes.

Notably, not all the studies reviewed explicitly documented obtaining informed consent from participants. The discrepancy in informed consent between studies, particularly in restrictive forensic settings, presents challenges extending beyond ethical considerations. Such discrepancies may compromise the validity of intervention comparisons, introduce biases in participant selection, and undermine the reliability of data.

Interventions

The interventions examined across the reviewed studies were diverse, as presented in Table  3 , titled ‘Summary of Interventions’.

Three studies incorporated both pharmacological and psychological interventions. Specifically, antipsychotics were used to address co-occurring psychosis, contributing to instances of offending behaviour [ 55 ]. Antipsychotics were also used to manage stress-induced psychosis [ 56 ]. In the context of directly treating offending behaviours, two distinct medications were applied in cases of sexual offending, each with different mechanisms of action [ 54 ] (Table  3 ).

Four studies relied exclusively on psychological interventions [ 57 , 58 , 59 , 60 ]. Among these, two studies implemented adapted forms of CBT. Specific details regarding the non-standardised adaptations used in CBT were not provided by the study author, except that individual delivery was necessary due to difficulties encountered within group settings [ 54 , 56 ].

The third study that incorporated CBT included elements similar to those of the Adapted Sex Offender Treatment Program (A-SOTP) [ 58 ]. The effectiveness of the A-SOTP was described in two studies [ 59 , 60 ]. Furthermore, the Equipping Youth to Help One Another (EQUIP) was adapted and piloted for use with individuals with ID and developmental disabilities (DD) who had committed sexual offences [ 57 ]. Supplementary interventions included speech and language therapy to facilitate communication [ 55 ], occupational therapy to address impairments in executive functioning [ 55 , 56 ] and art therapy [ 54 ].

Table  3 visually depicts a summary of the diverse interventions extracted, reviewed, and categorised according to intervention type: pharmacological, psychological, and supplementary intervention approaches. In addition, the table includes the type of offence, studies using intervention, underlying mechanism of action or theory, evidence base supporting intervention, and measurements used to assess effectiveness.

Measurements

Numerous approaches were adopted to measure effectiveness across the studies. Two studies measured effectiveness by reduced recidivism and the need to repeat the intervention. Other studies utilised a range of standardised measurements to evaluate psychological interventions. For example, one study [ 54 ] employed the Behavioural Status Index (BSI) every six months as a measurement tool. In contrast, another [ 56 ] employed the State Trait Anger Expression Inventory (STAXII II) and the Millon Multiaxial Personality Inventory (MMPI), combined with standardised risk assessment, one-year postintervention.

Regarding pharmacological interventions, one case report used a combination of subjective and objective measurements. These included self-reports and the systematic monitoring of inappropriate glancing behaviours over time by staff members [ 54 ]. In another instance, the reduction in verbalised delusions served as a measure of the effectiveness of antipsychotic medication [ 55 , 56 ].

The effectiveness of interventions such as the A-SOTP was assessed differently across the two studies. In one study, effectiveness was evaluated through clinician views [ 59 ], while in the other, effectiveness was determined by the participants’ subjective experiences with the intervention [ 60 ].

In the case of CBT, which shares similarities with A-SOTP, standardised measures were applied both pre- and post-intervention. These measures consisted of sexual attitudes consistent with sexual offending (QACSO), sexual offenders’ self-appraisal scale (SOSAS), the sexual attitudes and knowledge scale (SAKS), and the victim empathy scale-adapted (VES-A) [ 58 ].

The EQIP study, which also focused on sexual offending [ 57 ], assessed effectiveness by examining improvements in baseline scores on standardised tests related to moral reasoning, cognitive distortions, problem-solving abilities, and anger. In addition, a move to a lower security level was considered an indicator of overall effectiveness. Furthermore, in a case study that included speech and language therapy, the clinician’s subjective view of improved communication within the secure unit served as a measure of the intervention’s effectiveness [ 55 ].

Among the seven studies reviewed, only one pertaining to an arson offence considered the intervention(s) effective. In this case, a pharmacological intervention was used to treat co-occurring alcohol-induced psychosis, and the unspecified antipsychotic proved successful in reducing delusions. Furthermore, speech and language therapy aimed at improving communication skills was also deemed to be effective [ 55 ].

However, the remaining six studies, which included a total of nine participants, concluded that the interventions were largely ineffective. One case report addressing sexual offending behaviours used pharmacological interventions. The first involved cyproterone acetate, a testosterone inhibitor, however, the outcome could not be conclusively determined owing to adherence and dosage issues [ 54 ]. In the second, the selective serotonin reuptake inhibitor (SSRI) fluoxetine was deemed ineffective, as inappropriate behaviours did not significantly decrease [ 54 ]. It is worth noting that the evidence for both of these drugs has since been described as insufficient to guide clinical practice, with cyproterone acetate considered inadequate [ 61 ], and the evidence for fluoxetine has not been fully determined [ 62 ].

Among the two studies that utilised the A-SOTP and a similar form of CBT for sexual offending, one participant repeated the intervention program six times and subsequently re-offended and a further two participants repeated the yearlong intervention program and reoffended [ 58 ]. These findings are consistent with the results of the study that assessed clinician views [ 59 ]. Even in the case of CBT, as used in two studies, the intervention was deemed ineffective despite adaptations made to accommodate individuals with ASD [ 54 , 56 ].

ASD core features and impact upon intervention effectiveness

The application of a narrative synthesis facilitated the identification and extraction of recurring patterns within the data. These patterns were evident across all the studies, highlighting the considerable challenges posed by impairments in social communication and interaction (SCI) and the presence of restrictive and repetitive behaviours (RRBs) on the effectiveness of interventions, as depicted in Fig.  2 .

Impact of The Core Features of ASD upon Intervention Effectiveness. Note. This describes the core features of ASD, both ‘impairments to SCI’ and ‘presence of RRBs’, and their impact upon intervention effectiveness as extracted from studies

Additional factors impacting intervention effectiveness

In addition to the core features of ASD, this review sought to identify additional risk factors that may influence the effectiveness of the intervention(s). Potential risk factors highlighted by the authors of each study were collected, and through narrative synthesis, several recurring themes emerged from the data. Co-occurring personality disorders and psychosis [ 55 , 56 ], were identified as potential factors impacting intervention effectiveness, as described within the literature. Additionally, events such as childhood adversity, sexual abuse, trauma, and having a dysfunctional family life were described as potential contributors [ 58 ]. Late diagnosis of ASD was theorised to lead to maladaptive coping skills deriving from unmet needs, which were described in three of the studies [ 54 , 55 , 56 ].

An overarching theme identified across the majority of the seven studies was the insufficiency of service provision, staff expertise, and the evidence base.

The present systematic review identified seven studies with ten participants who underwent forensic interventions aimed at reducing offending behaviours in adults with ASD, particularly those without co-occurring ID. The principal aim of this review was to evaluate the effectiveness of these interventions. The secondary aim was to examine whether the core features of ASD have an impact on the effectiveness of these forensic interventions and to identify other variables that may impact the overall effectiveness of interventions.

Regarding the first aim, the evidence suggests that the interventions reviewed were inadequate. However, these findings should be treated with caution not only because of the small sample size but also because of limitations in the generalisability of the findings. Despite an extensive literature search, all the studies were conducted in southern England, UK, and included only male participants. In addition, all participants, with the exception of one individual living in the community, were detained within secure hospital settings under the provisions of the Mental Health Act (1983). This highlights the lack of data from prison and the probation service, which limits the scope of the review. Furthermore, this review highlights a critical lack of research within this domain. Even when the literature was identified, it was often of inadequate quality owing to various design limitations. The significant heterogeneity between studies, each utilising distinct intervention methods and tools for measuring intervention effectiveness, illustrates a notable lack of standardisation in both clinical and research methodologies within this field. This lack of consistency aligns with broader research on mental health in individuals with ASD [ 45 , 46 ]. Nonetheless, the forensic domain faces additional challenges, such as the lack of randomised control trials, which means that the effectiveness of interventions is difficult to fully determine. These challenges are exacerbated by unavoidable confounding variables, the risk of bias, and the ethical implications of a no-treatment group [ 66 ], all of which contribute to the lack of evidence.

The secondary aim was to examine the potential impact of the core features of ASD on the effectiveness of interventions designed to reduce recidivism. The data patterns identified through narrative synthesis consistently emerged across all studies, highlighting the significant challenges posed by impairments in social communication and interaction (SCI) and the presence of restrictive and repetitive behaviours (RRBs). These challenges highlight the general inappropriateness of forensic interventions within this population.

The third and final aim was to identify factors, beyond the core features of ASD, that may influence the effectiveness of interventions. Throughout the studies, a recurring theme emerged, highlighting significant systemic factors impacting intervention effectiveness. These include issues such as a shortage of government funding leading to inadequate service provision, the question of whether ASD and ID services should be combined, and the substantial unmet needs throughout the lifespan of individuals with ASD, all of which affect the success of forensic interventions. While the core features of ASD are significant, they may not be the primary cause of intervention failure. Rather, they seem to be contributing factors within a broader and more complex array of variables that collectively impact the overall effectiveness of these forensic interventions.

Implications

The inadequate provision of forensic services carries significant implications, especially when prolonged detainment becomes necessary due to the shortcomings of forensic interventions. Such deficiencies may subject individuals with ASD to non-evidence-based interventions, often repeatedly [ 56 , 58 ]. This then increases the likelihood of these individuals being labelled as ‘unrehabilitated,’ potentially leading to extended periods of detainment. Consequently, this creates a counterproductive cycle that not only exacerbates the economic burden but also raises serious concerns about human rights and the potential legal consequences of prolonged confinement.

These issues underscore fundamental questions about the fairness and adequacy of the legal system. Therefore, addressing these knowledge gaps and the lack of evidence-based approaches are crucial to ensuring a more equitable criminal justice system for individuals with ASD.

Future research

This review identifies several key areas for future research in this field. Developing evidence-based interventions tailored to the unique needs of individuals with ASD is crucial. Establishing a consensus on the measurements used for assessing the effectiveness of these interventions, as well as a clear definition of what constitutes effectiveness, would significantly enhance research quality.

Moreover, due to the bias towards studies conducted in southern England, the consistency of interventions for treating offending behaviours in adults with ASD in England remains unclear, especially considering the persistent regional health disparities between the North and South of England [ 67 , 68 ].

Data availability

No datasets were generated or analysed during the current study.

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Exploring the use of body worn cameras in acute mental health wards: a mixed-method evaluation of a pilot intervention

• Una Foye 1 , 2 ,
• Keiran Wilson 1 , 2 ,
• Jessica Jepps 1 , 2 ,
• James Blease 1 ,
• Ellen Thomas 3 ,
• Leroy McAnuff 3 ,
• Sharon McKenzie 3 ,
• Katherine Barrett 3 ,
• Lilli Underwood 3 ,
• Geoff Brennan 1 , 2 &
• Alan Simpson 1 , 2  

BMC Health Services Research volume  24 , Article number:  681 ( 2024 ) Cite this article

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Body worn cameras (BWC) are mobile audio and video capture devices that can be secured to clothing allowing the wearer to record some of what they see and hear. This technology is being introduced in a range of healthcare settings as part of larger violence reduction strategies aimed at reducing incidents of aggression and violence on inpatient wards, however limited evidence exists to understand if this technology achieves such goals.

