Locked doors in acute inpatient psychiatry: a literature review

Factors Influencing Staff Perceptions of Inpatient Psychiatric Hospitals: A Meta-Review of the Literature

Staff perceptions of inpatient psychiatric hospitals ultimately impact a range of organisational and care-related variables, including staff retention and quality of care for inpatients. The aim of this study was to conduct a meta-review to synthesise themes reported by staff to influence their perceptions of inpatient psychiatric hospitals. The review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines for systematic reviews. PsycINFO, CINAHL, MEDLINE and EMBASE were systematically searched. Reviews were eligible for inclusion if they examined the perception/experience of paid staff involved in caring for adults with mental illnesses admitted to an inpatient psychiatric hospital. Eligible reviews were assessed for methodological quality and bias. Thematic synthesis was used to merge thematically similar findings into an aggregate summary. Fifteen reviews were included, from which seven themes were reliably extracted: staff and patient safety, views on inpatients' experiences, relationships on the ward, ward rules, knowledge and experience, service delivery issues and coercive measures. Confidence in the evidence underlying each theme was analysed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) criteria. Results indicate that staff perceptions of inpatient psychiatric hospitals overlap with inpatients' perspectives, particularly regarding the therapeutic relationship, coercive measures and ward safety, in addition to unique experiences. Factors identified can help guide ways to improve staff retention, satisfaction and quality of treatment.

Feeling coerced during voluntary and involuntary psychiatric hospitalisation: A review and meta-aggregation of qualitative studies

Objective

This review aimed to provide an aggregative synthesis of the qualitative evidence on patients' experienced coercion during voluntary and involuntary psychiatric hospitalisation.

Design

A qualitative review.

Data sources

The search was conducted, in five bibliographic databases: Embase.com, Ovid MEDLINE(R) ALL, APA PsycINFO Ovid, Web of Science Core Collection and the Cochrane Database of Systematic Reviews.

Review methods

Following the Joanna Briggs Institute approach, a systematized procedure was applied throughout the review process, from data search to synthesis of results. The reporting of this review was guided by the standards of the PRISMA 2020 statement. The quality of the included studies was critically appraised by two independent reviewers using the JBI Critical Appraisal Checklist. Included findings were synthesized using meta-aggregation. Confidence in the review findings was assessed following the Confidence in the Output of Qualitative research synthesis (ConQual) approach.

Results

A total of 423 studies were identified through the literature search and 26 were included in the meta-aggregation. Totally, 151 findings were extracted and aggregated into 27 categories and 7 synthesized findings. The synthesized findings focused on: the patients' experience of the hospitalisation and the associated feeling of coercion; the factors affecting this feeling, such as the involvement in the decision-making process, the relationships with the staff and the perception of the hospital treatment as effective and safe; the coping strategies adopted to deal with it and the patients' suggestions for alternatives. All synthesized findings reached an overall confidence score of "moderate". The seven findings were downgraded one level due to dependability limitations of the included studies.

Conclusion

Based on these findings, seven recommendations for clinical practice where developed, such as fostering care ethics, promoting patients' voice and shared decision-making, and enhancing patients' perceived closeness, respect and fairness. Five recommendations for future research were also prompted, for instance improving the methodological quality and cultural variation of future qualitative studies, and exploring the psychosocial impact of experienced coercion on patients. For these recommendations to be effectively implemented, a profound change in the structure and culture of the mental health system should be promoted. The involvement of patients in the design, development and scientific evaluation of this change is strongly recommended.

Open Doors by Fair Means: a quasi-experimental controlled study on the effects of an open-door policy on acute psychiatric wards

Background

Psychiatric wards treating involuntarily admitted patients are traditionally locked to prevent absconding. However, on the basis of observational evidence, the necessity for locked units in psychiatric hospitals has increasingly been questioned. Updated Mental Health Laws in several Federal States of Germany legitimate involuntary commitment without generally locked doors.

Methods

We examined the effects of an open-door policy in a quasi-experimental, prospective design. For the first time, at each of two locations, two identical wards serving as control and intervention could be compared. After a baseline period of three months, one ward at each location started the 12 month intervention period with the implementation of an open-door policy, while the respective control ward, as before, used open doors only facultatively. Primary outcomes were average opening times of the four wards between 8 a.m. and 8 p.m., and the number of involuntary treatment days with the doors open. Secondary outcomes were adverse events including aggressive incidents, absconding, suicide attempts and coercive measures.

Results

Overall, door-opening times increased significantly at both sites´ intervention wards. The number of adverse events did not increase during intervention period. Frequencies of coercive measures decreased in Friedrichshafen and remained unchanged in Tuebingen. In case of the intervention ward in Friedrichshafen, doors were open in up to 91% of all involuntary treatment days, whereas in the control ward, this was only the case in 67% of all involuntary treatment days (p < .001). In case of the intervention ward in Tuebingen, 45% of involuntary treatment days had open doors, compared to 30% in the control ward (p < .001).

Conclusions

It is possible to manage psychiatric wards with open doors without taking inappropriate risks. The extent to which open-door policies are achievable is be dependent on staffing and patient characteristics. Further research is necessary to explore the role of staff attitudes.

Trial registration

Our trial "Open Doors by Fair Means" is retrospectively registered with DRKS (DRKS00015154) on Sept. 10^th 2018 and displayed on the public web site. It is searchable via its meta-registry (http://apps.who.int/trialsearch/).

Containment and therapeutic relationships in acute psychiatric care spaces: the symbolic dimensions of doors

BACKGROUND

There is an increasing trend of door locking practices in acute psychiatric care. The aim of the present study was to illuminate the symbolic dimensions of doors in Greek mental health nurses' experiences of open and locked working spaces.

RESULTS

A sequential mixed-method designexplored the experiences of nurses working in both open and locked psychiatric acute care units. Participants experiences revealed four types of doors related to the quality of recovery-oriented care: (a) the open door, (b) the invisible door, (c) the restraining door, and (d) the revolving door. Open doors and permeable spacesgenerated trust and facilitated the diffusion of tension and the necessary perception of feeling safe in order to be involved in therapeutic engagement. When the locked unit was experienced as a caring environment, the locked doors appeared to be "invisible". The restraining doors symbolized loss of control, social distance and stigma echoing the consequences of restrictingpeople's crucial control over spaceduring the COVID-19 pandemicin relation toviolence within families, groups and communities. The revolving door (service users' abscondence/re-admission) symbolised the rejection of the offered therapeutic environment and was a source of indignation and compassion fatigue in both open and locked spaces attributed to internal structural acute care characteristics (limited staffing levels, support, resources and activities for service users) as well as 'locked doors' in the community (limited or no care continuity and stigma).

