Locked inpatient units in modern mental health care: values and practice issues

Development of a checklist to aid in the assessment of 'failure to return' from approved leave by acute inpatients

Better assessment of consumer behaviour and intentions prior to the granting of approved leave may reduce failure to return from such episodes of leave. The aims of this study were (i) to gain consensus on the factors associated with failure to return, and (ii) use these factors to construct a checklist to aid in assessment of consumers prior to being granted leave. Following a review of the literature a pool of 36 factors was identified. These were then assessed for relevance to absconding from approved leave using a modified Delphi approach. After two Delphi rounds, 10 factors were retained and these were collapsed under 6 domains; history of absconding, current substance use, behaviour cues, verbal cues, lack of engagement, and changes in mental state. While staff reactions to the checklist were positive, further testing of its effectiveness in the clinical setting is required.

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.

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.

The experience of involuntary detention in acute psychiatric care. A review and synthesis of qualitative studies

OBJECTIVE

To build on a previous review and updated understanding of how patients experience involuntary detention for their mental health difficulties.

DESIGN

We provide a narrative synthesis review of qualitative studies.

DATA SOURCES

Using pre-defined search terms, the following databases were searched covering the period 2006 to March 2014: Psychinfo, Medline, Medline In-Process, Embase, Web of Knowledge, Scopus, Science Direct, British Nursing Index and Cinahl Plus. Three journals were electronically hand-searched.

REVIEW METHODS

The search resulted in the retrieval of 6230 records which were screened by title. Relevant studies were then screened by abstract and further articles were read for full text. References of articles read for full text were screened using an inclusion and exclusion criteria. A total of fifteen studies were identified and a quality evaluation tool was applied to each study. Themes and constructs from all fifteen studies were coded and synthesised.

RESULTS

Seven overarching themes emerged. 'Sanctuary', 'loss of normality and perceived independence', 'feeling terrified' and 'fluctuating emotions' illustrate the experiences of involuntary detention. The remaining themes reflect the factors that influence these experiences: 'a continuum of person-centred practice', 'disempowerment' and 'intra-psychic coping'.

CONCLUSIONS

Participants varied in how they experienced involuntary detention. Some people experienced a sense of sanctuary, whereas others experienced loss, fear and trauma. People's experiences were influenced by the degree of actual or perceived person-centred and empowering care, which also had an impact on their coping style. Development of a therapeutic bond with clinicians was a key factor which influenced positive experiences of involuntary detention. The implications of the findings are discussed with reference to existing literature and recommendations are made for clinical practice. Ideas for future research are identified.

The impact of structured decision making on absconding by forensic psychiatric patients: results from an A-B design study

BACKGROUND

Few studies have investigated absconding from forensic hospitals and there are no published studies of interventions aimed at reducing these incidents in forensic settings. We present a study of the impact of a new policy using structured professional judgment and an interdisciplinary team-based approach to granting privileges to forensic patients. We assess the impact of this policy on the rate and type of absconding from a metropolitan forensic facility.

METHODS

Following concern about the rate of absconding at our hospital, a new policy was implemented to guide the process of granting hospital grounds and community access privileges. Employing an A-B design, we investigated the rate, characteristics, and motivations of absconding events in the 18 months prior to, and 18 months following, implementation of this policy to assess its effectiveness.

RESULTS

Eighty-six patients were responsible for 188 incidents of absconding during the 42-month study window. The rate of absconding decreased progressively from 17.8% of all patients at risk prior to implementation of the new policy, to 13.8% during implementation, and further to 12.0% following implementation. There was a differential impact of the policy on absconding events, in that the greatest reduction was witnessed in absconsions occurring from unaccompanied passes; this was offset, to some extent, by an increase in absconding occurring from within hospital units or from staff accompanied outings. Seven of the absconding events included incidents of minor violence, and two included the commission of other illegal behaviors. The most common reported motive for absconding across the time periods studied was a sense of boredom or frustration. Discharge rate from hospital was 22.9% prior to the implementation of the policy to 22.7% after its introduction, indicating no change in the rate of patients' eventual community reintegration.

CONCLUSIONS

A structured and team-based approach to decision making regarding hospital grounds and community access privileges appeared to reduce the overall rate of absconding without slowing community reintegration of forensic patients.