This study aimed to evaluate the implementation of BWCs on two inpatient mental health wards, including the impact on incidents, the acceptability to staff and patients, the sustainability of the resource use and ability to manage the use of BWCs on these wards.

The study used a mixed-methods design comparing quantitative measures including ward activity and routinely collected incident data at three time-points before during and after the pilot implementation of BWCs on one acute ward and one psychiatric intensive care unit, alongside pre and post pilot qualitative interviews with patients and staff, analysed using a framework based on the Consolidated Framework for Implementation Research.

Results showed no clear relationship between the use of BWCs and rates or severity of incidents on either ward, with limited impact of using BWCs on levels of incidents. Qualitative findings noted mixed perceptions about the use of BWCs and highlighted the complexity of implementing such technology as a violence reduction method within a busy healthcare setting Furthermore, the qualitative data collected during this pilot period highlighted the potential systemic and contextual factors such as low staffing that may impact on the incident data presented.

This study sheds light on the complexities of using such BWCs as a tool for ‘maximising safety’ on mental health settings. The findings suggest that BWCs have a limited impact on levels of incidents on wards, something that is likely to be largely influenced by the process of implementation as well as a range of contextual factors. As a result, it is likely that while BWCs may see successes in one hospital site this is not guaranteed for another site as such factors will have a considerable impact on efficacy, acceptability, and feasibility.

Peer Review reports

Body worn cameras (BWC) are mobile audio and video capture devices that can be secured to clothing allowing the wearer to record some of what they see and hear. In England, these have been introduced in the National Health Service (NHS) as part of a violence reduction strategy [ 1 ] which emphasises the reduction of aggression and violence against staff. The NHS Staff Survey 2022 found that 14.7% of NHS staff had experienced at least one incident of physical violence from patients, relatives or other members of the public in the previous 12 months. Violent attacks on staff were found to contribute to almost half of staff illness [ 2 ]. Levels of violence against staff working in mental health trusts remain much higher than other types of healthcare providers [ 3 ]. Numerous reports internationally highlight the increased risks faced by staff working in psychiatric care [ 4 ], though studies have reported that both ward staff and mental health patients experience violence and feeling unsafe on inpatient wards [ 5 , 6 ].

Body worn cameras have been in use for over a decade within law enforcement, where they hoped to provide transparency and accountability within use-of-force incidents and in the event of citizen complaints against police [ 7 ]. It was believed that video surveillance would help identify integral problems within the organisation, improve documentation of evidence, reduce use-of-force incidents, improve police-community relations, and provide training opportunities for officers [ 8 ]. However, a recent extensive international systematic review by Lum et al. [ 9 ], found that despite the successes noted in early evaluations, the way BWCs are currently used by police may not substantially affect most officer or citizen behaviours. Irrespective of these findings, other public services such as train operators have been implementing BWCs for security purposes, with reductions reported in the number of assaults on railway staff [ 10 ].

A recent systematic review of BWC use in public sector services established that there is a poor evidence base supporting the use of BWCs in the reduction of violence and aggression [ 11 ]. Yet, we are seeing a swift increase in the use of BWCs in mental health settings with that aim, with few studies conducted on the use of BWC technology in inpatient mental health wards, and even fewer studies exploring staff or patients’ views. Two evaluations conducted in England reported mixed results with both increases and decreases in violence and aggression found, and variation between types of wards. There is some suggestion of a reduction in more serious incidents and the use of restraint, but quality of evidence is low [ 12 , 13 ].

The use of BWCs in mental healthcare settings for safety and security remains a contentious topic due to the lack of evidence regarding the influence that such technology has on preventing violence and aggression and the complex philosophical and ethical issues raised, particularly where many patients may lack capacity and/or are detained under mental health legislation [ 14 ]. Additionally, there are concerns that BWCs may be used as a ‘quick fix’ for staff shortages rather than addressing the wider systemic and resourcing issues facing services [ 15 ]. With little independent evaluation of body-worn cameras in mental health settings, many of these concerns remain unanswered. There is also limited understanding of this technology from an implementation perspective. Therefore, in this study we aimed to conduct an independent evaluation of the introduction of BWCs as a violence reduction intervention on two inpatient mental health wards during a six-month pilot period to explore the impact of using the technology, alongside an exploration of the facilitators and barriers to implementation.

Research aim(s)

To evaluate the implementation of BWCs on two inpatient mental health wards, including the impact on incidents, the acceptability to staff and patients, the sustainability of the resource use and ability to manage the use of BWCs on these wards.

Patient and public involvement

The research team included a researcher and independent consultant, each with lived experience of mental health inpatient care. In addition, we recruited and facilitated a six member Lived Experience Advisory Panel (LEAP). This group was made up of patients and carers, some of whom had experienced the use of BWCs. Members were of diverse ethnic backgrounds and included four women and two men. The LEAP provided guidance and support for the research team in developing an understanding of the various potential impacts of the use of BWCs on inpatient mental health wards. Members contributed to the design of the study, development of the interview schedule, practice interviews prior to data collection on the wards, and supported the analysis and interpretation of the data, taking part in coding sessions to identify themes in the interview transcripts. The LEAP met once a month for two hours and was chaired by the Lived Experience Research Assistant and Lived Experience Consultant. Participants in the LEAP were provided with training and paid for their time.

The pilot introduction of the body worn cameras was conducted within a London mental health Trust consisting of four hospital sites with 17 acute wards. The research team were made aware of extensive preparatory work and planning that was conducted at a directorate and senior management level prior to camera implementation, including lived experience involvement and consultation, and the development of relevant policies and protocols inclusive of a human rights assessment and legal consultation.

The pilot period ran from 25th April to 25th October 2022. Reveal (a company who supply BWCs nationally across the UK) provided the Trust with 12 Calla BWCs for a flat fee that covered use of the cameras, cloud-based storage of footage, management software, and any support/maintenance required during the pilot period. Cameras were introduced to two wards based on two hospital sites, with six cameras provided to each of the wards on the same date. Training on using the BWCs was provided by the BWC company to staff working on both wards prior to starting the pilot period. Ward one was a 20-bed male acute inpatient ward, representing the most common ward setting where cameras have been introduced. Ward two was a ten-bed male Psychiatric Intensive Care Unit (PICU), representing smaller and more secure wards in which patients are likely to present as more unwell and where there are higher staff to patient ratios.

To answer our research questions, we used a mixed-methods design [ 16 ]. Using this design allowed us to investigate the impact of implementing BWCs in mental health settings on a range of quantitative and qualitative outcomes. This mixed methods design allows the study to statistically evaluate the effectiveness of using BWCs in these settings on key dependent variables (i.e., rates of violence and aggression, and incidents of conflict and containment) alongside qualitatively exploring the impact that the implementation of such technology has on patients and staff.

To ensure that the study was able to capture the impact and effect of implementation of the cameras, a repeated measures design was utilised to capture data at three phases on these wards:

Pre-pilot data: data prior of the implementation of the BWCs (quantitative and qualitative data).

Pilot period data: data collected during the six-month pilot period when BWCs were implemented on the wards (quantitative and qualitative data).

Post-pilot: data collected after the pilot period ended and cameras had been removed from the wards (quantitative data only).

Quantitative methods

Quantitative data was collected at all three data collection periods:

Pre-period: Data spanning six months prior to the implementation of BWCs (Nov 21 to May 22).

Pilot period: Data spanning the six months of the Trusts pilot period of using BWCs on the wards (June 22 to Nov 22).

Post-pilot: Data spanning the six months following the pilot period, when BWCs had been removed (Dec 22 to May 23).

Quantitative measures

To analyse the impact of BWC implementation, we collected two types of incident data related to violence and aggression and use of containment measures, including BWCs. Combined, these data provide a view of a wide range of incidents and events happening across the wards prior to, during, and after the implementation and removal of the BWCs.

The patient-staff conflict checklist

The Patient-staff Conflict Checklist (PCC-SR) [ 17 ] is an end of shift report that is completed by nurses to collate the frequency of conflict and containment events. This measure has been used successfully in several studies on inpatient wards [ 18 , 19 , 20 ].The checklist consists of 21 conflict behaviour items, including physical and verbal aggression, general rule breaking (e.g., smoking, refusing to attend to personal hygiene), eight containment measures (e.g., special observation, seclusion, physical restraint, time out), and staffing levels. In tests based on use with case note material, the PCC-SR has demonstrated an interrater reliability of 0.69 [ 21 ] and has shown a significant association with rates of officially reported incidents [ 22 ].

The checklist was revised for this study to include questions related to the use of BWCs ( e.g., how many uses of BWCs happened during the shift when a warning was given and the BWC was not used; when a warning was given and the BWC was used; when the BWC was switched on with no warning given ) in order to provide insight into how the cameras were being used on each ward (see appendix 1). Ward staff were asked to complete the checklist online at the end of each shift.

Routinely collected incident data (via datix system)

To supplement the PCC-SR-R, we also used routinely collected incident data from both wards for all three data collection phases. This data is gathered as part of routine practice by ward staff members via the Datix system Datix [ 23 ] is a risk management system used widely across mental health wards and Trusts in the UK to gather information on processes and errors. Previous studies have utilised routinely collect data via this system [ 24 , 25 ]. Incidents recorded in various Datix categories were included in this study (see Table  1 ). Incidents were anonymised before being provided to the research team to ensure confidentiality.

Routinely collected data included:

Recorded incidents of violence and aggression.

Recorded use of restrictive practices including seclusion, restraint, and intra-muscular medication/rapid tranquilisations.

Patient numbers.

Staffing levels.

Numbers of staff attending BWC training.

Quantitative data analysis

Incident reports.

Incident reports retrieved from Datix were binary coded into aggregate variables to examine violence and aggression, self-harm, and other conflict as outlined in Table  1 . Multivariate analyses of variance (MANOVA) were used to identify differences in type of incident (violence against person, violence against object, verbal aggression, self-harm, conflict) for each ward. MANOVA was also used to examine differences in incident outcomes (severity, use of restrictive practice, police involvement) across pre-trial, trial, and post-trial periods for each ward. Incident severity was scored by ward staff on a four-point scale (1 = No adverse outcome, 2 = Low severity, 3 = Moderate severity, 4 = Severe). Use of restrictive practice and police involvement were binary coded for presence or absence. Analyses were conducted using SPSS [ 26 ].

Patient-staff conflict checklist shift-report – revised (PCC-SR-R; )

Data were condensed into weeks for analysis rather than shifts to account for variability in PCC-SR-R submission by shift. Linear regressions assessed the relationship between BWC use and incident outcome (severity, use of restrictive practice, police involvement).

Qualitative methods

We used semi-structured qualitative interviews to explore participants’ experiences of BWCs on the ward to understand the impact of their use as well as to identify any salient issues for patients, staff and visitors that align with the measures utilised within the quantitative aspect of this study. These interviews were conducted at two time points: pre-pilot and at the end of the six-month pilot period.

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. Patients that were identified as close to discharge and having capacity to consent were approached by a clinical member of the team who was briefed on the study inclusion criteria (see Table  2 ). The staff member spoke with the patient about the study and provided them with a copy of the information sheet to consider. If patients consented, a member of the research team approached the participant to provide more information on the study and answer questions. After initial contact with the research team, participants were given a 24-hour period to consider whether they wanted to participate before being invited for an interview.