CONCLUSIONS

The impact of COVID-19 restrictions on people's crucial control of space provides an impetus for erecting barriers masked by the veil of habit and reconsidering the impact of the simple act of leaving the door open/locked to allow both psychiatric acute care unit staff and service users to reach their potential.

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

INTRODUCTION

On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.

METHOD

In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.

RESULTS

The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.

CONCLUSION

Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

Opportunities, risks and challenges in global mental health and population neuroscience: a case of Sino-German cooperation

Large scale prospective cohorts have now been established across several countries, and continents, and among the aims include an assessment of the developmental trajectory of mental disorders. This level of international cooperation helps transfer research findings to new social contexts as well as enabling an assessment of which findings can be replicated, and which interventions are most effective, in different social and cultural settings. However, data sharing across different regional and national health care systems requires a careful consideration of different standards in ethical research, data protection and patient care, including respect for patients' rights, in cooperating jurisdictions. In our review, we discuss ethical, legal and practical challenges associated with such cooperation with a focus on research participants, specifically patient recruitment, by considering the instance of China and Germany. Our broader aim is to promote international cooperation by identifying key challenges that arise in international cooperation, and to facilitate an exchange in relation to legal and practical approaches.

Locked versus open ward environments and restrictive measures in acute psychiatry in Greece: Nursing students' attitudes and experiences

PURPOSE

To examine student nurses' attitudes and experiences of door policies and restrictive measures in acute psychiatric care.

METHODS

A mixed-method study with 274 third-year students.

RESULTS

Participants' attitudes towards door locking and other containment measures appeared to be more a matter of custom, practice and tradition at particular units. The therapeutic benefits of open doors was the central organizing element in open units experiences while locked doors appeared to be "invisible" when the locked unit was perceived as a caring environment.

PRACTICAL IMPLICATIONS

Exploring student nurses' attitudes towards crucial and debatable aspects of mental health practice contributes in cultivating a critical and analytical attitude towards the service they provide necessary for supporting a recovery mental health model and building a strong professional identity.

Factors associated with requests for premature discharge and the decision to support a service user through the discharge against medical advice process

In the Irish mental healthcare system, voluntarily admitted service users can request to leave hospital at any time. Following engagement with treating clinicians, service users remain as voluntary inpatients, are discharged, discharge themselves against medical advice, or are detained under legislation for the purposes of assessment. While detention conflicts with the principle of autonomy and a human rights-based approach, premature discharge is often associated with negative outcomes including reduced time to readmission, poorer quality of life, increased costs, and suicide. This study is a retrospective review of clinical records to identify factors associated with requests for premature discharge. Considerations of clinicians making the decision to detain the person or to support them through the discharge against medical advice process were also elucidated. Data were collected from clinical records of service users who requested discharge and were subsequently discharged against medical advice or detained involuntarily. Discharge against medical advice represented 3.5% of all discharges. The most frequent reasons for requests for discharge against medical advice were dissatisfaction with treatment, lack of engagement due to addiction, and leaving without notifying staff. Requests for discharge against medical advice frequently occurred out of hours, and nurses were the clinicians most likely to receive such requests.

Using patient experience data to support improvements in inpatient mental health care: the EURIPIDES multimethod study

Background

All NHS providers collect data on patient experience, although there is limited evidence about what to measure or how to collect and use data to improve services. We studied inpatient mental health services, as these are important, costly and often unpopular services within which serious incidents occur.

Aims

To identify which approaches to collecting and using patient experience data are most useful for supporting improvements in inpatient mental health care.

Design

The study comprised five work packages: a systematic review to identify evidence-based patient experience themes relevant to inpatient mental health care (work package 1); a survey of patient experience leads in NHS mental health trusts in England to describe current approaches to collecting and using patient experience data in inpatient mental health services, and to populate the sampling frame for work package 3 (work package 2); in-depth case studies at sites selected using the work package 2 findings, analysed using a realist approach (work package 3); a consensus conference to agree on recommendations about best practice (work package 4); and health economic modelling to estimate resource requirements and potential benefits arising from the adoption of best practice (work package 5). Using a realist methodology, we analysed and presented our findings using a framework based on four stages of the patient experience data pathway, for which we coined the term CRAICh (collecting and giving, receiving and listening, analysing, and quality improvement and change). The project was supported by a patient and public involvement team that contributed to work package 1 and the development of programme theories (work package 3). Two employed survivor researchers worked on work packages 2, 3 and 4.

Setting

The study was conducted in 57 NHS providers of inpatient mental health care in England.

Participants

In work package 2, 47 NHS patient experience leads took part and, in work package 3, 62 service users, 19 carers and 101 NHS staff participated, across six trusts. Forty-four individuals attended the work package 4 consensus conference.

Results

The patient experience feedback cycle was rarely completed and, even when improvements were implemented, these tended to be environmental rather than cultural. There were few examples of triangulation with patient safety or outcomes data. We identified 18 rules for best practice in collecting and using inpatient mental health experience data, and 154 realist context–mechanism–outcome configurations that underpin and explain these.

Limitations

The study was cross-sectional in design and we relied on examples of historical service improvement. Our health economic models (in work package 5) were therefore limited in the estimation and modelling of prospective benefits associated with the collection and use of patient experience data.

Conclusions

Patient experience work is insufficiently embedded in most mental health trusts. More attention to analysis and interpretation of patient experience data is needed, particularly to ways of triangulating these with outcomes and safety data.

Future work

Further evaluative research is needed to develop and evaluate a locally adapted intervention based on the 18 rules for best practice.

Study registration

The systematic review (work package 1) is registered as PROSPERO CRD42016033556.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 21. See the NIHR Journals Library website for further project information.

Preventing Suicide among Psychiatric Inpatients with Psychotic Depression

To investigate which factors individuals with a psychotic depression experience as preventive of suicide while beeing hospitalized. Semi-structured qualitative interviews with nine inpatients, all hospitalized for a unipolar or bipolar depressive episode with psychosis, were conducted at time of discharge. For analysis we used systematic text condensation. Main outcomes were accounts of participants' experiences of suicide prevention measures and treatment, and how these affected suicidal ideation, plans, and attempts. Participants experienced (1) suicide attempts being physically interrupted or prevented; (2) receiving medical treatment to alleviate unbearable suffering; (3) finding refuge behind locked doors; (4) receiving guidance to redefine their identity and situation. They reported being protected from suicidal impulses and imagined persecutors in a secure environment with staff present. They described their autonomy as compromised by intense suffering and chaos. They retrospectively appreciated staff interventions, if these were performed compassionately and with empathy. Participants described that suicidal thoughts and actions were triggered by terrifying psychotic experiences, anxiety and sleeplessness, and felt that medication - and in one instance electroconvulsive therapy- alleviated suffering. At time of discharge, participants reported no psychotically motivated suicidal thoughts. They described a new, insightful self-view and acknowledged having been severely mentally ill. To prevent impulsive suicidal behavior, findings highlight the need for both security measures and a treatment approach focusing on modifying psychotic experiences and intense anxiety. Gaining anxious and paranoid patients' trust is essential to build motivation for medical treatment. Patients emphasize that having time to talk is crucial to this process.

