Opening the doors: Critically examining the locked wards policy for public mental health inpatient units in Queensland Australia

Abstract

The Queensland Government issued a policy directive to lock all acute adult public mental health inpatient wards in 2013. Despite criticism from professional bodies and advocacy for an alternative, the policy has been retained to this day. A blanket directive to treat all psychiatric inpatients in a locked environment without individualised consideration of safety is inconsistent with least restrictive recovery-oriented care. It is against the principles of the United Nations Convention on the Rights of Persons with Disabilities, to which Australia is a signatory. It is also contrary to the main objects of the Mental Health Act 2016 (Qld). Queensland Health has reported a reduction in ‘absences without permission’ from psychiatric inpatient wards after the introduction of the locked wards policy; however, no in-depth analysis of the consequences of this policy has been conducted. It has been argued that patients returning late or not returning from approved leave is a more common event than patients ‘escaping’ from mental health wards, yet all may be counted as ‘absent without permission’ events. A review of the international literature found little evidence of reduced absconding from locked wards. Disadvantages for inpatients of locked wards include lowered self-esteem and autonomy, and a sense of exclusion, confinement and stigma. Locked wards are also associated with lower satisfaction with services and higher rates of medication refusal. On the contrary, there is significant international evidence that models of care like Safewards and having open door policies can improve the environment on inpatient units and may lead to less need for containment and restrictive practices. We recommend a review of the locked wards policy in light of human rights principles and international evidence.

Introduction

The Queensland Government made the policy decision to lock all acute adult public mental health inpatient wards in 2013 (Director of Mental Health, 2013). This decision was implemented across all the health service districts of Queensland. Despite concerns being raised by multiple stakeholders (Royal Australian and New Zealand College of Psychiatrists, 2013; The Australian College of Mental Health Nurses Inc, 2013), the policy remains in place to this day. An indiscriminate policy to treat all patients with mental health issues in locked wards is unusual when viewed in the context of contemporary trends towards recovery-oriented mental health service delivery and respecting the rights of people with disabilities. This article will consider the issue of ‘locked wards’ using the Queensland experience as a case study, considering relevant policy and legislative frameworks, and reviewing the evidence to support such a practice.

Locking the doors – the Queensland experience

Up until 2013, most inpatient psychiatric wards were designated as open units with individual hospitals having the discretion to lock the doors based on clinical grounds (e.g. case-mix, acuity and associated emergent risk concerns, and available staff and physical resources). In 2012, new sections were inserted into the Mental Health Act 2000 (Qld) which gave the Director of Mental Health discretion, in response to a significant risk, to ‘take any other action necessary to prevent a similar significant matter and related risk from arising again’ (s. 493). Before this power was conferred on the Director, there was no policy on whether authorised mental health units in Queensland were to be locked or unlocked. In the absence of a policy, decisions to lock mental health units were locally managed, which allowed locked doors to be used principally as a temporary measure to allow for reallocation of resources to address the specific needs of individual patients. In 2013, the Director of Mental Health ordered that all main entry and exit doors of all acute mental health inpatient units be locked starting on 15 December, in order to prevent harm as the result of involuntary patients absenting themselves without permission (Director of Mental Health, 2013). While the rationale for the policy was not clearly described, it was linked in the media with concerns about absconding and risk to patients and the community, as well as the burden on police who were tasked with returning people who were absent without leave (Wardill, 2013). As most wards in Queensland were designed to be open, this move had foreseeable impacts on patient well-being, such as reduced access to activity rooms and outdoor recreational areas (Fletcher et al., 2019).

The decision was contextualised in the popular press with the inflammatory language ‘HUNDREDS of mentally ill patients – including convicted killers and rapists –are absconding each year’ (Wardill, 2013). The locking of the inpatient wards was strongly criticised by the Royal Australian and New Zealand College of Psychiatrists, the Australian College of Mental Health Nurses, the National Mental Health Commission and the Australian Association of Social Workers, and described as ‘draconian’ and counter-therapeutic. The Queensland Mental Health Commission (QMHC) discussed options for reform and concluded the following:

The Commission is of the view that a decision to lock doors should be discretionary and based on local decision-making. Local decision-making should be supported by a statewide policy framework that takes a whole-of-ward approach to recovery-oriented, least restrictive practices. (Queensland Mental Health Commission, 2017: 3)

Despite the criticism from professional bodies, advocacy for an alternative to the locked-wards approach by the QMHC, and lack of evidence for patient and community safety, the policy has been retained through two changes of government and four state election cycles.

Contemporary mental health policy and planning frameworks

Contemporary Australian mental health policy and planning frameworks emphasise the importance of recovery-oriented care. Key related concepts include supporting the individual’s right to self-determination, reducing coercion and providing the ‘least restrictive’ care. A directive to treat all psychiatric inpatients in a locked environment without an individualised consideration of patient safety and need is inconsistent with recovery-oriented care principles, particularly when it affects people who could be adequately supported on an open ward. While it is not required by legislation or the published policy, in practice voluntary patients in Queensland provide written consent to receive care in a locked environment at the point of admission. However, the validity of this practice is questionable, as the only options available to patients are to be admitted under the locked door policy, or to be denied access to inpatient treatment. Reviews of international literature on the clinical utility and impact of locked door policies have found that there is limited evidence about the benefits of locked wards (McSherry, 2014; Wardle, 2015). There is mixed evidence about whether locked doors reduce absconding and there is evidence that locked wards change clinician–patient relationship from a therapeutic to a custodial emphasis (Haglund et al., 2006).