Participants were invited to take part in an interview within a private space on the 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. To thank patients for their time, we offered a £10 voucher following the interview. Interviews were audio-recorded and saved to an encrypted server. Interview 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 MicroSoft Excel [ 27 ] for analysis.

Qualitative data analysis

Qualitative data were analysed using a framework analysis [ 28 ] informed by implementation science frameworks. Our coding framework used the Consolidated Framework for Implementation Research (CFIR) [ 29 ], which is comprised of five major domains including: Intervention Characteristics, Implementation Processes, Outer Setting, Inner Setting, and Characteristics of the Individual. Each domain consists of several constructs that reflect the evidence base of the types of factors that are most likely to influence implementation of interventions. The CFIR is frequently used to design and conduct implementation evaluations and is commonly used for complex health care delivery interventions to understand barriers and facilitators to implementation. Based on its description, the CFIR is an effective model to address our research question, particularly given the complexity of the implementation of surveillance technology such as BWCs in this acute care setting.

The initial analytic stage was undertaken by eight members of the study team with each researcher charting data summaries onto the framework for each of the interviews they had conducted on MicroSoft Excel [ 27 ]. Sub-themes within each broad deductive theme from our initial framework were then derived inductively through further coding and collaborative discussion within the research team, inclusive of Lived Experience Researcher colleagues. Pseudonyms were assigned to each participant during the anonymisation of transcripts along with key identifiers to provide context for illustrative quotes (e.g., P = patient, S = staff, A = acute ward, I = Intensive Care, Pre = pre-BWC implementation interview, Post = Post BWC implementation interview).

All participants gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Health Research Authority: London - Camden & Kings Cross Research Ethics Committee (IRAS Project ID 322,268, REC Reference 23/LO/0337).

Quantitative results

Exploring how body worn cameras were used during the pilot period.

Analysis of the PCC-SR-R provides information about how the BWCs were used on a day-to-day basis during the pilot period. Out of 543 total shift reports completed, BWC use was reported 50 times, indicating that BWCs were used on less than 10% of shifts overall; 78% of those deployments were on the Acute ward (see Figure 1 ). Overall, the majority of deployments happened as activations without a warning being given ( n  = 30, 60% of activations), 19 times the BWC was deployed with a warning but the camera was not activated (38%), and only one was the camera activated without a warning being given (2%).

BWC use by ward per week of pilot (no data available before week 6 on Ward 1)

According to the PCC-SR-R, a total of 227 incidents of aggression occurred during the pilot period across both wards (see Table  3 ). Overall, there were small statistically significant correlations between BWC usage and certain types of conflict, aggression, and restrictive practice. Results found that BWC use was positively correlated with verbal aggression and use of physical restraint. BWC use was moderately positively correlated with verbal aggression ( r  = .37, p  < .001). This indicates that BWCs were more likely to be used in incidents involving verbal aggression, which do not tend to be documented in Datix. Similarly, BWC use was moderately positively correlated with physical restraint ( r  = .31, p  < .001) indicating that they were also more likely to be used alongside physical restraint.

Exploring the impact of BWCs utilising routinely collected ward data

Acute ward results.

Routine data collected via Datix records were used to examine differences in frequency of conflict and aggression, incident severity, and use of containment measures before, during, and after introduction of BWCs on each trial ward (see Table  4 ).

There was no effect of trial period on incident type ( F (10, 592) = 1.703, p  = .077, Wilk’s Λ = 0.945), meaning there was no discernible difference in the type of incidents that occurred (E.g., verbal aggression, physical aggression) before, during, and after the pilot phase.

Incident outcomes

There was an effect of trial period on incident outcomes ( F (6, 596) = 10.900, p  < .001, Wilk’s Λ = 0.812). Incident severity was statistically significantly higher in the trial and post-trial periods compared to the pre-trial period. Use of restrictive practice was significantly lower in the post-trial period compared to the pre-trial and trial period. Police involvement was also lower in the post-trial period compared to the pre-trial and trial periods (see Table  5 ).

Results for the psychiatric intensive care unit

There was an effect of trial period on incident type ( F (10, 490) = 4.252, p  < .001, Wilk’s Λ = 0.847). Verbal aggression was statistically significantly higher in the post-trial period compared to the pre and trial periods. Self-harm was statistically significantly higher in the trial period compared to the pre-trial and post-trial periods. There were no differences in violence against a person ( p  = .162), violence against an object or conflict behaviour (see Table  4 ).

There was a statistically significant difference in incident outcome across the trial periods ( F (6, 494) = 12.907, p  < .001, Wilk’s Λ = 0.747). There was no difference in incident severity or police involvement. However, use of restrictive practice was statistically significantly higher in the pre-trial period, reducing in the test period, and reducing further in the post-trial period (see Table  5 ).

Qualitative findings

A total of 22 participants took part in interviews: five patients and 16 staff members. During the pre-pilot interviews a total of nine staff took part (five in the acute ward, four in the PICU ward) and two patients (both from the acute ward). After the pilot period, a total of eight staff took part (four from each ward) and three patients (all from the acute ward). Table  6 includes a full description of participants.

Below we have presented the key themes aligning to the five core CFIR categories of Intervention Characteristics, Characteristics of Individuals, The Process of Implementation, the Inner Setting, and The Outer Setting (see Table  7 ).

Intervention characteristics

Design and usability of wearing a bwc on the ward.

When discussing the use of the BWCs, staff noted a range of design issues related to the cameras that they said impacted on their use and acceptance of the cameras. This included the nature of the camera pulling on clothing necklines (a particular issue for female staff working on male wards), and overheating causing discomfort and irritation to skin, challenges with infection control, as well as the issue of cameras in a mental health setting where they can be easily grabbed, thrown and broken during an incident. Staff often cited these design issues as related to the lack of proactive use of the cameras on the wards.

There were issues around the devices getting overheated or about it going on your clothing, it pulls down the top… we had one person who was leading on it, whenever he was around, of course, the camera was being used, but if he wasn’t there, people weren’t as proactive in using the camera. Petra (f), Staff, A, Post.

There were also issues with staff forgetting to wear the cameras, forgetting to switch them on during incidents, and forgetting to charge them at the end of the shift, reducing the potential use of the cameras by other staff. These were perceived as key logistical issues prior to the pilot and were reported as issues at the end of the pilot by several staff on the wards.

The practicalities of will they actually turn it on in those sorts of incidents, I don’t know. Just little stuff as well, like if they don’t put it back on the docking station, so you think you’re charging it for next shift but then it’s not charged and the battery is dead, that’s one less camera to use, so little stuff. Jamal (m), Staff, A, Pre.

In relation to usability, staff noted that the cameras were small and easy to use given their simple single switch interface. It was felt that not having to upload and manage the data themselves made cameras more user friendly and usable by staff members. Protocols put into place such as signing the cameras in and out, and allocation for use during shifts were likened to procedures in place for other security measures therefore the implementation of this for the BWCs was viewed as easy for many staff.

It’s just like the ASCOM alarms that we wear. There’s a system to sign in and sign out, and that’s it. Alice (f), Staff, A, Pre.

While staff were generally positive about the usability of the cameras, some were cautious of with concerns for those less confident with technology.

… you have to be conscious that there’s some people – it’s quite easy to use, but I can say that because I’m alright using devices and all that but there’s some that are older age or not that familiar with using devices that may struggle with using it… they’re feeling a bit anxious and a bit scared, if they’re not familiar with it then they won’t use it. Jamal (m), Staff, A, Pre.

Evidence strength and quality: do BWCs change anything?

There were conflicting reports regarding the potential benefits of using BWCs on the wards, with both staff and patients reporting mixed perceptions as to whether the cameras might reduce violence and aggression. In the pre-pilot interviews, some staff reported feeling that the BWCs may have a positive impact on reducing physical violence.

I think it’s going to reduce violence and aggression on the ward…I don’t think they’ll want to punch you…they might be verbally abusive but in terms of physical that might reduce. Sarah (f), Staff, I, Pre.

Patients however noted that the cameras might hold staff to account of their own behaviours and therefore may improve care, however they felt that this impact would wear off after the first few months after which people might forget about the cameras being there.

Now they’ve got the body cams, it’s going to be a lot of changes. They’ll think, ‘Ooh well he’s on tape’. So, it might do something to their conscience, they actually start to listen to patients… until the novelty wears off and it might go back to square one again. Ian (m), Patient, A, Pre.

One staff member suggested that incident rates had reduced following introduction of the BWCs, but they remained unsure as to whether this was due to the cameras, reflecting that violence and aggression on wards can be related to many factors.

I know our violence and aggression has reduced significantly since the start of the cameras pilot… I don’t know, because obviously wearing the camera’s one thing, but if they weren’t in use, I don’t know maybe just the presence of the camera made a difference. But yeah, it’s hard to tell. Petra (f), Staff, A, Post.

In contrast, several staff reported that they had seen limited evidence for such changes.

I used it yesterday. He was aggressive and I used it, but he even when I was using [it] he doesn’t care about the camera… it didn’t make any difference… It doesn’t stop them to do anything, this camera does not stop them to do anything. Abraham (m), Staff, I, Post.

Some staff suggested that in some circumstances the cameras increased patient agitation and created incidents, so there was a need to consider whether the BWCs were going to instigate aggression in some circumstances.

There has been with a few patients because they will threaten you. They will tell you, ‘if you turn it on, I’m gonna smash your head in’. So incidents like that, I will not turn it on… Yeah, or some of them will just tell you, ‘if you come close by, I’m going to pull that off your chest’. So things like that, I just stay back. Ada (f), Staff, A, Post.

One rationale for a potential lack of effectiveness was noted by both staff and patients and was related to the levels of acute illness being experienced by patients which meant that for many they were too unwell to have insight into their own actions or those of staff switching on the cameras.

We’ve had instances where patients are so unwell that they just don’t care. You switch on the camera, whether you switch it on or not, it doesn’t really change the behaviour. ‘All right, okay, whatever switch it on’. They’re so unwell, they’re not really understanding. Petra (f), Staff, A, Post. It might make [staff] feel safer as a placebo effect, but I don’t think it would necessarily make them safer… I think the people that are likely to attack a member of staff are crazy enough that they’re not gonna even consider the camera as a factor. Harry (m), Patient, A, Pre.

This lack of evidence that the cameras were necessarily effective in reducing incident rates or severity of incidents may have had an impact on staff buy-in and the use of the cameras as a result. One staff member reflected that having feedback from senior management about the impact and evidence would have been useful during the pilot period to inform ward staff whether the cameras were influencing things or not.

Staff want feedback. I don’t think we’ve had any since we’ve had the cameras… it would be nice to get feedback from, I don’t know, whoever is watching it, and stuff like that. Ada (f), Staff, A, Post.

Relative advantage: are BWCs effective and efficient for the ward?

Due to a combination of personal beliefs related to BWCs, the lack of evidence of their impact on violence and aggression, and other elements of care and culture on the wards, a number of staff and patients explored alternative interventions and approaches that may be more beneficial than BWCs. Both staff and patients suggested that Closed Circuit Television (CCTV) as an intervention that provided the transparency of using cameras and video footage but with an independent perspective. This was felt by many to remove the bias that could be introduced in BWC use as the video capture didn’t require staff control of the filming.