Opening the Doors of a Substance Use Disorder Ward-Benefits and Challenges From a Consumer Perspective

Open doors in psychiatry have been a subject of controversy in recent years. While some studies postulate the clinical necessity of closed doors, others challenge the theoretical advantages of this setting, mention numerous drawbacks of closed wards, and focus on the advantages of open-door settings. With regard to patients diagnosed with substance use disorders (SUD), other standards may apply. Very little research has been done on this topic. Some studies adopted a consumer perspective (i.e. asking involved parties about their experience of the door status). To the authors' knowledge, no study has so far addressed the ideal setting for the treatment of SUD. With our data from the opening of a specialized SUD ward, we take one step to closing this knowledge gap. Applying a qualitative design, we asked patients and health care professionals (HCP) to report changes following the opening of the ward. The results are mainly in line with the literature on the general psychiatric population. The newly introduced open-door setting was mostly perceived as positive, but some disadvantages were mentioned (e.g. less protection of patients, less control over who enters/leaves the ward, the theoretically increased risk of patients absconding). Moreover, HCP (but not patients) mentioned potentially increased substance use on the ward as an additional disadvantage that could arise. Opening a previously closed ward was generally perceived as a positive and progressive decision. These findings support the trend towards an overall open-door policy in psychiatry.

Seeking freedom: A systematic review and thematic synthesis of the literature on patients' experience of absconding from hospital

WHAT IS KNOWN ON THE SUBJECT?: Absconding refers to patients leaving psychiatric hospitals in an unexpected and/or unauthorized way and is often recognized as a form of challenging behaviour. There is some research about the rates of absconding, risks associated with it and interventions to try and reduce it; however, relatively little is known about the experience from the perspective of patients and this evidence has not previously been systematically reviewed. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Patients abscond to find relief, to regain power and control over their lives and/or to address unmet needs. Absconding can therefore be viewed as a means of seeking freedom. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to be aware that absconding is a positive act from the patient perspective and work collaboratively with them to reduce factors which motivate this behaviour. From the point of admission, nurses have an important role to play in reducing the sense of fear, isolation and powerlessness which motivates patients to abscond. Practical interventions such as giving patients the time and information necessary to be involved in decision-making, or asking about their responsibilities and commitments outside of hospital, may have a significant impact on the experience of admission and reduce the risk of absconding. Abstract Introduction Absconding from psychiatric hospitals is associated with significant risks, but is difficult to assess. It is often considered a form of challenging behaviour for mental health nurses, yet there is little evidence considering the behaviour from the patient perspective. Aim To identify and review evidence pertaining to the experience of patients who abscond from hospital, paying particular attention to their reasons for doing so. Method A systematic review and thematic synthesis of eight peer-reviewed studies. Results The meaning patients associated with absconding is best characterized as an act of seeking freedom. Within this, four sub-themes were identified: 1) seeking freedom to find relief, 2) to regain power and control over their lives, 3) to address unmet needs and 4) opportunistically. Discussion Perspectives on absconding are markedly different between nurses and patients. Nurses may view absconding as challenging or deviant behaviour, whilst patients understand it as a positive experience. This is because the hospital environment is not meeting their needs. Implications for practice Patients decide to abscond from hospital for valid and rational reasons. Mental health nurses are in a position to understand and address the issues underpinning them with a view to reducing absconding. Further research on absconding from hospital, taking the patient's perspective, is needed.

[Open doors in psychiatric hospitals : An overview of empirical findings]

BACKGROUND

Currently, it is a topic of debate whether psychiatric hospitals can and should be managed with a full open door policy. The revised legislation of public law for involuntary commitment explicitly allows or even encourages such practice in several German federal states. In parts of Austria, open doors are required for legal reasons. A systematic literature search was conducted for articles providing empirical data related to this issue.

METHOD

Literature search in PubMed augmented by a manual search in references of retrieved papers and reviews with similar objectives.

RESULTS

A total of 26 articles reporting empirical data could be identified. Most of these articles came from Germany or Switzerland. The majority were published within the past 5 years. The definition of "open doors" ranged from an only vaguely defined open door policy up to explicit set time periods with open doors. Some studies reported a decrease in coercive interventions. No study reported any associated adverse events resulting from open doors in psychiatric wards.

DISCUSSION

Generally, all studies had methodological weaknesses. Prospective randomized controlled studies or quasi-experimental studies are missing in the context of European healthcare systems. The risk of bias was considerable in most studies. A final conclusion regarding the possible extent of psychiatry with open doors and the associated risks is currently not possible. There is an urgent need for future high-quality prospective studies.

Experiences of in-patient mental health services: systematic review

BACKGROUND

In-patients in crisis report poor experiences of mental healthcare not conducive to recovery. Concerns include coercion by staff, fear of assault from other patients, lack of therapeutic opportunities and limited support. There is little high-quality evidence on what is important to patients to inform recovery-focused care.AimsTo conduct a systematic review of published literature, identifying key themes for improving experiences of in-patient mental healthcare.

METHOD

A systematic search of online databases (MEDLINE, PsycINFO and CINAHL) for primary research published between January 2000 and January 2016. All study designs from all countries were eligible. A qualitative analysis was undertaken and study quality was appraised. A patient and public reference group contributed to the review.

RESULTS

Studies (72) from 16 countries found four dimensions were consistently related to significantly influencing in-patients' experiences of crisis and recovery-focused care: the importance of high-quality relationships; averting negative experiences of coercion; a healthy, safe and enabling physical and social environment; and authentic experiences of patient-centred care. Critical elements for patients were trust, respect, safe wards, information and explanation about clinical decisions, therapeutic activities, and family inclusion in care.

CONCLUSIONS

A number of experiences hinder recovery-focused care and must be addressed with the involvement of staff to provide high-quality in-patient services. Future evaluations of service quality and development of practice guidance should embed these four dimensions.Declaration of interestK.B. is editor of British Journal of Psychiatry and leads a national programme (Synergi Collaborative Centre) on patient experiences driving change in services and inequalities.

