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

Adverse mental health inpatient experiences: Qualitative systematic review of international literature

BACKGROUND

Trauma has a well-established link with poor health outcomes. Adverse experiences in mental health inpatient settings contribute to such outcomes and should impact service design and delivery. However, there is often a failure to fully address these experiences.

OBJECTIVE

To describe the spectrum of negative experiences that people identify while they are inpatients in adult mental health services.

DESIGN

Qualitative systematic review of the international literature.

SETTING(S)

Inpatient mental health settings globally.

PARTICIPANTS

Analysis includes findings from 111 studies across 25 countries.

METHODS

CINAHL, MEDLINE and PsycINFO were searched from 2000 onwards, supplemented by Google Scholar. Studies were appraised using the Critical Appraisal Skills Programme qualitative checklist. Data were synthesised using the 'best-fit' framework synthesis approach, enriched by patient and public involvement.

RESULTS

Adverse mental health inpatient experiences can be conceptualised under three headings: the ecosystem (the physical environment and the resources available, and other people within or influential to that environment); systems (processes and transitions); and the individual (encroachments on autonomy and traumatisation).

CONCLUSIONS

This paper highlights the interplay between systemic, environmental and individual factors contributing to adverse experiences in mental health inpatient settings. By recognising and addressing these factors, we can significantly enhance patient outcomes. Application of adversity to Bronfenbrenner's ecological systems theory provides a strategic approach to improving service design and delivery, advocating for environments that prioritise patient safety, dignity and respect. However, further research is needed to validate the framework and effectively integrate these insights into practice, ultimately transforming the inpatient care experience for all stakeholders.

REGISTRATION

The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022323237).

TWEETABLE ABSTRACT

Review suggests traumatic experiences in mental health inpatient settings can worsen outcomes. Urges redesign of environment, processes and autonomy to improve care @dr_nutmeg @EmxEn @RAVresearchUoB @IMH_UoB.

A qualitative meta-synthesis of service users' and carers' experiences of assessment and involuntary hospital admissions under mental health legislations: a five-year update

BACKGROUND

Compulsory admissions occur in psychiatric hospitals around the world. They result in coercive and sometimes traumatic experiences for service users and carers. Legal and service reforms in various countries are intended to reduce rates of detention and improve service user experience. We aimed to inform policy and service delivery by providing an up-to-date synthesis of qualitative evidence on service users' and carers' experiences of assessment and detention under mental health legislation, updating previous reviews in which we searched for literature published up to 2018.

METHODS

We searched five bibliographic databases for studies published between January 2018 and March 2023. We identified 24 additional studies reporting qualitative investigations of service users' or carers' experiences of assessment or detention under mental health legislation. A team including researchers with relevant personal experience analysed and synthesised data using a thematic synthesis approach.

RESULTS

Findings suggest that views on compulsory admissions and assessment varied: many reports highlighted its often negative, traumatic impacts on emotional well-being and self-worth, with fewer accounts of it as an opportunity to access help and support, accompanied by feelings of relief. Experiences of racial discrimination, inequality of access, and dissatisfaction with support before and after hospital stay were more prominent than in our previous reviews.

CONCLUSIONS

Increasing service user and carer involvement in treatment decisions, provision of timely information at key stages of the admission process, training of key personnel, addressing the issue of discrimination, and investing in community alternatives of inpatient care may contribute to and lead to better overall treatment experiences.

PROTOCOL REGISTRATION

The study protocol has been registered in the PROSPERO database on 30th May 2023 (CRD42023423439).

Open-door policy versus treatment-as-usual in urban psychiatric inpatient wards: a pragmatic, randomised controlled, non-inferiority trial in Norway

BACKGROUND

Open-door policy is a recommended framework to reduce coercion in psychiatric wards. However, existing observational data might not fully capture potential increases in harm and use of coercion associated with open-door policies. In this first randomised controlled trial, we compared coercive practices in open-door policy and treatment-as-usual wards in an urban hospital setting. We hypothesised that the open-door policy would be non-inferior to treatment-as-usual on the proportion of patients exposed to coercive measures.

METHODS

We conducted a pragmatic, randomised controlled, non-inferiority trial comparing two open-door policy wards and three treatment-as-usual acute psychiatric wards at Lovisenberg Diaconal Hospital in Oslo, Norway. An exemption from the consent requirements enabled inclusion and random allocation of all patients admitted to these wards using an open list (2:3 ratio) administrated by a team of ward nurses. The primary outcome was the proportion of patient stays with one or more coercive measures, including involuntary medication, isolation or seclusion, and physical and mechanical restraints. The non-inferiority margin was set to 15%. Primary and safety analyses were assessed using the intention-to-treat population. The trial is registered with ISRCTN registry and is complete, ISRCTN16876467.