I feel like [BWCs] puts all the power and trust into the hands of the staff and I feel that it would be better to have CCTV on the ward because CCTV is neutral. Harry (m), Patient, A, Pre. I have control over that [BWC recording] … It kind of gives that split as well between staff and patients. You can tell me or I can tell you when to switch it on. Whereas I feel like a CCTV camera is there all the time. Nobody’s asking to switch it on. It’s there. If you wanted to review the footage you can request it, anyone can request to view the footage for a legitimate reason. Whereas the camera can come across as if you’re threatening. Petra (f), Staff, A, Post.

In addition, some participants reflected that the nature and design of BWCs meant that unless staff were present for an incident it wouldn’t be captured, whereas CCTV has the advantage of being always present.

If there’s CCTV, then it’s the same thing, you get me. Like, if its body worn cameras that people can always do things away from staff. They can always go down to that corridor to have their fight or go to the side where staff ain’t gonna see them to have their fight, but with CCTV you can’t do that. Elijah (m), Patient, A, Post.

In addition to exploring technological and video-based interventions, many staff noted that the key tool to violence reduction had to be the use of de-escalation skills, noting that the use of communication and positive relationships had to be the primary tool before other interventions such as BWCs or CCTV.

We do a lot of verbal de-escalation. So we got our destress room now still open. That has a punch bag, and it’s got sensory tiles, and the aim and hope is that when people do get frustrated, because we’re all human. We all get annoyed at anything or many little things in life. There is the aim that they go into that room and start punching the bag instead of property and damaging furniture. But we also are working really hard on verbal de-escalation and actually trying to listen to patients and talk to them before anything else. And that’s helped a lot. And between this kind of shared, or role modelling, where while we’re showing staff, actually even spending an extra 20 min is okay. If it means you’re not going to end up having to restrain a patient. Petra (f), Staff, A, Post.

By using communication skills and de-escalation techniques skilfully, some staff felt there was no need to utilise the BWCs. One concern with the introduction of the BWCs for staff was that the use of this technology may negatively impact on trust and relationships and the use of de-escalation.

Some situations I feel like it can make a situation worse sometimes… I think a lot of situations can be avoided if you just talk with people…. Trying to find out why they’re angry, trying to just kind of see it from their point of view, understand them… I think maybe additional training for verbal de-escalation is needed first. Patrick (m), Staff, A, Post.

Characteristics of individuals

Staff and patients’ knowledge and beliefs about the intervention.

Overall, there were mixed views among both staff and patients as to whether cameras would reduce incidents, prior to and after the pilot period. When considering the possible impact on violence and aggressive incidents there was a view among staff that there was the need for a nuanced and person-centred view.

All the patients that come in, they’re different you know. They have different perceptions; they like different things… everyone is different. So, it just depends. We might go live, and then we have good feedback because the patients they are open and the understand why we have it, and then as they get discharged and new patients come in it might not go as well. It just depends. Serene (f), Staff, A, Pre.

As a result of the desire to be person-centred in the use of such interventions, one staff member noted that they weighed-up such consequences for the patient before using the BWC and would make decisions not to use the camera where they thought it may have a negative impact.

Actually, with this body worn camera, as I did mention, if a patient is unwell, that doesn’t, the patient will not have the capacity to I mean, say yes, you cannot just put it on like that. Yeah, I know it’s for evidence, but when something happens, you first have to attend to the patient. You first have to attend to the patient before this camera is, for me. Ruby (f), Staff, I, Post.

Some staff questioned the existing evidence and theories as to why BWCs work to reduce incidents, and instead noted that for some people it will instigate an incident, while others may be triggered by a camera.

I’m on the fence of how that is going to work because I know the evidence is that by telling a patient ‘look if you keep escalating I’m gonna have to turn this on’, but I know several of our patients would kind of take that as a dare and escalate just to spite so that you would turn it on. Diana (f), Staff, A, Pre.

In contrast, some staff felt the cameras helped them feel safer on wards due to transparency of footage as evidence for both staff and patients.

They [staff] need to use it for protection, for recording evidence, that type of thing… They can record instances for later evidence. Yeah, for them as well. Safer for them and for patients because you can also have the right to get them to record, because a patient might be in the wrong but sometimes it may be the staff is in the wrong position. And that’s achieving safety for patients as well. Yeah, I think it works both ways. Dylan (m), Patient, A, Post.

Positive buy-in was also related to the potential use of the intervention as a training, learning or reflective tool for staff to improve practice and care and promote positive staff behaviour.

If you know that your actions might be filmed one way or the other, that would make me to step up your behaviour to patients… if you know that your actions can be viewed, if the authority wants to, then you behave properly with patients so I think that will improve the quality of the care to patient. Davide (m), Staff, I, Pre.

While there were some positive attitudes towards the cameras, there remained considerable concerns among participants regarding the transparency of camera use to collate evidence in relation to incidents as it was widely noted that the cameras remain in staff control therefore there is an issue in relation to bias and power.

I do think my gut would say that it wouldn’t necessarily be well received. Because also I think people feel like prisoners in here, that’s how some of the patients have described their experience, so in terms of the power dynamic and also just – I think that can make one feel a bit, even worse, basically, you know? Leslie (m), Staff, A, Pre.

These issues lead to staff reporting they didn’t want to wear the camera.

I’d feel quite uncomfortable wearing one to be honest. Leslie (m), Staff, A, Pre.

The staff control of the cameras had a particular impact on patient acceptability of the intervention as it led to some patients viewing BWCs as being an intervention for staff advantage and staff safety, thus increasing a ‘them and us’ culture and leading to patient resistance to the cameras. This was particularly salient for those with prior negative experiences of police use of cameras or mistrust in staff.

I feel like the fact that the body worn cameras is gonna be similar to how the police use them, if a staff member has negative intent toward a patient, they would be able to instigate an incident and then turn the camera on and use the consequences of what they’ve instigated to expect restraint or injection or whatever else might happen. So, I feel like it would be putting all the power and trust into the hands of the staff and I feel that it would be better to have CCTV on the ward because CCTV is neutral. Whereas, the body worn camera, especially with some of the personality conflicts/bad attitudes, impressions I’ve had from certain members of staff since I’ve been here, I feel like body worn cameras might be abused in that way possible. Harry (m), Patient, A, Pre.

Perceived unintended consequences and impact on care

Prior to the implementation there were concerns from staff that the introduction of BWCs could have consequences beyond the intended use of reducing violence and aggression, unintentionally affecting a range of factors that may impact on the overall delivery of care. There was a key concern regarding the potential negative impact that cameras may have for patients who have paranoia or psychosis as well as for those who may have prior traumatic experiences of being filmed.

It might have negative impacts on these patients because I’m thinking about kind of patients with schizophrenia and things like that who already have paranoid delusions, thinking that people are after them, thinking that people are spying on them, people are watching them, and then seeing kind of cameras around. It might have negative impacts on them. Tayla (f), Staff, I, Pre. When I was admitted I was going through psychosis… I don’t want to be filmed and things like that. So you just see a camera, a guy with a camera on, you are like, are you filming me? Elijah (m), Patient, A, Post.

There was also a considerable concern among both staff and patients that the use of cameras would have a negative impact on the therapeutic relationship between staff and patients. This was felt to be related to the implication that the cameras enhanced a ‘them and us’ dynamic due to the power differential that staff controlling the cameras can create, likened to policing and criminalisation of patients. With the potential of a negative impact on relationships between staff and patients, staff suggested they may be disinclined to use BWCs if it would stop patients speaking to them or approaching them if they needed support.

Yeah, I think it would probably damage [the therapeutic relationship] because I think what’s probably quite helpful is things that maybe create less of a power difference. I think to some extent, [the BWC] might hinder that ability. Like for example imagine going to a therapist and them just like ‘I’ve got this camera in the corner of the room and it’s gonna be filming our session and just in case – or like, just in case I feel that you might get aggressive with me’. Um, I don’t think that’s going to help the therapeutic relationship! Jamal (m), Staff, A, Pre. When you get body worn cameras on there, the relationship as well between staff and patients, is just gonna instantly change because you’re looking like police! Elijah (m), Patient, A, Post.

In contrast, a minority of staff felt that the presence of cameras may improve relationships as they provide transparency of staff behaviour and would encourage staff to behave well and provide high quality care for patients.

It will also help how, improve the way we look at the patients… because if you know that your actions might be filmed one way or the other, that would make me to step up your behaviour you know… you behave properly with patients so I think that will improve the quality of the care to patient. More efficiently, more caring to patient. Davide (m), Staff, I, Pre.

The process of implementation

Planning: top-down implementation.

Staff perceived that BWC implementation directives had been given by senior management or policy stakeholders whom they felt viewed the process from a position of limited understanding due to a lack of ‘frontline’ mental health service experience. This led to a lack of faith amongst staff, and a perception that funds were being misspent.

They sit up there, they just roll it out and see how it works, how it goes. They waste a whole lot of money, millions or whatever, thousands of pounds in it, and then they see that ‘Oh, it’s not gonna work’. They take it back and all of that. Before coming out with it, you need to come speak to us… they just sit up there drinking tea and coffee, and then they’re just like, Oh, yeah, well, let’s do it this way…come stay with these people, work with them, for just I give you a 12 h shift, stay with them. Richard (m), Staff, I, Post.

This was exacerbated when staff felt there was a lack of consultation or explanation.

we don’t always get the ins and outs of certain things…We know that the cameras are coming in and stuff like that, but you know, and obviously it’s gone through every avenue to make sure that it’s fine. But then sometimes we don’t always know the ins and outs to then explain to people why we have the cameras. Patrick (m), Staff, A, Post.

It was also highlighted that due to multiple initiatives being implemented and directives handed down in parallel, staff felt negative towards interventions more widely, with the BWCs being ‘ just another thing to do’ , adding to workload for staff and reducing enthusiasm to use the cameras.

it’s not just to do with the camera, I just think there’s lots of changes happening at once, and there’s loads of new things being constantly introduced that people are just thinking oh it’s another thing. I think that’s what it is more than the camera itself. Alice (f), Staff, A, Pre.

Execution: training, Use and Ward Visibility

Overall, there was a lack of consistency amongst staff in their understanding of the purpose and processes of using the BWCs on the wards.

What do you do, do you record every single thing or, I don’t know. Do you record like, if a patient said, I want to talk to you, confidential, you go sit in a room, do you record things like those or is it just violence and aggression? Ada (f), Staff, A, Post.

The lack of clarity regarding the purpose of the intervention and the appropriate use of the cameras was felt to impact staffs’ attitudes and acceptance of using them and contributed to a lack of transparency or perhaps trust regarding the use of any subsequent video footage.

I think if the importance of the recording was explained a bit more…and how it would improve things, I think people would use it more… that’s why I don’t think it’s always used sometimes… if you’re not sure why some of it’s important, then you’re not going to see the value…I think if you’re gonna keep with them, it’s about updating the training, teaching staff when to use it, then where does that information go? How does that look in terms of improving? Just a bit of transparency, I think. But when you don’t know certain things it’s a bit hard to get behind something or back it, you know? Patrick (m), Staff, A, Post.

The lack of information about the purpose and processes related to the intervention was also seen among patients, with most patients noting that they hadn’t received information about the cameras during their admissions.

No information at all. I don’t think any of the patients know about it. Toby (m), Patient, A, Post.