Working towards least restrictive environments in acute mental health wards in the context of locked door policy and practice

There has been a shift towards provision of mental health care in community-based settings in Australia. However, hospitals continue to care for people in acute mental health wards. An increasing proportion of the people in wards are admitted involuntarily, subject to restrictions of movement to minimize risk of harm to self and others. In response to concerns about the safety of people absconding from care, Queensland Health introduced a policy requiring all acute mental health wards in the State to be locked. In response, the Queensland Mental Health Commission funded a project to understand the impact of this policy and develop evidence-based recommendations regarding provision of least restrictive, recovery-oriented practices in acute wards. Facilitated forums were conducted with 35 purposively selected participants who identified as consumers, carers, or staff of acute mental health hospital wards, to test the acceptability, feasibility, and face validity of a set of evidence-informed recommendations for providing least restrictive, recovery-oriented practices. Participant responses were recorded, and data were analysed through an inductive, thematic approach. A recovery-oriented approach was supported by all stakeholders. Reducing boredom and increasing availability of peer support workers were considered key to achieving this. Focusing less on risk aversion was reported as central to enabling true Recovery Orientation. This project enabled recognition of the perspectives of consumers, carers, and staff in the consideration of evidence-informed recommendations that could be implemented to provide least restrictive care in the context of locked doors.

Ward Atmosphere and Patient Satisfaction in Psychiatric Hospitals With Different Ward Settings and Door Policies. Results From a Mixed Methods Study

Background: Open-door policies in psychiatry are discussed as a means to improve the treatment of involuntarily committed patients in various aspects. Current research on open-door policies focuses mainly on objective effects, such as the number of coercive interventions or serious incidents. The aim of the present study was to investigate more subjective perceptions of different psychiatric inpatient settings with different door policies by analyzing ward atmosphere and patient satisfaction. Methods: Quantitative data on the ward atmosphere using the Essen Climate Evaluation Scale (EssenCES) and on patient satisfaction (ZUF-8) were obtained from involuntarily committed patients (n = 81) in three psychiatric hospitals with different ward settings and door policies (open, facultative locked, locked). Furthermore, qualitative interviews with each of 15 patients, nurses, and psychiatrists were conducted in one psychiatric hospital with a facultative locked ward comparing treatment in an open vs. a locked setting. Results: Involuntarily committed patients rated the EssenCES' subscale "Experienced Safety" higher in an open setting compared with a facultative locked and a locked setting. The subscale "Therapeutic Hold" was rated higher in an open setting than a locked setting. Regarding the safety experienced from a mental health professionals' perspective, the qualitative interviews further revealed advantages and disadvantages of door locking in specific situations, such as short-term de-escalation vs. increased tension. Patient satisfaction did not differ between the hospitals but correlated weakly with the EssenCES' subscale "Therapeutic Hold." Conclusion: Important aspects of the ward atmosphere seem to be improved in an open vs. a locked setting, whereas patient satisfaction does not seem to be influenced by the door status in the specific population of patients under involuntary commitment. The ward atmosphere turned out to be more sensitive to differences between psychiatric inpatient settings with different door policies. It can contribute to a broader assessment by including subjective perceptions by those who are affected directly by involuntary commitments. Regarding patient satisfaction under involuntary commitment, further research is needed to clarify both the relevance of the concept and its appropriate measurement.

Text Analysis of Electronic Medical Records to Predict Seclusion in Psychiatric Wards: Proof of Concept

Aim: With the introduction of "Electronic Medical Record" (EMR) a wealth of digital data has become available. This provides a unique opportunity for exploring precedents for seclusion. This study explored the feasibility of text mining analysis in the EMR to eventually help reduce the use of seclusion in psychiatry. Methods: The texts in notes and reports of the EMR during 5 years on an acute and non-acute psychiatric ward were analyzed using a text mining application. A period of 14 days was selected before seclusion or for non-secluded patients, before discharge. The resulting concepts were analyzed using chi-square tests to assess which concepts had a significant higher or lower frequency than expected in the "seclusion" and "non-seclusion" categories. Results: Text mining led to an overview of 1,500 meaningful concepts. In the 14 day period prior to the event, 115 of these concepts had a significantly higher frequency in the seclusion category and 49 in the non-seclusion category. Analysis of the concepts from days 14 to 7 resulted in 54 concepts with a significantly higher frequency in the seclusion-category and 14 in the non-seclusion category. Conclusions: The resulting significant concepts are comparable to reasons for seclusion in literature. These results are "proof of concept". Analyzing text of reports in the EMR seems therefore promising as contribution to tools available for the prediction of seclusion. The next step is to build, train and test a model, before text mining can be part of an evidence-based clinical decision making tool.

Requirements for the implementation of open door policies in acute psychiatry from a mental health professionals' and patients' view: a qualitative interview study

BACKGROUND

Treating legally committed patients on open, instead of locked wards is controversially discussed and the affected stakeholders (patients, mental health professionals) have ambiguous views on the benefits and disadvantages. The study aims to assess the opinions and values of relevant stakeholders with regard to the requirements for implementing open wards in psychiatric hospitals.

METHODS

Semi-structured interviews were conducted with 15 psychiatrists, 15 psychiatric nurses and 15 patients, and were analyzed using qualitative content analysis.

RESULTS

The interviewees identified conceptual, personnel and spatial requirements necessary for an open door policy. Observation and door watch concepts are judged to be essential for open wards, and patients appreciate the therapeutic value they hold. However, nurses find the door watch problematic. All groups suggest seclusion or small locked divisions as a possible way of handling agitated patients. All stakeholders agree that such concepts can only succeed if sufficient, qualified staff is available. They also agree that freedom of movement is a key element in the management of acutely ill patients, which can be achieved with an open door policy. Finally, the interviewees suggested removing the door from direct view to prevent absconding.

CONCLUSIONS

For psychiatric institutions seeking to implement (partially) open wards, the present results may have high practical relevance. The stakeholders' suggestions also illustrate that fundamental clinical changes depend on resource investments which - at least at a certain point - might not be feasible for individual psychiatric institutions but presumably require initiatives on the level of mental health care providers or policy makers.

