Opening ward doors doesn’t make staff any more coercive
When I started working on acute mental health wards in the mid-1990s, the ward doors on my unit were never locked. Occasionally, nursing staff would be posted on the door if there was a particularly high risk of a patient wanting to leave the ward to harm themselves. The remainder of the time, staff were anxiously vigilant (Bowers et al., 2008).
Over time, doors in the UK became locked due to incidents, inquiries, and policy makers. The doors got broken and were reinforced with air-locks, making wards increasingly secure. There has long been a suspicion that locking doors and imposing other blanket restrictions on wards have led to care becoming more coercive with less attention paid to the therapeutic milieu. Despite the debate, the evidence for or against the locking of doors is largely weak (Steinert et al., 2019).
The present 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 the levels of coercion patients experience. The evidence for or against the locking of doors on acute mental health wards is largely weak.
Methods
This was a pragmatic, randomized controlled, non-inferiority trial comparing two wards with an open-door policy to three locked wards (treatment as usual – TAU) in a single psychiatric unit in Norway. The open-door policy was co-created, and preparatory activities included workshops and the introduction of peer-support workers to increase therapeutic dialogue. The doors were open from 9am to 9pm unless locking would ensure safety.
The allocation sequence was a simple binomial list allocating participants to either group in a 2:3 ratio for open-door policy and TAU. Staff and patients were not blinded to the intervention. The authors analyzed the data based on intention-to-treat analysis. The primary outcome focused on coercive measures, including involuntary medication, isolation or seclusion, and physical and mechanical restraints. Secondary outcome measures included the Experience of Coercion Scale (ECS) and Essen Climate Evaluation Scale (EssenCES).
Results showed that the open-door policy was non-inferior to treatment as usual on all outcomes focused on coercion. The proportion of patient stays with exposure to coercion was lower in open-door wards compared to TAU wards. Patients in open-door wards had a significantly shorter length of stay and rated their experience of coercion lower than those in TAU wards. They also reported higher scores on therapeutic holding and experienced feelings of safety.
Conclusion
The study concluded that the open-door policy could be safely implemented without an increase in coercive measures. The findings highlight the need for more reliable and relevant randomized trials to investigate the effectiveness of interventions like open-door policies in mental health care.
Discussion
While the study suggests that opening ward doors does not lead to increased coercion, there are still many unanswered questions. It would be interesting to see if similar results could be replicated in other settings, as the intervention in this study was multi-facetted and involved significant input before implementation. More research is needed to support decision-making in mental health services.