FINDINGS

Between Feb 10, 2021, and Feb 1, 2022, we randomly assigned 556 patients to either open-door policy wards (n=245; mean age 41·6 [SD 14·5] years; 119 [49%] male; 126 [51%] female; and 180 [73%] admitted to the ward involuntarily) or treatment-as-usual wards (n=311; mean age 41·6 [4·3] years; 172 [55%] male and 138 [45%] female; 233 [75%] admitted involuntarily). Data on race and ethnicity were not collected. The open-door policy was non-inferior to treatment-as-usual on all outcomes: the proportion of patient stays with exposure to coercion was 65 (26·5%) in open-door policy wards and 104 (33·4%) in treatment-as-usual wards (risk difference 6·9%; 95% CI -0·7 to 14·5), with a similar trend for specific measures of coercion. Reported incidents of violence against staff were 0·15 per patient stay in open-door policy wards and 0·18 in treatment-as-usual wards. There were no suicides during the randomised controlled trial period.

INTERPRETATION

The open-door policy could be safely implemented without increased use of coercive measures. Our findings underscore the need for more reliable and relevant randomised trials to investigate how a complex intervention, such as open-door policy, can be efficiently implemented across health-care systems and contexts.

FUNDING

South-Eastern Norway Regional Health Authority and The Research Council of Norway.

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/).

2022: IS IT TIME TO OPEN THE DOORS IN THE ACUTE PSYCHIATRIC HOSPITALISATION?

Providing the least restrictive mental health care is an unavoidable ethical principle and is one of the 10 basic prin- ciples of the “Mental Health Care Law” published in 1996 by the World Health Organization (WHO).

Rules and ward climate in acute psychiatric setting: Comparison of staff and patient perceptions

The ward climate or atmosphere refers to its material, emotional and social conditions. A good ward climate in psychiatric settings can influence the mood, behaviour and self-concept of patients and staff members and improve patient outcomes. Many studies have examined the relationship between ward climate and aggression, but only a few have investigated the effect of a ward's environment, rules and activities. This multicentric observational study aimed to assess the relationship between the rules/activities and the climate of four acute psychiatric units of Northern Italy. The Essen Climate Evaluation Scheme (EssenCES) questionnaire, which was administered to patients and staff, was used to evaluate the different dimensions of ward atmosphere. There was a good response rate (79%) in patients and staff members who completed the questionnaire (114 patients and 109 staff). Safety perception appeared to be quite different in patients and staff. The patients who were authorized to have more visiting hours and more time to use their mobile phone had higher scores on Experienced Safety subscale. A negative correlation between the Therapeutic Hold and Experienced Safety subscales was found in the staff members, and this was due to their negative perception. The ward climate seemed to be affected by the unit's rules, especially with respect to visits and the smartphones use. Nurses need to be aware of the importance of ward climate and how their own perception may differ from and that of patients: this gap could lead to decisions detached from the patients' needs.

Protocol for the Lovisenberg Open Acute Door Study (LOADS): a pragmatic randomised controlled trial to compare safety and coercion between open-door policy and usual-care services in acute psychiatric inpatients

INTRODUCTION

The reduction of coercion in psychiatry is a high priority for both the WHO and many member countries. Open-door policy (ODP) is a service model for psychiatric ward treatment that prioritises collaborative and motivational measures to better achieve acute psychiatric safety - and treatment objectives. Keeping the ward main door open is one such measure. Evidence on the impact of ODP on coercion and violent events is mixed, and only one randomised controlled trial (RCT) has previously compared ODP to standard practice. The main objectives of the Lovisenberg Open Acute Door Study (LOADS) are to implement and evaluate a Nordic version of ODP for acute psychiatric inpatient services. The evaluation is designed as a pragmatic RCT with treatment-as-usual (TAU) control followed by a 4-year observational period.

METHODS AND ANALYSIS

In this 12-month pragmatic randomised trial, all patients referred to acute ward care will be randomly allocated to either TAU or ODP wards. The primary outcome is the proportion of patient stays with one or more coercive measures. Secondary outcomes include adverse events involving patients and/or staff, substance use and users' experiences of the treatment environment and of coercion. The main hypothesis is that ODP services will not be inferior to state-of-the art psychiatric treatment. ODP and TAU wards are determined via ward-level randomisation. Following conclusion of the RCT, a longitudinal observational phase begins designed to monitor any long-term effects of ODP.

ETHICS AND DISSEMINATION

The trial has been approved by the Regional Committees for Medical and Health Research Ethics (REC) in Norway (REC South East #29238), who granted LOADS exemption from consent requirements for all eligible, admitted patients. Data are considered highly sensitive but can be made available on request. Results will be published in peer-reviewed journals and presented at scientific conferences and meetings.

TRIAL REGISTRATION NUMBER

ISRCTN16876467.

PROTOCOL VERSION

1.4, 21 December 2021.

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.

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.

Comprehensive Treatment Module for Medically Unexplained Physical Symptoms - A Guide for General Practitioners

Purpose: This study was aimed to develop a comprehensive treatment module that the general physician can use to manage patients with Medically Unexplained Physical Symptoms (MUPS) at a primary care level. 

Methods: This comprehensive module was developed after a literature review followed by its validation by a two-step Delphi technique with experts from internal medicine, psychiatry, and clinical psychology.