While training was provided it was widely felt that it was insufficient to provide understanding about the purpose of the cameras or the more in-depth processes beyond operational aspects such as charging and docking. Several staff interviewed were unaware of the training, while others noted that they had an informal run-through by colleagues rather than anything formal.

What training are you talking about?… I wasn’t here, so I was taught by my colleague. I mean, from what I was taught, to operate the camera, and to give a warning to the patient that you’re going to use the camera. Nevis (f), Staff, A, Post.

Longer training with further details beyond operational use was felt to be needed by staff.

I think the training should have to be longer, even if it’s like an hour or something… Like what situations deem the camera to be… more information on the cameras, when to use it, why it’s used, and I think if the importance of the recording was explained a bit more and what it was doing and how that recording would go and how it would improve things. Patrick (m), Staff, A, Post.

Furthermore, there was a need for training to be on a rolling basis given the use of bank staff who were not trained to use the cameras or to understand the proper processes or purpose of using the BWCs, which could leave them vulnerable to misuse or abuse.

We have bank staff [who aren’t trained] so they say ‘I don’t know how to use that camera you are giving me’. Nevis (f), Staff, A, Post.

The inner setting

Ward context: acceptance of violence and aggression is part of the job.

It was widely believed by staff that the nature of working on a mental health ward included accepting that violence and aggression was part of the job. This was not seen as an acceptance of violence but more that the job was providing care for individuals who are mentally unwell, and confusion, fear, frustration and aggression can be part of that. As a result, there was an ambivalence among some staff that the introduction of cameras would change this.

I think like in this line of work, there’s always that potential for like risky behaviours to happen. I’m not sure if putting the camera on will make much difference. Patrick (m), Staff, A, Post.

Staff noted that because of the nature of the job, staff are used to managing these situations and they understood that it was part of the job; therefore, it was unlikely that they would record everything that on paper might be considered an incident.

There’s also enough things that happen here, so I don’t think they would record [the incidents] because it’s just another day here. You know what I’m saying… [staff] can just say, ‘Stop, go back to your room and leave it at that and that kind of be the end of it’. Dylan (m), Patient, A, Post. We are trained for it. Eveline (f), Staff, I, Pre.

This acceptance that incidents are a hazard of mental healthcare was linked to staff’s acknowledgment that many factors make up the complexity of violence and aggression including the nature of individual patients, acuity levels, ward atmosphere, staffing levels, access to activities, leave and outside space. The interplay of multiple factors creates a context in which frustrations and incidents are likely, thus become part of the everyday and ‘normal’ life on the ward for staff and patients alike.

I feel like, you know, how in GP services you say, zero tolerance to abusive language, or any kind of harassment. I don’t think there is that on a psychiatric ward you are kind of expected to take all the abuse and just get on with it. Petra (f), Staff, A, Post.

With staff reported having a higher threshold for these behaviours it was perceived that this was likely to impact on the efficiency of the intervention as staff would be less likely to consider a situation as violent but more ‘ part of the job’ .

Reactive nature of the ward and incidents

Most participants noted that the ward context is always changing with people being admitted and discharged, with daily staff changes and wider turnover of staff, so things are never static and can change at any point. This reflects the dynamic nature of the ward which creates a complex moving picture that staff need to consider and react to.

[the atmosphere] it’s very good at the moment. If you had asked me this two weeks ago, I would say, ‘Oh, my gosh’. But it changes… The type of patient can make your whole ward change… it depends on the client group we have at the time. Nevis (f), Staff, A, Post.

Staff noted that a key limitation of using the cameras to reduce incidents was the reactive nature of the environment and care being provided. This was felt to impact on the feasibility and use of the cameras as staff noted that they often react to what is happening rather than thinking to ‘ put the camera on first ’. It was felt by staff with experience of reacting to incidents that the failure to use BWCs during these processes were linked to staff’s instincts and training to focus on patients as a priority.

Say for instance, you’re in the office, and two patients start fighting, or a patient attacks someone and, all you’re thinking about is to go there to stop the person. You’re not thinking about putting on any camera. You understand? So sometimes it’s halfway through it, somebody might say, ‘Has anybody switched the camera on’? And that’s the time you start recording… If something happens immediately, you’re not thinking about the camera at that time, you’re just thinking to just go, so yeah. Nevis (f), Staff, A, Post.

Incidents happen quickly and often surprise staff, therefore staff react instantly so are not thinking about new processes such as recording on the cameras as this would slow things down or is not in the reactive nature needed by staff during such incidents.

When you’re in the middle of an incident and your adrenaline’s high, you’re focusing on the incident itself. It’s very difficult for you to now remember, remind yourself to switch on the camera because you’re thinking, patient safety, staff safety, who’s coming to relieve you? What’s going on? Who’s at the door? Petra (f), Staff, A, Post.

In addition, the need for an immediate response meant that it was felt that by the time staff remember to, or have the chance to, switch the camera on it was often too late.

Sometimes in the heat of moments and stuff like that, or if the situation’s happening, sometimes you don’t always think to, you know, put your camera on. Patrick (m), Staff, A, Post.

Outer setting

Resources: staffing.

Issues related to staffing were highlighted by several participants as a key problem facing mental health wards thus leading to staff having higher workloads, and higher rates of bank and agency staff being used on shift and feeling burnt-out.

Out of all the wards I’ve been on I’d say this is the worst. It’s primarily because the staff are overworked…it seems like they spend more time doing paperwork than they do interacting with the patients. Harry (m), Patient, A, Pre. We’re in a bit of a crisis at the minute, we’re really, really understaffed. We’re struggling to cover shifts, so the staff are generally quite burnt out. We’ve had a number of people that have just left all at once, so that had an impact… Staff do get frustrated if they’re burnt out from lack of staff and what have you. Alice (f), Staff, A, Pre.

It was noted by one participant that the link of a new intervention with extra workload was likely to have a negative impact on its acceptability due to these increasing demands.

People automatically link the camera to then the additional paperwork that goes alongside it. It’s like, ‘Oh god, if we do this, we’ve got to do that’, and that could play a part. Petra (f), Staff, A, Post.

One staff member noted that the staffing issue meant there were more likely to be bank staff on wards so the care of patients may be affected as temporary staff may be less able to build meaningful therapeutic relationships.

So obviously there is the basic impact on safety of not having adequate staffing, but then there’s the impact of having a lot of bank staff. So obviously when you have permanent staff they get to know the patients more, we’re able to give them the more individualised care that we ideally should be giving them, but we can’t do that with bank staff. Diana (f), Staff, A, Pre.

It was also suggested that staffing levels and mix often made it more difficult to provide activities or facilitate escorted leave which can lead to patients feeling frustrated and becoming more aggressive.

So you know there is enough staff to facilitate the actual shift, so you know when there’s less staff like you say you’ve got people knocking at the door, but then you don’t have staff to take people out on leave straight away, that all has a rippling effect! Serene (f), Staff, A, Pre.

Wider systemic issues

Overall, there was a concern that the introduction of BWCs would not impact on wider, underlying factors that may contribute to frustration, aggression and incidents on wards. Providing a more enhanced level of care and better addressing the needs of patients was felt to be central to helping people but also reducing the frustration that patients feel when on the ward.

… for violence and aggression, [focus on] the mental health side of things like therapy and psychology should be compulsory. It shouldn’t be something you apply for and have to wait three or four weeks for. I think every person should, more than three or four weeks even, months even… we need psychology and therapists. That’s what will stop most violence, because psychologists and a therapist can edit the way that they speak to people because they’ve been given that skill depending on the way the person behaves. So that’s what we need regularly… not like all this dancing therapy, yoga therapy. That’s a person, that you come and you actually sit down and talk through your shit with them. That will help! Elijah (m), Patient, A, Post. There’s a lack of routine and I think there’s a lack of positive interaction between the patient and the staff as well. The only time you interact with a member of staff is if you’re hassling them for something, you have to hassle for every little thing, and it becomes a sort of, frustration inducing and like I’m a very calm person, but I found myself getting very fucking angry, to be honest, on this ward just because out of pure frustration… there’s bigger problems than body worn cameras going on. Harry (m), Patient, A, Pre.

Staff agreed that there was a need to invest in staff and training rather than new technologies or innovations as it is staff and their skills behind the camera.

It’s not the camera that will do all of that. It’s not making the difference. It’s a very good, very beautiful device, probably doing its job in its own way. But it’s more about investing in the staff, giving them that training and making them reflect on every day-to-day shift. Richard (m), Staff, I, Post.

There was felt to be a need to support staff more in delivering care within wards that can be challenging and where patients are unwell to ensure that staff feel safe. While in some circumstances the cameras made some staff feel safer, greater support from management would be more beneficial in making staff feel valued.

In this study exploring the implementation and use of body-worn cameras on mental health wards, we employed two methods for collecting and comparing data on incidents and use of containment measures, including BWCs, on one acute ward and one psychiatric intensive care unit. We found no clear relationship between the use of BWCs and rates or severity of incidents on either ward. While BWCs may be used when there are incidents of both physical and verbal aggression, results indicate that they may also provoke verbal aggression, as was suggested during some interviews within this study. This should be a concern, as strong evidence that being repeatedly subject to verbal aggression and abuse can lead to burnout and withdrawal of care by staff [ 30 ]. These mixed findings reflect results that were reported in two earlier studies of BWCs on mental health wards [ 12 , 13 ]. However, the very low use of the cameras, on just 10 per cent of the shifts where data was obtained, makes it even more difficult to draw any conclusions.

While the data shows limited impact of using BWCs on levels of incidents, we did find that during the pilot period BWC use tended to occur alongside physical restraint, but the direction of relationship is unclear as staff were asked to use BWCs when planning an intervention such as restraint. This relationship with restraint reflected the findings on several wards in a previous study [ 13 ], while contrasting with those reported in a second study that found reductions in incidents involving restraint during the evaluation period [ 12 ]. Such a mix of findings highlights the complexity of using BWCs as a violence reduction method within a busy healthcare setting in which several interacting components and contextual factors, and behaviours by staff and patients can affect outcomes [ 31 ]. The qualitative data collected during this pilot period highlighted the potential systemic and contextual factors such as low staffing that may have a confounding impact on the incident data presented in this simple form.

The findings presented within this evaluation provide some insights into the process of implementing BWCs as a safety intervention in mental health services and highlight some of the challenges and barriers faced. The use of implementation science to evaluate the piloting of BWCs on wards helps to demonstrate how multiple elements including a variety of contextual and systemic factors can have a considerable impact and thus change how a technology may vary not only between hospitals, but even across wards in the same hospital. By understanding the elements that may and do occur during the process of implementing such interventions, we can better understand if and how BWCs might be used in the future.

Within this pilot, extensive preparatory work conducted at a directorate and senior management level did not translate during the process of implementation at a ward level, which appeared to impact on the use of BWCs by individuals on the wards. This highlights that there is a need to utilise implementation science approaches in planning the implementation of new technologies or interventions and to investigate elements related to behavioural change and context rather than just the desired and actual effects of the intervention itself.

