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When I started working in acute mental health wards in the mid-1990s, the ward doors on my unit were never locked, with nursing staff occasionally stationed at the door if the patient was at high risk of wanting to leave the ward. Injured themselves, the rest of the time staff were anxiously alert (Bowers et al., 2008). Over time, the UK’s doors have been locked by events, inquiries and policy makers. The doors are broken and they are reinforced with air locks so that the doors are more secure.
Locking doors and imposing other blanket restrictions on wards have long been suspected to be increasingly coercive, with less attention paid to the therapeutic environment. Despite the debate, the evidence for or against door locking is very weak (Steinert et al., 2019), and as with most things in acute mental health care, more research is needed as most previous studies have relied largely on observational data. .. For example, see Hubers et al., (2016), blogged by Mental Elf in 2016.
The current study by Indregard et al., (2024) is a unique pragmatic, randomized controlled study of the effect of an open-door policy vs. locked doors (treatment as usual) on patient experience levels.
The evidence for or against locking doors in acute mental health wards is very weak.
methods
This is a pragmatic, randomized controlled, non-inferiority trial (based on the hypothesis that opening ward doors is no worse than locking them). It compared two wards with an open-door approach to three locked wards (treatment as usual – TAU) in a single psychiatric unit in Norway.
An open-door policy was co-created and preparatory activities included workshops, introduction of peer-support workers to increase therapeutic dialogue. Doors are open from 9am to 9pm unless locking guarantees security.
The allocation sequence was a simple binomial list that allocated participants to a group in a 2:3 ratio for the open-door policy and TAU (respectively). Apparently staff and patients were not blinded to the intervention. The authors analyzed the data on an intention-to-treat basis.
The primary outcome focused on coercive measures, including involuntary medication, seclusion or isolation, and physical and mechanical restraints. Secondary outcome measures included the Experience of Concern Scale (ECS) and the Essen Climate Evaluation Scale (EssenCES). See ISRCTN16876467 for registry.
Results
At approximately one year, 556 patients were randomized to open-door wards (n=245) or TAU (n=311). Patients were broadly matched demographically, and three-quarters of both groups were nonadherent. About half of the patients suffer from mental disorders.
- In two open-door wards the doors were open 73% of the time.
The open-door approach was non-inferior (not worse) than treatment as usual (TAU) on all outcomes that focused heavily on coercion:
- The proportion of patient stays in open-door wards was 65 (26.5%) and 104 (33.4%) in TAU wards (risk difference 6.9%; 95% CI -0.7 to 14.5);
- Incidents of reported violence against staff were 0.15 per patient in open-door wards and 0.18 in treatment-general wards;
- There were no suicides during the study period;
- Median length of stay was significantly shorter in the open-door policy group (16 days; IQR 7–31) than in TAU wards;
- Patients in open-door wards rated their coercive experience significantly lower than those in TAU wards, (mean difference in ECS 0.5 (95% CI 0.8 to -0.2; range 0–4));
- Those admitted to the open-door ward reported a significantly higher score on therapeutic holding (mean difference 2.4; 95% CI 1.2 to 3.5) and perceived safety (3.5; 95% CI 1.8 to 5.2).
This Norwegian study of acute psychiatric wards found that an open-door policy could be implemented safely without the use of coercive measures.
The end
The authors conclude:
An open-door policy can be implemented safely without the use of coercive measures. Our findings underscore the need for more reliable and relevant randomized trials to investigate how a complex intervention such as an open-door policy can be effectively implemented across healthcare systems and contexts.
Discussions
According to this study, it might seem like you could open the doors of acute mental health wards without seeing an increase in coercion, but many unanswered questions remain. For example, runaway data (although in the original protocol) were not reported, the trial design meant that definitive conclusions could not be drawn, and no serious events occurred that would have stopped the trial.
It is interesting that this was not a trial of a purely open-door policy, but that the intervention appeared multifaceted, focusing on increasing therapeutic communication, the addition of peer-support workers, and the outcome of input 12 months earlier. The doors were also opened. This can be tricky to replicate. All wards have strong staffing ratios of two patients per day and evening staff and four patients per night staff, plus an additional admission ward and PICU to support five trial wards. I suspect that the unit has more beds per population than is the case in the UK, but comparisons are tricky as there is no firm measure.
The authors’ undertaking of a trial in this area is an important milestone, as we need more evidence to support clinical and managerial decision making in mental health services. I wonder if such a study would be funded in the UK and if the necessary ethical and governance procedures could be agreed. There is a paucity of evidence about how to deliver interventions to patients in inpatient and community services that take into account actual benefit and service designs.
We need more evidence to support clinical and managerial decision making in UK mental health services.
Declaration of interest
There is none.
Links
Primary paper
Indregard A, Nussle H, Hagen M, Vandvik P, Tesli M, Gather J, Kunøe N (2024) Open-door policy versus usual treatment in urban psychiatric inpatient wards: a pragmatic, randomized controlled, non-inferiority trial Norway. Lancet Psychiatry, Published by: March 06, 2024 DOI:
Other references
Bowers L, Allan T, Haglund K, Meir-Cochrans E, Nijman H, Simpson A, van der Merwe M, (2008) The City 128 extension: locked doors in acute psychiatry, outcome and acceptability. National Co-ordinating Center for NHS Service Delivery and Organization R&D (NCCSDO).
Huber CG, Schneeberger AR, Kowalinski E, Frohlich D, Van Felten S, Walter M, Zinkler M, Bean K, Heinz A, Borgward S, Long UE. (2016) Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15-year, observational study. Lancet Psychiatry 2016, Published online Jul 28, 2016 S2215-0366(16)30168-7
Steinert, T., Schreiber, L., Metzger, FG. forever Open doors in psychiatric clinics. Neurologist 90680–689 (2019).