Results: The developed module for the patients with MUPS includes case diagnosis, initial evaluation, strategy for referral, and a comprehensive treatment module. The comprehensive treatment module includes symptom discussion, rapport establishment, physical health counselling, stress management, cognitive strategies for symptom control, comorbidities treatment, and medical management. 

Conclusion: The developed module has unique features, such as intensive sessions with these patients, a patient-specific treatment strategy, and a holistic approach incorporating pharmacological and non-pharmacological interventions. General Practitioners across the world can use this comprehensive treatment module for the management of patients with MUPS.

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.

Coercion in psychiatric and mental health nursing: A conceptual analysis

The use of coercion in psychiatric and mental health nursing is a major challenge, which can lead to negative consequences for nurses and patients, including rupture in the therapeutic relationship and risk of injury and trauma. The concept of coercion is complex to define and is used in different ways throughout the nursing literature. This concept is defined broadly, referring to both formal (seclusion, restraint, and forced hospitalization), informal (persuasion, threat, and inducement), and perceived coercion, without fully addressing its evolving conceptualizations and use in nursing practice. We conducted a concept analysis of coercion using Rodgers' evolutionary method to identify its antecedents, attributes, and associated consequences. We identified five main attributes of the concept: different forms of coercion; the contexts in which coercion is exercised; nurses' justification of its use; the ethical issues raised by the presence of coercion; and power dynamics. Our conceptual analysis shows the need for more nursing research in the field of coercion to achieve a better understanding of the power dynamics and ethical issues that arise in the presence of coercion.

Experiences of acute care by persons with mental health problems: An integrative literature review

WHAT IS KNOWN ON THE SUBJECT?: Understanding experiences of acute care by persons with mental health problems is vital for improving these experiences through the development of different parts of the care delivery and its facilities. Literature has extensively addressed experiences of persons with mental health problems in acute care settings. Yet, there is a paucity of studies that aggregate and organize these findings in presenting development-oriented solutions for the improvements of these experiences. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Acute care can be understood through patients' experiences of structure (such as setting, staff and resources); process (such as communication and interpersonal relations); and outcome (such as satisfaction and post-discharge well-being and health) and suggests improvements in these domains. The paper illuminates that previous literature has mainly captured negative experiences of acute care by persons with mental health problems, and suggests diverting the focus to the best practices and to seek inspiration from other fields of research. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Attending to the improvement and development of different parts of the acute care might be an important step in improving experiences of persons with mental health problems. For example, improving resource allocation systems and facilities, emphasizing professionalism in encounters with these patients and systematically assessing patient satisfaction during and after visits are important areas that require attention. ABSTRACT: Aim The provision of acute care to persons with mental health problems is challenging due to difficulties in encountering this group and the vulnerability of these persons. Understanding this group's experiences with acute care is thus an important endeavour. The purpose of this review was to critically and systematically identify and assess previous research on experiences of acute care by persons with mental health problems, guided by Donabedian's structure-process-outcome framework (Prospero ID: CRD42019116652). Method and results An integrative literature review was performed, resulting in the identification of 43 studies. The search was conducted using five electronic databases: Web of Science Core, PubMed, MEDLINE, CINAHL and PsycINFO. Discussion The review revealed that patients experienced structure components such as setting, staff and resources in a predominantly negative way. A predominately negative picture also emerged of the process components, where, for example, communication and interpersonal relations were represented by negative experiences, with limited positive experiences reported. The outcome components, related to patients' satisfaction and their well-being after discharge, were also predominantly experienced negatively. Implications for practice Using Donabedian's framework of structure, process and outcome allowed us to systematize the literature reviewed, to identify the research gaps and to suggest ways forward for the field's development.

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

[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.

[What replaces the locked door? : Conceptual and ethical considerations regarding open door policies, formal coercion and treatment pressures]

BACKGROUND

Mental health professionals use various strategies to prevent involuntarily committed persons from absconding under an open door policy.

OBJECTIVE

To provide an ethical framework for the evaluation of the replacement of locked ward doors by formal coercion or treatment pressures.

METHODS

Empirically informed conceptual and ethical analysis.

RESULTS

The replacement of locked ward doors by formal coercive measures applied to individual persons, such as mechanical restraint or seclusion, is ethically problematic. The use of treatment pressures, for example in the context of intensified observational measures, requires a differentiated ethical evaluation and does not necessarily constitute the milder means in comparison to locked ward doors.

CONCLUSION

Unexplored conceptual, empirical and ethical issues surrounding open door policies and treatment pressures should be clarified by means of psychiatric and ethical research. In clinical practice, the choice of the least burdensome and least restrictive measures for involuntarily committed persons should be facilitated by appropriate ethical support services.

[Open-door psychiatry and community mental health work]

In connection with the UN Convention on the Rights of Persons with Disabilities, mental healthcare concepts increasingly focus on the prevention of violence and coercion. Hospital care with an open-door policy is linked with a reduction in violence and coercive measures. The authors describe a specific therapeutic milieu aiming to promote social resources and to reduce institutional exclusion. Open-door policies can be extended to and tied in with outreach community mental health work. Model projects according to § 64b of the German Social Code (SGB V) on interdisciplinary care enable flexible needs-based care including home treatment for severe mental illness.

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.