While ward staff and patients identified the potential for BWCs to enhance safety on the wards, participants distrusted their deployment and expressed concerns about ethical issues and possible harmful consequences of their use on therapeutic relationships, care provided and patient wellbeing. These themes reflect previous findings from a national interview study of patient and staff perspectives and experiences of BWCs in inpatient mental health wards [ 14 ]. Given these issues, alternatives such as increasing de-escalation skills were identified by staff as possible routes that may be more beneficial in these settings. Furthermore, other approaches such as safety huddles have also been highlighted within the literature as potential means to improve patient safety by looking ahead at what can be attended to or averted [ 32 ].

Furthermore, it is important to consider that the presence of power imbalances and the pre-existing culture on the ward have considerable implications for safety approaches and must be considered, as exemplified by the preferences by both staff and patients in this evaluation for more perceived ‘impartial’ interventions such as CCTV. As identified within previous studies [ 14 ], BWCs can have different implications for psychological safety, particularly for vulnerable patients who already feel criminalised in an environment with asymmetrical power imbalances between staff and patients. This is particularly salient when considering aspects of identity such as race, ethnicity, and gender both in terms of the identities of the patient group but also in terms of the staff/patient relationship.

While preferences in this study note CCTV as more ‘impartial’, work by Desai [ 33 ] draws on the literature about the use of surveillance cameras in other settings (such as public streets) as well as on psychiatric wards and concludes that CCTV monitoring is fraught with difficulties and challenges, and that ‘watching’ patients and staff through the lens of a camera can distort the reality of what is happening within a ward environment. In her recently published book, Desai [ 34 ] develops this theme to explore the impacts of being watched on both patients and staff through her ethnographic research in psychiatric intensive care units. She highlights concerns over the criminalisation of patient behaviour, safeguarding concerns in relation to the way women’s bodies and behaviours are viewed and judged, and the undermining by CCTV of ethical mental health practice by staff who attempt to engage in thoughtful, constructive, therapeutic interactions with patients in face-to-face encounters. Appenzeller et al.’s [ 35 ] review found that whilst the presence of CCTV appeared to increase subjective feelings of safety amongst patients and visitors, there was no objective evidence that video surveillance increases security, and that staff may develop an over-reliance on the technology.

In addition, our findings add to the existing literature which notes that alternative interventions and approaches that address underlying contextual and systemic issues related to improving care on inpatient wards require attention to address the underlying factors related to incidents, e.g., flashpoints [ 36 ]. Evidence suggests that factors leading to incidents can be predicted; therefore, there is a need to enable staff to work in a proactive way to anticipate and prevent incidents rather than view incidents as purely reactive [ 37 , 38 , 39 ]. Such skills-based and relational approaches are likely to impact more on improving safety and reducing incidents by addressing the complex and multi-faceted issue of incidents on inpatient mental health wards [ 40 ].

These findings highlight that interventions such as BWCs are not used within a vacuum, and that hospitals are complex contexts in which there are a range of unique populations, processes, and microsystems that are multi-faceted [ 41 ]. As a result, interventions will encounter both universal, specific, and local barriers that will impact on its functioning in the real world. This is salient because research suggests that camera use inside mental health wards is based on a perception of the violent nature of the mental health patient, a perception that not only influences practice but also impacts how patients experience the ward [ 33 ]. As a result, there needs to be careful consideration of the use of any new and innovative intervention aimed at improving safety within mental health settings that have limited research supporting their efficacy.

Limitations

While the study provides important insights into the efficacy and acceptability of introducing BWCs onto inpatient mental health wards, there were several limitations. Firstly, the analysis of incident data is limited in its nature as it only presents surface level information about incidents without wider contextual information. Results using such data should be cautiously interpreted as they do not account for confounding factors, such as staffing, acuity, ward culture or ward atmosphere, that are likely to contribute to incidents of violence and aggression. For example, while there was a statistically significant decrease in restrictive practice on the PICU across the study period, we know that BWCs were not widely used on that ward, so this is likely due to a confounding variable that was not accounted for in the study design.

Secondly, the study faced limitations in relation to recruitment, particularly with patients. Researchers’ access to wards was challenging due to high staff turnover and high rates of acuity, meaning many patients were not deemed well enough to be able to consent to take part in the study. In addition, the low use of the cameras on wards meant that many patients, and some staff, had not seen the BWCs in use. Similarly, patients had been provided limited information about the pilot, so their ability to engage in the research and describe their own experiences with BWCs was restricted.

Thirdly, analysis captures the active use of the BWC, however it does not fully capture the impact of staff wearing the cameras even where they do not actively use them. While our qualitative analysis provides insight into the limitation of such passive use, it is likely that the presence of the cameras being worn by staff, even when turned off, may have an impact on both staff and patient behaviours. This may explain trends in the data that did not reach significance but warrant further investigation in relation to the presence of BWCs, nonetheless.

Finally, researchers had planned to collect quantitative surveys from staff and patients in relation to their experiences of the ward atmosphere and climate, views related to therapeutic relationships on the ward, levels of burnout among staff, views on care, and attitudes to containment measures. Due to issues related to staff time, patient acuity, and poor engagement from staff leading to challenges accessing the wards, the collection of such survey data was unfeasible, and this element of the study was discontinued. As a result, we have not reported this aspect in our paper. This limitation reflects the busy nature of inpatient mental health wards with pressures on staff and high levels of ill health among patients. As such, traditional methodologies for evaluation are unlikely to elicit data that is comprehensive and meaningful. Alternative approaches may need to be considered.

Future directions

With BWCs being increasingly used across inpatient mental health services [ 14 ], it is important that further research and evaluation is conducted. To date, there is limited data regarding the effectiveness of this technology in relation to violence reduction; however, there may be other beneficial uses in relation to safeguarding and training [ 13 ]. Future research should consider alternative methods that ensure contextual factors are accounted for and that patient voices can be maximised. For example, focus groups with patients currently admitted to a mental health ward or interviews with those who have recently been on a ward that has used the cameras, would bypass problems encountered with capacity to consent in the present study. Furthermore, ethnographic approaches may provide a deeper understanding of the implementation, deployment and impact that BWCs have on wards.

Overall, this research sheds light on the complexities of using BWCs as a tool for ‘maximising safety’ in mental health settings. The findings suggest that BWCs have a limited impact on levels of incidents on wards, something that is likely to be largely influenced by the process of implementation as well as a range of contextual factors, including the staff and patient populations on the wards. As a result, it is likely that while BWCs may see successes in one hospital site this is not guaranteed for another site as such factors will have a considerable impact on efficacy, acceptability, and feasibility. Furthermore, the findings point towards the need for more consideration to be placed on processes of implementation and the complex ethical discussions regarding BWC use from both a patient and a staff perspective.

In conclusion, while there have been advances in digital applications and immersive technologies showing promise of therapeutic benefits for patients and staff more widely, whether BWCs and other surveillance approaches are to be part of that picture remains to be seen and needs to be informed by high-quality, co-produced research that focuses on wider therapeutic aspects of mental healthcare.

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Acknowledgements

We would like to thank The Burdett Trust for Nursing for funding this work. We would also like to acknowledge our wider Lived Experience Advisory Panel and Project Advisory Panel for their contributions and support and would like to thank the staff and service users on the wards we attended for their warmth and participation.

Funding was provided by The Burdett Trust of Nursing. Funders were independent of the research and did not impact findings.

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All authors have read and approved the manuscript. Authors AS, UF, KW, GB created the protocol for the study. KW, JJ, UF conducted the recruitment for the study, and conducted the interviews. UF, JJ, JB, LMA, LU, SMK, KB, ET coded data, and contributed to the analysis. All authors supported drafting and development of the manuscript.

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Foye, U., Wilson, K., Jepps, J. et al. Exploring the use of body worn cameras in acute mental health wards: a mixed-method evaluation of a pilot intervention. BMC Health Serv Res 24 , 681 (2024). https://doi.org/10.1186/s12913-024-11085-x

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The factors of job crafting in emergency nurses: regression models versus qualitative comparative analysis

• Yu Wang 2 ,
• Qiaofang Yang 2 ,
• Luwen Wang 3 ,
• Qingwei Zhang 2 &
• Yingli Li 1  

BMC Nursing volume  23 , Article number:  369 ( 2024 ) Cite this article

Metrics details

Job crafting is defined as a series of proactive behaviors exhibited by employees in order to balance work resources and needs, which has a significant positive impact on the nurses. It is necessary to find the core factors that influence the job crafting, as emergency nurses deal with the most complex tasks, so as to improve their job satisfaction.

To investigate the core factors of job crafting among emergency nurses.

A cross-sectional design was used in the study. A total of 255 nurses were recruited from two hospitals in Zhengzhou and Shenzhen, China in December 2021. 255 nurses completed an online questionnaire. Hierarchical regression models and fsQCA models were used to explore the factors influencing job crafting among emergency nurses and helped us to identify core factors.

The hierarchical regression model and the fsQCA model found that the occupational benefit, psychological empowerment, and research experience were the core factors affecting their job crafting. Job involvement was not significant in the regression model, but the QCA model indicated that it needs to be combined with other factors to impact on job crafting. The QCA model uncovered seven key conditional configurations that led to high and low job crafting among emergency nurses, explaining 80.0% of the results for high job crafting and 82.6% of the results for the low job crafting, respectively.

Conclusions

The results of this study provide valuable insights into the job crafting experienced by emergency nurses. Junior emergency nurses should be granted a high level of psychological empowerment without assigning them overly complex tasks, such as research tasks, as these challenges can stop their job crafting. Intermediate and senior emergency nurses, on the other hand, can be assigned research tasks coupled with high psychological empowerment to enhance their job crafting.

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Introduction

As diseases become more complex and technology evolves rapidly, nursing work is changing, which has posed new tasks and demands for the nurses these days. It was noted that employees should work stepwise in the traditional human resource management system. However, in recent years, researchers have encouraged employees to change their jobs in line with the reality of their work. ‘Job crafting’ is an employee-focused approach to job redesigning [ 1 ].Job crafting is defined as a series of proactive behaviors exhibited by employees in order to balance work resources and needs, with the aim of aligning their work with their own preferences, motivations, and passions [ 2 ].YEPES-BALDÓ surveyed 530 Spanish nurses and found that the job crafting score was 3.17 ± 0.66 [ 3 ]. BAGHDADI conducted a survey among 594 nurses in Saudi Arabia, reporting the job crafting score was 3.54 ± 0.50 [ 4 ]. In summary, it is observed that there are variations in the level of job crafting among nurses, which is generally at a moderate level.

Wrzesniewski first proposed job crafting, suggesting that employees could engage in job crafting in three dimensions: cognitive, task, and relational [ 1 ]. Job demand-resource was further integrated by Tims and Bakker, and it suggested that all working conditions can be classified as job demands or resources [ 5 , 6 ], which includes four dimensions: reducing hindering job demands, increasing challenging job demands, increasing structural job resources and increasing social job resources. Promoting-focused job crafting has been shown to be positively related to job involvement and satisfaction, and negatively related to burnout, depression, and illness [ 7 , 8 ]. Furthermore, studies conducted in the field of career development have shown that promotion-focused job crafting is positively related to career competency and career promotion [ 9 ]. Emergency nurses encounter more complex clinical environments and problems than other departments. The emergency department serves as the first line of defense in hospitals to save patients’ lives. However, it is also the department where adverse events such as nurse-patient disputes and complaints are most likely to occur. According to reports, emergency nurses experience higher occupational stress than other departments, which can lead to dissatisfaction with nursing work among nurses, and even turnout [ 10 ]. This, in turn, will result in a shortage of emergency nurses, further increasing the occupational stress on those remaining in the emergency department. Furthermore, nurses face additional research tasks and pressures in addition to solving clinical problems in China. So, we defined emergency nurse’s hindering and challenging demands as a research experience, professional position, number of night shifts, etc.