Patient safety on psychiatric wards: A cross-sectional, multilevel study of factors influencing nurses' willingness to share power and responsibility with patients

The World Health Organization highlights the need for more patient participation in patient safety. In mental health care, psychiatric nurses are in a frontline position to support this evolution. The aim of the present study was to investigate the demographic and contextual factors that influence the willingness of psychiatric nurses to share power and responsibility with patients concerning patient safety. The patient participation culture tool for inpatient psychiatric wards was completed by 705 nurses employed in 173 psychiatric wards within 37 hospitals. Multilevel modelling was used to analyse the self-reported data. The acceptance of a role wherein nurses share power and responsibility with patients concerning patient safety is influenced by the nurses' sex, age, perceived competence, perceived support, and type of ward. To support nurses in fulfilling their role in patient participation, patient participation-specific basic and continuing education should be provided. Managers and supervisors should recognize and fulfil their facilitating role in patient participation by offering support to nurses. Special attention is needed for young nurses and nurses on closed psychiatric wards, because these particular groups report being less willing to accept a new role. Ward characteristics that restrict patient participation should be challenged so that these become more patient participation stimulating. More research is needed to explore the willingness and ability of psychiatric nurses to engage in collaborative safety management with patients who have specific conditions, such as suicidal ideation and emotional harm.

Psychometric Properties of the Essen Climate Evaluation Schema (EssenCES) in a Sample of General Psychiatric Wards

OBJECTIVE

The questionnaire EssenCES (Essen Climate Evaluation Schema) is a widely used instrument to assess social climate in forensic psychiatric and correctional institutions. The purpose of this study was to evaluate the EssenCES in a general psychiatric setting, where it had not previously been evaluated.

DESIGN

648 staff members and 551 patients from 47 general psychiatric wards across 16 hospitals in Germany completed the EssenCES. Factor-, correlation- and scale-analyses were carried out to inspect the questionnaire's properties.

RESULTS

The proposed three-dimensional factor structure of the instrument was confirmed. Results indicated that the EssenCES subscales Patients' Cohesion and Experienced Safety had high internal consistency, whereas elimination of item 16 would improve the internal consistency of Therapeutic Hold. Correlations between the EssenCES subscales and other measures supported the validity of the questionnaire.

CONCLUSION

The results suggest that the EssenCES is suitable for usage in general psychiatric settings. Along with its brevity, it seems useful as an economic and valid screening instrument for a ward's social climate. Reasons are given why item 16 should be retained.

Aggression and violence in psychiatric hospitals with and without open door policies: A 15-year naturalistic observational study

Aggressive behavior and violence in psychiatric patients have often been quoted to justify more restrictive settings in psychiatric facilities. However, the effects of open vs. locked door policies on aggressive incidents remain unclear. This study had a naturalistic observational design and analyzed the occurrence of aggressive behavior as well as the use of seclusion or restraint in 21 German hospitals. The analysis included data from 1998 to 2012 and contained a total of n = 314,330 cases, either treated in one of 17 hospitals with (n = 68,135) or in one of 4 hospitals without an open door policy (n = 246,195). We also analyzed the data according to participants' stay on open, partially open, or locked wards. To compare hospital and ward types, we used generalized linear mixed-effects models on a propensity score matched subset (n = 126,268) and on the total dataset. The effect of open vs. locked door policy was non-significant in all analyses of aggressive behavior during treatment. Restraint or seclusion during treatment was less likely in hospitals with an open door policy. On open wards, any aggressive behavior and restraint or seclusion were less likely, whereas bodily harm was more likely than on closed wards. Hospitals with open door policies did not differ from hospitals with locked wards regarding different forms of aggression. Other restrictive interventions used to control aggression were significantly reduced in open settings. Open wards seem to have a positive effect on reducing aggression. Future research should focus on mental health care policies targeted at empowering treatment approaches, respecting the patient's autonomy and promoting reductions of institutional coercion.

Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice

The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self‐harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re‐centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re‐evaluating the risk management culture that gives rise to and legitimizes harmful practices.

Unlocking an acute psychiatric ward: the impact on unauthorised absences, assaults and seclusions

Aims and method The acute psychiatric in-patient service in Christchurch, New Zealand, recently changed from two locked and two unlocked wards to four open wards. This provided the opportunity to evaluate whether shifting to an unlocked environment was associated with higher rates of adverse events, including unauthorised absences, violent incidents and seclusion. We compared long-term adverse event data before and after ward configuration change. Results Rates of unauthorised absences increased by 58% after the change in ward configuration (P = 0.005), but seclusion hours dropped by 53% (P = 0.001). A small increase in violent incidents was recorded but this was not statistically significant. Clinical implications Although unauthorised absences increased, the absence of statistically significant changes for violent incidents and a reduction in seclusion hours suggest that the change to a less restrictive environment may have some positive effects.

Suicidal patients' experiences regarding their safety during psychiatric in-patient care: a systematic review of qualitative studies

Background

In-patient suicide prevention is a high priority in many countries, but its practice remains poorly understood. Patients in a suicidal crisis who receive psychiatric care can provide valuable insight into understanding and improving patient safety. The aim of this paper was therefore to summarize the qualitative literature regarding suicidal patients’ in-patient care experiences. The following question guided the review: How can we describe suicidal patients’ experiences regarding safety during psychiatric in-patient care?

Methods

Systematic searches were conducted in the MEDLINE, Academic Search Premier, CINAHL, SOCINDEX and PsycINFO databases, identifying 20 qualitative studies on suicidal patients and their psychiatric in-patient care experiences. These studies were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, synthesized via thematic analysis and subjected to quality appraisals.

Results

Patients described safety as “feeling safe”, and three components, i.e., connection, protection and control, were vital to their experiences of safety. Fulfilling these needs was essential to patients recovering from suicidal crises, feeling safe during encounters with health care professionals and feeling safe from suicidal impulses. Unmet needs for connection, protection and control left patients feeling unsafe and increased their suicidal behaviour.

Conclusion

Our review addresses the importance of adopting a wider perspective of patient safety than considering safety solely in technical and physical terms. Safety for the suicidal patient is highly dependent on patients’ perceptions of their psychological safety and the fulfilment of their needs. The three patient-identified factors mentioned above – connection, protection and control – should be considered an integral part of patient safety practices and should form the basis of future efforts to understand the safety of suicidal patients during psychiatric in-patient care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2023-8) contains supplementary material, which is available to authorized users.

Critical Incidents During Leave From an Australian Security Hospital - A 12 Year Audit

All critical incidents between 2003 and 2015 relating to leave episodes from the High Security Inpatient Services, Brisbane, Australia were audited. The audit found that since March 2003, when the High Security Inpatient Service opened, there was a very small number of critical incidents related to over 46,000 leave episodes. Of the 17 patients who went absent without permission over the 12-year study period, only 2 patients re-offended and 1 patient deliberately self-harmed during a leave episode. One patient assaulted his escort nurse during a leave and four patients attempted unsuccessfully to flee their escort nurses during escorted off-ground leave. No patient committed a serious violent offence and no patient committed suicide during an absence from leave. Only 4 of the 17 patients who went absent during leave between 2003 and 2015 remain as inpatients in the High Security Inpatient Service.