Five-year review of absconding in three acute psychiatric inpatient wards in Australia

Absconding, where patients under an involuntary mental health order leave hospital without permission, can result in patient harm and emotional and professional implications for nursing staff. However, Australian data to drive nursing interventions remain sparse. The purpose of this retrospective study was to investigate absconding in three acute care wards from January 2006 to June 2010, in order to determine absconding rates, compare patients who did and did not abscond, and to examine incidents. The absconding rate was 17.22 incidents per 100 involuntary admissions (12.09% of patients), with no significant change over time. Being male, young, diagnosed with a schizophrenia or substance-use disorder, and having a longer hospital stay were predictive of absconding. Aboriginal and Torres Strait Islander patients had higher odds of absconding than Caucasian Australians. Over 25% of absconding patients did so multiple times. Patients absconded early in admission. More incidents occurred earlier in the year, during summer and autumn, and later in the week, and few incidents occurred early in the morning. Almost 60% of incidents lasted ≤24 hours. Formulation of prospective interventions considering population demographic factors and person-specific concerns are required for evidence-based nursing management of the risks of absconding and effective incident handling when they do occur.

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.

Door locking and exit security measures on acute psychiatric admission wards

Locking the exit doors of psychiatric wards is believed to reduce the risk of patients absconding. The aims of the study were to investigate both the prevalence of door locking and other exit security measures on UK admission wards, as well as whether door locking appears to be effective in keeping inpatients in. A cross-sectional survey on 136 acute psychiatric wards in the UK was conducted, in which a range of data on patients, staff, and conflict and containment events, including door locking and absconding, were collected from shift to shift during a period of 6 months. About one-third of the participating wards (30%) operated with their ward exit door permanently locked, whereas another third (34%) never locked the ward door. Univariate analyses suggested little association between exit security measures and absconding. A more robust multilevel statistical analysis, however, did indicate a reduction of about 30% of absconding rates when the ward door was locked the entire shift. Although locking the ward door does seem to reduce absconding to a certain extent, it far from completely prevents it. As it may be unrealistic to strive for a 100% absconding-proof ward, alternative measures for door locking to prevent absconding are discussed.

The profile of absconding psychiatric inpatients in Australia

AIMS AND OBJECTIVES

The purpose of this study was to examine absconding behaviour (a patient leaving the hospital without permission) in acute and rehabilitation wards of one Australian psychiatric institution to describe the characteristics of the absconding patient and these events.

BACKGROUND

Absconding is a significant issue in psychiatric inpatient settings, with risks that include patient harm, aggression and violence. In spite of this, limited research has been conducted in Australia on patients who abscond while receiving psychiatric care.

DESIGN

The study was a retrospective descriptive analysis.

METHOD

Absconding events from three acute and seven rehabilitation wards over a 12-month period were studied.

RESULTS

The rate of absconding events by detained patients was 20.82%. Gender was not significantly associated with absconding, although 61.19% of those who absconded were men diagnosed with schizophrenic disorders. Over half of acute care patients who absconded left during their first 21-day detention order. More than half of absconding events were by patients that absconded more than once. There was limited support for the efficacy of locking ward doors. Age and diagnosis emerged as particularly important factors to consider.

DISCUSSION

The study revealed that men are not more likely to abscond than women, that locking ward doors does not deter the determined absconders and that once a person has absconded, they are more likely to do so again. Younger patients and those with a schizophrenic disorder may be particularly likely to abscond. There also appears to be a link between continuing detention orders and an absconding event.

CONCLUSIONS

Findings provide new data about the profile of absconding patients in Australia. Exploration of the reasons why patients abscond and why many do so repeatedly warrants further investigation.

RELEVANCE TO CLINICAL PRACTICE

Risk management approaches taking into account factors associated with absconding could be trialled to reduce the incidence of absconding in psychiatric inpatient settings.

Managing risk: clinical decision-making in mental health services

Risk assessment and management is a major component of contemporary mental health practice. Risk assessment in health care exists within contemporary perspectives of management and risk aversive practices in health care. This has led to much discussion about the best approach to assessing possible risks posed by people with mental health problems. In addition, researchers and commentators have expressed concern that clinical practice is being dominated by managerial models of risk management at the expense of meeting the patient's health and social care needs. The purpose of the present study is to investigate the risk assessment practices of a multidisciplinary mental health service. Findings indicate that mental health professionals draw on both managerial and therapeutic approaches to risk management, integrating these approaches into their clinical practice. Rather than being dominated by managerial concerns regarding risk, the participants demonstrate professional autonomy and concern for the needs of their clients.