Autonomy is an important work feature, as it can be associated with a better capacity to handle stress [ 6 ]. Structural and psychological empowerment are two categories of authority that can give nurses some autonomy at work. Psychological empowerment as an extension of structural empowerment, focuses on the internal feelings of an individual toward organizational empowerment. Spritzer defined psychological empowerment as a sense of control over one’s work environment, which includes the dimensions of impact, meaning, competence, and self-determination [ 11 ]. Increased psychological empowerment of nurse has been shown to lead to job satisfaction and more positive organizational behavior [ 12 ]. The sense of control over their work behaviors can be increased if nurses have a stronger psychological empowerment. They feel more confident acquiring the required knowledge and skills to do their job, and also have a greater perception of their impact on organizational management, decision-making, and performance [ 13 ]. This helps nurses take the initiative toward rebuilding the organizational relationships and actively redesigning work content to address the challenges on the job [ 14 ]. Therefore, we defined the work resources as the level of psychological empowerment given to nurses by their organizations.

Occupational benefits are internal, personal motivators that nurses blend with their good work experiences and cognitive assessments [ 15 ]. It can also result in greater job satisfaction, the promotion of creative behavior, and a reduction in burnout and turnover intentions [ 16 ]. Occupational benefits reflect how satisfied employees are with the organization’s management, which has a significant impact on whether or not they want to stay. According to the JD-R theory, nurses’ job crafting has resulted in favorable occupational benefits for them. Emergency nurses are often faced with critically ill patients, and their nursing work demands a high level of expertise. Correspondingly, the rehabilitation of patients can bring them a sense of accomplishment and self-worth, providing a strong sense of occupational benefits [ 17 ]. In order to continually obtain this feeling, emergency nurses may engage in job crafting to reshape their work.Their practice reflects how they view the rewards and advantages of their profession, which supports their involvement in their work.

Job involvement, as a type of work commitment, is the psychological recognition of an individual’s work. It is more linked with the satisfaction of internal needs.From the perspective of an organization, Pfeffe stated that job involvement is crucial for motivating employees [ 18 ]. However, there is a disagreement at the moment on whether or not job involvement affects individual performance [ 19 ]. On the other hand, some studies have shown that job involvement is the only variable associated with the nurses’ intention to continue working in their current position, not withstanding their work environment [ 20 ]. When demands exceed resources, employees feel immense pressure, leading to negative emotions and affecting job involvement [ 21 ]. Thus, this suggests that work involvement may arise from job crafting. From this, we hypothesized that emergency nurses with high levels of job involvement may pay more attention to the details of work, which in turn identifies work processes or tasks that need to be improved and triggers job crafting. Therefore, it is worth to be further analyzed whether job involvement would have an impact on job crafting.

Due to the growing complexity of the nurses’ work, one antecedent variable cannot fully explain the causes of the findings. Regression model could only examine the net effect of one of the independent variables on outcomes rather than exploring complex causal relationships between the antecedent variables [ 22 ]. The configuration theory is based on the idea of sets, as it allows the analysis of configuration effects generated by multiple conditional variables of the organization’s management [ 23 ]. This study used both regression modeling and fsQCA modeling. fsQCA adds depth by showing complex paths to job crafting, where variables can combine differently to explain outcomes. Even non-significant regression variables can impact job crafting in fsQCA. Combining both methods gives a comprehensive view of why emergency nurses reshape their work, revealing intrinsic motivations. Therefore, the aim of our study is to explore the core factors influencing job crafting in emergency nurses through a hierarchical regression model and fuzzy set qualitative comparative analysis.

A convenience sampling method was applied in the study, an online questionnaire was sent to the emergency nurses through a mobile program in the cities of Shenzhen and Zhengzhou, China, in March 2023. The inclusion criteria were: working in the emergency department; working for more than 1 year; voluntary participation, and informed consent. The exclusion criteria were: trainee nurses, vacation nurses. Based on sample size estimation principles, this study calculated the required sample size to be 5–10 times the number of independent variables. We calculated a required sample of 110–220, given 22 independent variables. Considering a 20% invalid questionnaire rate, we distributed 280 questionnaires.

Instruments

General information questionnaire.

The general information questionnaire was designed by the researcher and includes gender, age, monthly income, etc.

Perceived occupational benefits Questionnaire[ 24 ]

The questionnaire contains 5 dimensions and 29 items. The questionnaire had a 5-point Likert scale, with 1 indicating “strongly disagree” and 5 indicating “strongly agree”. No reverse scoring items were available for the scale. The scores represented the nurses’ perception of professional benefits along with a Cronbach’s alpha of 0.96 in the study.

Job crafting Scale[ 2 ]

With 21 items, the scale is scored on a 5-point Likert scale. Here, higher scores indicate better job crafting. The scale comprises four dimensions: increasing structural work resources, increasing social work resources, increasing challenging work demands, and decreasing hindering work demands. The Cronbach’s alpha coefficient is 0.93 in the study.

Psychological empowerment Scale[ 25 ]

This scale includes 4 dimensions: work meaning, autonomy, self-efficacy, and work influence. Each dimension has 3 items under it, totaling 12 items. The 5-point Likert scale is used, where a higher total score indicates a higher degree of PE. The Cronbach’s alpha coefficient of this scale was tested to be 0.94.

Job involvement Scale[ 26 ]

The scale consists of 10 items on a 5-point Likert scale, with items 2 and 7 being reverse-scored. The level of score indicates the extent of job involvement. The Cronbach’s alpha coefficient of the scale in the study was tested to be 0.82.

Date collection

Researchers contacted nursing management personnel from various hospitals to obtain their consent and support. Nurses were informed about the research objectives, significance, and principles of anonymity and then shared the questionnaire links to those who agreed to participate. The survey was set up through a survey platform, and to ensure quality, all questions were mandatory. Each nurse gets the link via WeChat and is limited to one response. After the survey concluded, a total of 280 questionnaires were collected. Among them, those questionnaires with identical responses for all items and completion times less than 3 min were excluded. Ultimately, 255 questionnaires were valid, resulting in an effective response rate of 91.07%.

SPSS 24.0 software was used to analyze the data; it was described using frequencies, percentages, or means ± standard deviations, depending on the data type. Comparisons between groups were analyzed using independent samples t-test or one-way ANOVA with a test level of α = 0.05. The paper looks at the amount of variance explained by demographic factors on Job crafting(R 2 ) in the one-way analysis of the first level of the hierarchical regression model. In the second level of the hierarchical regression model, other factors that may affect job crafting are integrated to observe the amount of variance explained variance (ΔR 2 ).

Qualitative comparative analysis (QCA ) is a new method for analysing complex causal relationships in histological problems based on Boolean algebra and set theory.QCA is a new method that combines quantitative and qualitative analysis, providing strong support for studying the configuration problem. Based on variable type, QCA is divided into csQCA, mvQCA, and fsQCA. fsQCA has been selected in this paper to analyze the configuration effects of job crafting factors among emergency nurses. QCA requires the calibration of the original data into the set. Calibration is the process of assigning sets to cases. Sociodemographic variables that were meaningful for univariate analysis were included in the analysis of the fsQCA model. In this case (Research experience: 0 = None; 1 = have), (Professional Position: 0 = Advanced; 0.5 = Intermediate; 1 = Junior). The fuzzy set requires setting three critical values according to the theoretical or conceptual settings: fully affiliated, crossover, and fully unaffiliated, and with the affiliation of the transformed set between 0 and 1. For the continuous variables, the 0.05th, 0.5th and 0.95th percentile of the data were taken and substituted into the Calibrate function (x, fully in, crossover, fully out).It was analyzed whether the antecedent variable was necessary for job crafting in emergency nurses before the sufficient analysis. If the antecedent variable was greater than 0.9 [ 27 ], it was considered necessary. A truth table for sufficient analysis was constructed using fsQCA 3.0, with consistency set to 0.8 and frequency set to 1. If variables appear in both parsimonious and intermediate solutions, they are called core conditions. If they only appear in intermediate solutions, they are called edge conditions [ 28 ].

Descriptive and univariate analysis

A total of 255 nurses were included, of which 228 (89.4%) were female and up to 209 (82.0%) had no research experience. The results demonstrated that research experience and job position were considered influential variables for job crafting among emergency nurses. Also, the differences were all statistically significant ( p  < 0.05), as seen in Table  1 .

Hierarchical regression models

A variance variation of 0.047 was obtained after entering the sociodemographic factors into the regression model, with significance in the one-way analysis. In the paper, it was shown that nurses with no research experience had a lower job crafting than nurses with research experience( P <0.05) In the second step, three psychological variables were added, and it was found that a variance variation of 0.283 was obtained. The significant variables were research experience (β=-0.135, p  < 0.05), perceived occupational benefits (β = 0.177, p  < 0.05), and psychological empowerment (β = 0.317, p  < 0.001), as can be seen in Table  2 .

Necessary analysis

The consistency score was considered necessary for evaluating whether the antecedent variable was available as the outcome variable. The consistency score is similar to the significance of the coefficient in a regression model. It represents the extent to which the outcome has to rely on the antecedent variable. In this study, no variable existed as a necessary condition since none of the antecedent variables reached 0.9. Refer to Table  3 for details.

Sufficient analysis

Six conditional configurations that generated high job crafting and six conditional configurations that generated low job crafting were analyzed together. The twelve configurations were sufficient conditions to constitute high and low job crafting for the emergency nurses. The overall solution coverage of high and low job crafting was 0.800 and 0.826, as seen in Table  4 . This shows that the twelve configurations explain 80% of the results for high job crafting and 82.6% for low. The paper remove unique coverage of less than 0.1 for the configuration because it was hard to cover 10% of the samples. Three configurations of high job crafting and four configurations of low job crafting for emergency nurses are obtained.The raw coverage of H1 was 0.106 in the high job crafting configuration, which meant that this configuration could explain 10.6% of the sample.Among the low job crafting configurations, it was found that L2 had the highest raw coverage. The configurations are elaborated as follows: ① H1: high psychological empowerment + high job involvement + junior professional position + no research experience. ② H2: high psychological empowerment + high job involvement + have research experience. ③ H3:high job involvement + high perceived occupational benefits + senior professional position + no research experience. ④ L1: low perceived occupational benefits + senior professional position + no research experience. ⑤ L2: low psychological empowerment + senior professional position + no research experience. ⑥ L3: high job involvement + senior professional position + low perceived occupational benefits. ⑦ L4: low job involvement + senior professional position + research experience.The most relevant pathway or combination to explain low job crafting was L2 (raw coverage = 0.038; consistency = 0.879), which explained 64.3% of the cases. The most relevant pathway or combination to explain high job crafting was H1 (raw coverage = 0.106; consistency = 0.798), which explained 60.1% of the cases.Refer to Table 4 for details.