Effect of Door-Locking Policy on Inpatient Treatment of Substance Use and Dual Disorders

OBJECTIVE

Substance use treatment is often performed inside locked wards. We investigate the effects of adopting a policy of open-door treatment for a substance use treatment and dual diagnosis ward.

METHODS

This is a prospective open-label study investigating 3-month study periods before opening (P1), immediately after (P2), and 1 year after the first period (P3). Data on committed patients, coercion (seclusion, forced medication, absconding events with subsequent police search), violence, and substance use was collected daily. We applied generalised estimating equation models.

RESULTS

The mean daily number of patients with ongoing commitment changed from 2.64 (P1) to 2.12 (P2) to 0.96 (P3), corresponding to a reduction of relative risk (RR) for having an ongoing commitment by 20% in P2 (RR 0.80; 95% CI 0.66-0.98) and 67% in P3 (RR 0.33; 95% CI 0.25-0.42). The mean daily number of coercive events was 0.29, 0.13, and 0.05, corresponding to a risk for undergoing coercive measures reduced by 56% (RR 0.44; 95% CI 0.22-0.90) and 85% (RR 0.15; 95% CI 0.05-0.45). Substance use, violence or ward atmosphere did not differ significantly.

CONCLUSIONS

Our results support findings from general psychiatric wards of reduced coercion after adopting a primarily open-door policy. However, coercive events were rare during all periods. The widespread practice of restricting the freedom of inpatients with substance use disorders by locking ward doors is highly questionable.

Aggression in psychiatric hospitalizations: a qualitative study of patient and provider perspectives

BACKGROUND

When the people hospitalized in psychiatric units demonstrate aggression, it harms individuals and creates legal and financial issues for hospitals. Aggression has been linked to inpatient, clinician and environmental characteristics. However, previous work primarily accessed clinicians' perspectives or administrative data and rarely incorporated inpatients' insights. This limits validity of findings and impedes comparisons of inpatient and clinician perspectives.

AIMS

This study explored and compared inpatient and clinician perspectives on the factors affecting verbal and physical aggression by psychiatric inpatients.

METHODS

This study used an interpretive theoretical framework. Fourteen inpatients and 10 clinicians were purposefully sampled and completed semi-structured interviews. Data were analyzed using inductive thematic analysis.

RESULTS

Six themes were identified at personal and organizational levels. The three person-level themes were major life stressors, experience of illness and interpersonal connections with clinicians. The three organization-level themes were physical confinement, behavioural restrictions and disengagement from treatment decisions.

CONCLUSIONS

Aggression is perceived to have a wide range of origins spanning personal experiences and organizational policies, suggesting that a wide range of prevention strategies are needed.

Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study

BACKGROUND

Inpatient suicide and absconding of inpatients at risk of self-endangering behaviour are important challenges for all medical disciplines, particularly psychiatry. Patients at risk are often admitted to locked wards in psychiatric hospitals to prevent absconding, suicide attempts, and death by suicide. However, there is insufficient evidence that treatment on locked wards can effectively prevent these outcomes. We did this study to compare hospitals without locked wards and hospitals with locked wards and to establish whether hospital type has an effect on these outcomes.

METHODS

In this 15 year, naturalistic observational study, we examined 349 574 admissions to 21 German psychiatric inpatient hospitals from Jan 1, 1998, to Dec 31, 2012. We used propensity score matching to select 145 738 cases for an analysis, which allowed for causal inference on the effect of ward type (ie, locked, partly locked, open, and day clinic wards) and hospital type (ie, hospitals with and without locked wards) on suicide, suicide attempts, and absconding (with and without return), despite the absence of an experimental design. We used generalised linear mixed-effects models to analyse the data.

FINDINGS

In the 145 738 propensity score-matched cases, suicide (OR 1·326, 95% CI 0·803-2·113; p=0·24), suicide attempts (1·057, 0·787-1·412; p=0·71), and absconding with return (1·288, 0·874-1·929; p=0·21) and without return (1·090, 0·722-1·659; p=0·69) were not increased in hospitals with an open door policy. Compared with treatment on locked wards, treatment on open wards was associated with a decreased probability of suicide attempts (OR 0·658, 95% CI 0·504-0·864; p=0·003), absconding with return (0·629, 0·524-0·764; p<0·0001), and absconding without return (0·707, 0·546-0·925; p=0·01), but not completed suicide (0·823, 0·376-1·766; p=0·63).

INTERPRETATION

Locked doors might not be able to prevent suicide and absconding.

FUNDING

None.

Suicide after absconding from inpatient care in England: an exploration of mental health professionals' experiences

BACKGROUND

Absconding from inpatient care is associated with suicide risk in psychiatric populations. However, little is known about the real world context of suicide after absconding from a psychiatric ward or the experiences of clinical staff caring for these patients.

AIMS

To identify the characteristics of inpatients who died by suicide after absconding and to explore these and further key issues related to suicide risk from the perspective of clinical staff.

METHODS

A mixed-methods study using quantitative data of all patient suicides in England between 1997 and 2011 and a thematic analysis of semi-structured interviews with 21 clinical staff.

RESULTS

Four themes were identified as areas of concern for clinicians: problems with ward design, staffing problems, difficulties in assessing risk, and patient specific factors.

CONCLUSIONS

Results suggest that inpatients who died by suicide after absconding may have more complex and severe illness along with difficult life events, such as homelessness. Closer monitoring of inpatients and access points, and improved risk assessments are important to reduce suicide in this patient group.

Limiting Patients as a Nursing Practice in Psychiatric Intensive Care Units to Ensure Safety and Gain Control

PURPOSE

The aim of this study was to describe how the limitation of patients is being practiced in psychiatric intensive care units.

DESIGN AND METHODS

A focused ethnographic methodology was applied. To gather data, the author conducted fieldwork involving participant observation.

FINDINGS

The results of the study are presented in two categories, which describe the limited access patients had to items and in the ward environments.

PRACTICE IMPLICATIONS

It is advisable for practitioners to critically reflect upon local regulations and policies related to the practice of limiting patients during the worst phase of their mental illness.

Reduction of seclusion on a hospital-wide level: successful implementation of a less restrictive policy

PURPOSE

Change of treatment policy from closed to open ward settings has been shown to reduce coercive measures. The aim of the current study was to examine the effects of the change from closed to open wards on the frequency of seclusion and forced medication in a hospital-wide setting.

SUBJECTS AND METHODS

2-year, longitudinal observational study with 2838 inpatient cases.