Discussions

This study explored the effects of sociodemographic variables, psychological empowerment, occupational benefits, and job involvement, on job crafting among the emergency nurses. The majority of existing studies have concentrated on linear regression models. This neglects the complement of other methods, like the fsQCA model [ 29 ]. The study overlooked the synergy between factors if the researcher focuses only on regression models. In helping the researcher to construct intervention plans, the fsQCA models with different pathways formed by the synergy between factors are particularly important [ 30 ]. Regression models indicated that research experience, psychological empowerment and occupational benefits were associated with job crafting, which is consistent with existing research [ 31 ]. Based on the results of the fsQCA analysis, no necessary conditions for job crafting were found. In terms of the sufficiency analysis, it was found that H1 has the highest coverage, explaining 10.6% of cases after comparing the raw coverage of the three configurations that stimulate high job crafting among emergency nurses. This suggested that the majority of emergency nurses who exhibit high job crafting are influenced by the conditions present in H1, and psychological empowerment is the core condition. For the four paths of the low job crafting, L2 has the highest raw coverage. This indicated that nurses with junior professional position and no research experience who lack sufficient psychological empowerment are unlikely to engage in job crafting. Once again, psychological empowerment emerges as a core condition in this path, reinforcing the results obtained through regression analysis.

We can discuss the professional position and research experience from “increasing the challenging work demands” and “lessening hindering work demands”, based on the job crafting theory [ 6 ]. Since junior emergency nurses were newly exposed to clinical nursing work along with the special characteristics of emergency nursing, they faced higher work stress when addressing clinical problems that were primarily acute and serious. The problems mentioned above can also serve as a cause of stress that constantly reduces self-efficacy in the emergency care process. Additionally, the junior emergency nurses lack knowledge and experience in nursing research when they were students, and the research ability of nurses working in clinical settings is low in China [ 32 ]. Most nurses are under pressure to perform the job guided by the goal of job position improvement [ 33 ], and the inner drive to explore and solve research problems was insufficient [ 34 ]. If the nurses were assigned to research work by the organization, the work demands would inevitably exceed their abilities, leading to work hindrances. Junior nurses experience less pressure about job position improvement, and they may be fearful of research work. This may create defensive job crafting by lessening hindering work demands. Although this helps them to accomplish their clinical goals, it may reduce their work motivation and job involvement. The second dimension of job crafting is about increasing the challenging work demands. It has been revealed that a lack of challenging work may lead to absences and job dissatisfaction. Research tasks, as a challenge, may lead to the creation of job crafting for advanced practice nurses. By expanding task boundaries and increasing challenging work demands, the nurses have contributed to the organization. It was shown that challenge demands were associated with goal achievement and work motivation [ 6 ]. The H2, with research experience as a core condition, confirmed that the high job crafting was associated with the individuals’ promotion of “challenge demands”.

The high level of psychological empowerment in nurses was a core condition that influenced the level of job crafting on both core configurations (H1&L2). From regression models, it was also seen that psychological empowerment was a core element affecting job crafting (β = 0.317, p  < 0.001). This means that the job crafting gradually increased with the psychological empowerment. The self-determination theory suggests that autonomous motivational orientation, as opposed to control motivational orientation, would be more beneficial in addressing the basic psychological needs. A high level of psychological empowerment as a variable of autonomous motivational orientation could enhance individual job performance and job ability [ 35 ]. The resource conservation theory states that employees can experience higher psychological security as they sense higher levels of psychological empowerment through a cycle of resource loss and gain spirals. These positive job resources assist them in conserving and building more resources to cope with the prospect of poor career outcomes and job demands [ 36 ], which precisely confirm the findings of this paper.

In the emergency departments, nurses face a large number of job challenges on a daily basis. The ability of nurses to cope better with these challenges is closely related to perceived occupational benefits. Emergency nurses who perceive high levels of empowerment were better able to respond to the work challenges [ 37 ]. With increased resources for employees to do their jobs, a positive impact was bound to be seen on their psychological empowerment [ 14 ]. By acquiring and conserving resources, nurses are most likely to achieve the most appropriate match between people and job demands. Nurses who are motivated and empowered can develop more job crafting [ 38 ]. If this goal is achieved, it would increase nurses’ satisfaction and thus would promote job crafting resulting in a virtuous circle. To summarize, the results of both the QCA and the regression model demonstrated that the psychological empowerment was a core condition that influenced job crafting among the emergency nurses. From H1, H2 and L2, it can also be proved that high psychological empowerment was the core condition for a high job crafting, regardless of whether or not they had done clinical research work.

The identification with one’s job based on its potential to meet one’s needs and expectations is called job involvement. The job involvement has been mentioned in the literature as a reason why nurses feel so committed to their jobs [ 39 ]. Nurses with a high level of job involvement deliberately consider their work an important part of their lives. Whether or not they can feel good about themselves is closely related to their personal work. Thus, a healthy management structure should consider job involvement as an important predictor of organizational productivity. This attitude of nurses toward their jobs should be promoted [ 20 ]. However, the regression model shows that job involvement does not influence job crafting. Meanwhile, the H1-H3 all indicated that job involvement was an impact on job crafting, and two of these paths indicated that job involvement was a core condition for a high job crafting. Job involvement is influenced by the worker’s identification with the job they are doing. This is, in turn, derived from whether the job can meet the needs of the worker or not. This means that once a nurse has job involvement, a balance between job resources and demands can be reached and the nurse’s job crafting would be suspended. The QCA model revealed that job involvement may need to have an impact on job crafting in conjunction with the other factors. Several studies have also shown that job involvement is correlated with psychological empowerment [ 40 ]. The impact of nurses’ job involvement on their job crafting needs to be further explored.

The occupational benefits of nurses is a cognitive assessment of their feelings about the content of their work, which comes from their internal traits and the external work environment [ 41 ]. Job crafting is a positive behavior for individuals to balance job demands and resources. It can help individuals use available job resources to cope with the stress of job demands and achieve higher levels of job performance [ 42 ]. It enables the nurses to perceive occupational benefits. The H3 demonstrated that both the occupational benefits and the job involvement must be maintained at high levels for junior emergency nurses to lead to a high job crafting. The existence of a low occupational benefits and job involvement will inevitably lead to low job crafting, as seen from L3 and L4. When junior emergency nurses perceive occupational benefits, it may lead to more job autonomy which results in increased psychological recognition of their work [ 43 ]. High levels of job involvement allow nurses to be fully immersed in their work, improving efficiency and quality. With increased efficiency and quality, nurses can obtain more job performance and achievement, in turn bringing them stronger occupational benefits.

Limitations

Although the study obtained some results that could be effective in improving the job crafting for the emergency nurses, the limitations of the study are as follows. First, this cross-sectional survey was conducted with emergency nurses in China, which may limit the extension of these results to other regions. And convenient sampling techniques and the non-calculated sample size of the study limits the generalizability. Secondly, the cross-sectional study does not allow for the detection of possible changes in the levels of job crafting in each participant over time. Lastly, the data were collected from participants using self-report measures, and thus may not reflect their true feelings.

Implications for the profession

The findings of the paper provided two important insights for motivating job crafting in emergency nurses. Firstly, we recognized challenge demands have a significant contribution to job crafting. As such, nursing managers in emergency departments should assign nurses challenging tasks, such as participating in nursing research. These challenges not only stimulate nurses’ potential but also foster their personal growth. However, it’s crucial to align these challenging work demands with commensurate rewards, such as promotion in position, bonus allocation, etc. Meanwhile, it is necessary to give adequate psychological empowerment and cultivate a proper understanding of challenge demands such as research tasks to inspire job crafting in the nurses. This approach will encourage nurses to more actively engage in job crafting, continually improving their work efficiency. Secondly, emergency nursing managers should should carry out a layered method and focus on the main job demands of the nurses at different levels. Junior nurses experience more difficulty in facing the challenges brought by clinical work, which may not deal with the busy and ever-changing work of the emergency department. Thus, special attention should be paid to their psychological endurance and work stress to prevent job burnout and turnover when assigning research or other challenging tasks to them. For senior nurses, management should provide more psychological empowerment, making them feel trusted and respected by the organization. An organization that meets the staff needs and promotes staff development on priority allows nurses to perceive occupational benefits, enhances their sense of emotional belonging, and lastly, boosts the job crafting with a rise in job involvement [ 44 ]. Nurses will be more proactive in participating in work planning and implementation, actively adjusting and optimizing work processes to better meet the various challenges in the emergency department.

The study explored various influencing factors on the job crafting of emergency nurses through hierarchical regression and fsQCA models. Both the models have demonstrated that research experience, psychological empowerment, and occupational benefits were predictors of job crafting, along with high levels of psychological empowerment being the core condition on the higher paths (H1 & S2). Based on research findings, junior emergency nurses should be granted a high level of psychological empowerment without assigning them overly complex tasks, such as research tasks, as these challenges can stop their job crafting. Intermediate and senior emergency nurses, on the other hand, can be assigned research tasks coupled with high psychological empowerment to enhance their job crafting.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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This work was supported by grants from Henan Provincial Medical Science and Technology Research Project(LHGJ20200109);and Jiaxing University Research Fund (CD70522005).

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Yu Wang : Preparation, creation and/or presentation of the published work, specifically writing the initial draft (including substantive translation). Development or design of methodology; creation of models. Qiaofang Yang : Provision of study materials, participants, instrumentation, computing resources, or other analysis tools. Luwen Wang : Visualization, Investigation. Qingwei Zhang: Application of statistical, mathematical, computational, or other formal techniques to analyze or synthesize study data, and acquisition of the financial support for the project leading to this publication. Yingli Li : Writing- Reviewing and Editing, and Funding acquisition.

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Wang, Y., Yang, Q., Wang, L. et al. The factors of job crafting in emergency nurses: regression models versus qualitative comparative analysis. BMC Nurs 23 , 369 (2024). https://doi.org/10.1186/s12912-024-02035-3

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Exploring Alcohol Consumption and Coping Strategies among Female University Students in India During the COVID-19 Pandemic: A Qualitative Analysis

| Published: May 31, 2024

The COVID-19 pandemic has precipitated profound shifts in the lives of individuals globally, necessitating an examination of coping mechanisms and alcohol consumption patterns, particularly among vulnerable populations like female university students. This qualitative study delves into the nuanced interplay between stressors, perceived coping styles, and alcohol consumption habits among 32 Indian female university students during the pandemic. Thematic analysis revealed three major themes: “Factors Influencing Alcohol Consumption” and “Coping Strategies,” each comprising distinct sub-themes. Under “Factors Influencing Alcohol Consumption,” participants reported an increase in alcohol consumption rates amidst the pandemic, alongside notable decreases, with identified factors including stress, social/familial influences, and individual coping mechanisms. Subsequent exploration unearthed “Healthy” and “Unhealthy” coping strategies, encompassing diverse approaches from online interaction to self-harm. These findings underscore the multifaceted nature of responses to stress among female university students in India, shedding light on the complexities of alcohol consumption and coping behaviors during times of crisis. The study’s implications resonate across mental health professionals, educators, and families, emphasizing the necessity of tailored interventions to promote adaptive coping strategies and mitigate substance use risks among this demographic. Furthermore, it calls for continued research efforts to unravel the evolving dynamics of coping strategies amidst post-pandemic transitions, advocating for interdisciplinary approaches to address the holistic well-being of university students in India.

COVID-19 Pandemic , Alcohol Consumption Rate , Healthy & Unhealthy Coping Strategies , Students’ Perspective

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Received: April 16, 2024; Revision Received: May 27, 2024; Accepted: May 31, 2024

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