RESULTS

On a hospital-wide level, the percentage of patients with at least one seclusion was decreased significantly (χ(2)(1) = 5.8; p = .016), while there was no significant change in forced medication (χ(2)(1) = .08; p = .775). The frequency of seclusions and forced medication decreased significantly on newly opened wards, and there were no significant changes regarding seclusion on permanently closed or open wards, while the number of forced medications increased significantly on closed wards. The decrease in seclusions on newly opened wards remained statistically significant after controlling for diagnoses and severity of illness.

DISCUSSION

Our results indicate that a reduction of overall seclusion can be successfully attained, and that, in particular, the frequency of seclusion and forced medication on newly opened wards was decreased significantly. These changes were not accompanied by a significant increase in seclusion on other wards.

CONCLUSION

Open ward treatment was successfully implemented and was associated with a significant decrease of coercive measures in our study. It might therefore provide a good care model, strengthening the patient's right to autonomy and leading to a reduction of coercive measures.

Police officers' views of absconding from mental health units in Victoria, Australia

Patients regularly abscond from mental health units and at times the consequences for patients and for others can be serious. The police are involved with absconding events, but are rarely considered in the mental health literature. In most jurisdictions, the police can take missing person reports for involuntary patients whose whereabouts are unknown and there are genuine concerns for their safety or welfare. Those people remain active cases for the police until located. This paper presents extracts of 25 police officers' narratives from a qualitative research project. Officers viewed absconding as a regular event, and workload burden that was exacerbated when mental health staff rarely initiated any search for the absconded patient and abdicated responsibility too quickly to the police. The officers were concerned about communication with mental health services and reported that information about the absconded patient could be inadequate or not given to police, and police often were not informed when the patient was found or discharged. Improved liaison and cooperative working that promote effective communication could strengthen police and mental health nursing collaboration and ensure better outcomes for patients.

Perceived coercion in voluntary hospital admission

The legal status of service users admitted to psychiatric wards is not synonymous with the level of coercion that they can perceive during the admission. This study aimed to identify and describe the proportion of individuals who were admitted voluntarily but experienced levels of perceived coercion comparable to those admitted involuntarily. Individuals admitted voluntarily and involuntarily to three psychiatric hospitals were interviewed using the MacArthur Admission Experience Interview and the Structured Clinical Interview for DSM-IV diagnoses. One hundered sixty-one individuals were interviewed and 22% of the voluntarily admitted service users had levels of perceived coercion similar to that of the majority of involuntarily admitted service users. Voluntarily admitted service users who experienced high levels of perceived coercion were more likely to have more severe psychotic symptoms, have experienced more negative pressures and less procedural justices on admission. Individuals brought to hospital under mental health legislation but who subsequently agreed to be admitted voluntarily and those treated on a secure ward also reported higher levels of perceived coercion. It needs to be ensured that if any service user, whether voluntary or involuntary, experiences treatment pressures or coercion that there is sufficient oversight of the practice, to ensure that individual's rights are respected.

Systemic perspective of violence and aggression in mental health care: towards a more comprehensive understanding and conceptualization: part 1

Aggression and violence (A/V) in mental health care are all too frequent occurrences; they produce a wide range of deleterious impacts on the individual client, staff, organizations, and the broader community. A/V is a multifaceted and highly-complex problem, and is associated empirically with a wide range of phenomena. However, most attempts to reduce A/V in mental health care have invariably focused on one or two aspects of the problem at the expense of a more comprehensive, systemic approach; these have produced inconclusive results. As a result, this two-part paper seeks to: (i) recognize the wide range of phenomena that have been found to have an association with A/V in mental health care; (ii) synthesize these propositions according to fit or congruence into a systemic model of A/V; (iii) explore empirical evidence pertaining to these propositions; and (iv) begin to consider the application of this model to better inform our individual and/or organizational responses to A/V in mental health care. The paper advances a systemic model of these phenomena comprised of four thematic categories, with Part 1 of this paper focusing on the first two categories: environmental and intrapersonal (client-related) phenomena.

Patient safety in psychiatric inpatient care: a literature review

Patient safety is widely discussed, but little has been written from the perspective of psychiatric inpatient care, nor on which factors create its patient safety. This paper seeks to understand the concept of patient safety and its intension in psychiatric inpatient care, and to identify factors in organization management, staff and patients' roles which constitute patient safety in such units. A literature search was conducted, and the articles selected were analysed by identifying factors defined to be connected to patient safety and classifying them according to their connection to organization management, staff and patient roles. According to the literature, organization safety culture is present in all aspects of patient safety. Organization management has the main role in patient safety within the organization culture, for example, through leadership, safety practices and creating good working conditions and environment for the staff. Staff's role is influenced by management, but has more individual input in different areas, while the patient's role is more that of an informant so that care can be planned according to the patient's preferences. When developing patient safety it is important to remember the diversity of the concept so that all areas are considered in the developmental work.

Understanding psychiatric institutionalization: a conceptual review

BACKGROUND

Since Goffman's seminal work on psychiatric institutions, deinstitutionalization has become a leading term in the psychiatric debate. It described the process of closure or downsizing of large psychiatric hospitals and the establishment of alternative services in the community. Yet, there is a lack of clarity on what exactly the concept of institutionalization means in present-day psychiatry. This review aims to identify the meaning of psychiatric institutionalization since the early 1960s to present-day.

METHOD

A conceptual review of institutionalization in psychiatry was conducted. Thematic analysis was used to synthesize the findings.

RESULTS

Four main themes were identified in conceptualizing institutionalization: bricks and mortar of care institutions; policy and legal frameworks regulating care; clinical responsibility and paternalism in clinician-patient relationships; and patients' adaptive behavior to institutionalized care.

CONCLUSIONS

The concept of institutionalization in psychiatry reflects four distinct themes. All themes have some relevance for the contemporary debate on how psychiatric care should develop and on the role of institutional care in psychiatry.

The experience of working on a locked acute psychiatric ward

This study's aim was to elucidate health-care staff experience of working on a locked acute psychiatric ward. In many countries changes in health care has contributed to fewer beds available in inpatient care, and a concentration of patients with severe psychiatric conditions. This implies a changing work environment in acute psychiatric care. Qualitative interviews with health-care staff (n= 10) were carried out on a ward for patients with affective disorder and eating disorder in a Swedish hospital. Qualitative content analysis was used. Four themes were identified from the data: 'undergoing changes in care delivery', 'feeling a need for security and control', 'managing the demands at work' and 'feeling a sense of responsibility'. This study adds to earlier research into how a sense of responsibility can place a significant burden on health-care staff working on a locked psychiatric ward and also contribute to increased control of patients. This study also shows that relationships and power structures among health-care staff need to be addressed when organizational changes are made in care delivery. Further research is needed to reach a comprehensive understanding of care on locked acute psychiatric wards, including a development of nursing and medicine as knowledge domains in one common context.

Psychiatric elopement: using evidence to examine causative factors and preventative measures

BACKGROUND

Elopement is a problem in the inpatient mental health community. Elopement can have serious and long term effects for the patients and staff.

OBJECTIVE

The purposes of this paper are to present a review of the literature regarding elopement and to provide recommendation for practice.

DESIGN

Using several databases, a search of the existing literature was conducted.

RESULTS

Elopement occurs due to a number of factors, including: psychosocial issues, staff-patient interaction, the patient's attitude toward hospitalization, and their mental illness.

CONCLUSION

It is important to understand why patients seek to elope from treatment facilities to prevent further occurrences.

Conflict and containment events in inpatient psychiatric units

AIMS AND OBJECTIVES

To describe the types and frequency of conflict behaviours exhibited by patients during the first 2 weeks of admission to acute psychiatric units, the methods staff use to manage them and bring to the surface underlying common patterns.

BACKGROUND

Many studies have investigated the prevalence and impact of psychiatric inpatient aggression. Much of the research to date has studied conflict and containment behaviours separately; however, some studies have reported relationships between certain behaviours suggesting that there are complex causal links between conflict and containment behaviours.

DESIGN

A cross-sectional survey of conflict and containment events.

METHODS

Nursing notes were accessed for 522 patients during the first 2 weeks of admission, in 84 wards in 31 hospitals in the South East of England. Conflict and containment events occurring during this period were recorded retrospectively.

RESULTS

Factor analysis revealed six patterns of conflict behaviour, which were related to containment methods and patient demographic factors. These factors confirm some previously reported patterns of conflict.

CONCLUSIONS

This study brings to light underlying common patterns of disruptive behaviour by psychiatric inpatients. The reasons for these remain obscure, but may relate to (1) national variations in policy and practice shaping static structural differences of interest between patients and staff and (2) normal developmental age and gender-specific behaviours.

RELEVANCE TO CLINICAL PRACTICE

Conflict behaviour patterns may be differently motivated and therefore require different management strategies by staff. There is a need for awareness by clinical staff to the fact that different types of conflict behaviours may be co-occurring or indicative of each other. Clinical staff should consider that implementation of and changes to hospital policies have the potential to change the nature and frequencies of certain conflict behaviours by patients.

The Environment of Inpatient Healthcare Delivery and Its Influence on the Outcome of Care

Aim:

This paper addresses issues arising in the literature regarding the environmental design of inpatient healthcare settings and their impact on care.

Background:

Environmental design in healthcare settings is an important feature of the holistic delivery of healthcare. The environmental influence of the delivery of care is manifested by such things as lighting, proximity to bedside, technology, family involvement, and space. The need to respond rapidly in places such as emergency and intensive care can override space needs for family support. In some settings with aging buildings, the available space is no longer appropriate to the needs—for example, the need for privacy in emergency departments. Many aspects of care have changed over the last three decades and the environment of care appears not to have been adapted to contemporary healthcare requirements nor involved consumers in ascertaining environmental requirements. The issues found in the literature are addressed under five themes: the design of physical space, family needs, privacy considerations, the impact of technology, and patient safety.

Conclusion:

There is a need for greater input into the design of healthcare spaces from those who use them, to incorporate dignified and expedient care delivery in the care of the person and to meet the needs of family.

Investigation into the acceptability of door locking to staff, patients, and visitors on acute psychiatric wards

There is disagreement among psychiatric professionals about whether the doors of acute psychiatric wards should be kept locked to prevent patients from leaving and harming themselves or others. This study explored patient, staff, and visitor perceptions about the acceptability of locking the ward door on acute psychiatric inpatient wards. Interviews were conducted with 14 registered nurses, 15 patients, and six visitors from three different acute wards. Findings revealed commonalities across all groups, with general agreement that locking the door reduced absconding. Staff expressed feelings of guilt, embarrassment, and fear of being blamed when a patient absconded. Staff also reported that open wards created anxious vigilance to prevent an abscond and increased workload in allocating staff to watch the door, whereas staff on partially-locked doors also perceived an increased workload in letting people in and out of the ward. Patients had mixed feelings about the status of the door, expressing depression, a sense of stigma, and low self-esteem when the door was locked. The issue of balancing safety and security on acute psychiatric wards against the autonomy of patients is not easily resolved, and requires focused research to develop innovative nursing practices.

Under the gaze of staff: special observation as surveillance

PURPOSE

This study explores the relationship of special observation (SO) to a range of patient, staff, and ward variables.

DESIGN AND METHODS

End-of-shift reports were completed by nurses on 136 acute mental health wards in England during 2004 and 2005.

FINDINGS

Intermittent SO (patient checked at specified intervals) was used five times more frequently than constant SO (patient kept within sight or reach). Significant relationships were found between SO and measures of ward surveillance, door locking, and the ease of observing patients on the wards. Both types of SO were more common when higher numbers of staff without a nursing qualification were on duty.

PRACTICE IMPLICATIONS

Improved ward design, less reliance on unqualified staff, and greater use of surveillance measures may reduce the need for SO.

Locked doors: a survey of patients, staff and visitors

ACCESSIBLE SUMMARY

• Locking of psychiatric wards doors is more frequent, but the impact is unknown. • Staff patients and visitors returned a questionnaire about the issue. • Patients did not like the door being locked as much as staff, and being on a locked ward was associated with greater rejection of the practice. • Staff working on locked wards were more positive about it than those who did not.

ABSTRACT

Locking the door of adult acute psychiatric wards has become increasingly common in the UK. There has been little investigation of its efficacy or acceptability in comparison to other containment methods. We surveyed the beliefs and attitudes of patients, staff and visitors to the practice of door locking in acute psychiatry. Wards that previously participated in a previous study were contacted and sent a questionnaire. A total of 1227 responses were obtained, with the highest number coming from staff, and the smallest from visitors. Analysis identified five factors (adverse effects, staff benefits, patient safety benefits, patient comforts and cold milieu). Patients were more negative about door locking than the staff, and more likely to express such negative judgments if they were residing in a locked ward. For staff, being on a locked ward was associated with more positive judgments about the practice. There were significant age, gender and ethnicity effects for staff only. Each group saw the issue of locked doors from their own perspective. Patients registered more anger, irritation and depression as a consequence of locked doors than staff or visitors thought they experienced. These differences were accentuated by the actual experience of the ward being locked.