A review of 35 Australian policy documents related to mental health found that Queensland’s state-wide locked ward directive is unique among Australian states and found that ‘Australian policies regarding acute mental health services make little mention of “door locking” policies and procedures in services’ (Fletcher et al., 2019: 540). There appears to be a general lack of transparency and inconsistency regarding the locking of the doors in inpatient units across Australia (Wardle, 2015). We have been able to confirm with Office of the Chief Psychiatrist (or equivalent) in South Australia, Victoria, Western Australia and New South Wales that locking a ward is a local decision based on clinical needs including the need to prevent harm to individual patients on the ward, as well as the needs and safety of the community of patients and staff.

Legislative and human rights frameworks

Like the mental health legislation from other jurisdictions in Australia, the Mental Health Act 2016 (Qld) emphasises the importance of safeguarding the rights of the individual, stating:

The main objects are to be achieved in a way that – (a) safeguards the rights of persons; and (b) is the least restrictive of the rights and liberties of a person who has a mental illness . . . (Mental Health Act 2016 (Qld) s3(2))

Locking the doors of all psychiatric units without consideration of the clinical appropriateness of this restriction is contrary to the main objects of the Mental Health Act.

Respecting the inherent dignity, autonomy and liberty of every human being is central to contemporary human rights frameworks and has become an increasingly important part of Australian mental health legislation since ratification of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) (United Nations, 2006) in 2008. The CRPD requires that all persons with disabilities have a right to equal recognition before the law (article 12), right to liberty (article 14) and right to physical and mental integrity (article 17) on an equal basis with others. Article 14 reads,

States Parties shall ensure that persons with disabilities, on an equal basis with others:a) Enjoy the right to liberty and security of person;

b) Are not deprived of their liberty unlawfully or arbitrarily, and that any deprivation of liberty is in conformity with the law, and that the existence of a disability shall in no case justify a deprivation of liberty . . . (United Nations, 2006. Art. 14)

Contrary to these principles for minimising coercion and protecting the liberty and integrity of persons with disabilities, the locked door policy in Queensland acute mental health units directly leads to deprivation of liberty of patients who are assessed to require a voluntary admission to an acute mental health unit in Queensland and have capacity to consent to treatment. By the exercise of that capacity, some patients will judge that admission to a locked ward will be detrimental to their right to liberty and respect for their integrity. They will then be forced to decide either to suffer the deprivation of liberty in order to gain the benefit of the indicated inpatient treatment or they will decide to forgo the indicated treatment in order to avoid the deprivation of their liberty, thus compromising their right to the highest attainable standard of health (article 25).

Is there any evidence to support the locked wards policy?

Queensland Health has reported favourably on a reduction in absences without permission from psychiatric inpatient wards coinciding with the introduction of the locked wards policy (State of Queensland, 2014). However, no in-depth analysis of the consequences of this policy has been conducted. Internationally, there is little evidence for a locked doors policy in psychiatric wards. Indeed, the evidence suggests that it may do harm. Large-scale studies of service data in German psychiatric hospitals from 1998 to 2012 found that open wards were less likely to use seclusion and restraint, and to experience aggressive episodes (Schneeberger et al., 2017); and did not lead to higher levels of suicide, suicide attempts or absconding (Huber et al., 2016). In Switzerland, seclusion rates were noted to substantially decrease over 6 years after wards were changed from locked to open (Hochstrasser et al., 2018).

Furthermore, there is little international evidence that locked wards reduce the incidence of absconding. The reasons why patients abscond or are ‘absent without permission’ often relate to ward conditions such as boredom and frustration, which locked doors may exacerbate. Fletcher et al. (2019) interviewed staff, carers and people who had experience as patients in inpatient units in Queensland and there was general agreement that reducing boredom and having a more recovery-oriented environment would reduce the need for locking doors on inpatient units, although some participants also supported the discretionary and purposeful locking of doors for short periods for safety reasons. Locking the doors can also increase the need for staff to be aware of what is happening at the door and may increase aggressive confrontations initiated by the door being locked (Muir-Cochrane et al., 2012). Furthermore, patients returning late or not returning from approved leave is a more common event than patients ‘escaping’ from mental health wards, yet all may be counted as ‘absent without leave’ events (McSherry, 2014). In addition, disadvantages for inpatients of locked wards include lowered self-esteem and autonomy, and a sense of exclusion, confinement and irritability (Fletcher et al., 2014; Muir-Cochrane et al., 2012). Locked wards are also associated with lower satisfaction with services (Müller et al., 2002) and higher rates of medication refusal (Baker et al., 2009). Importantly, there is no evidence that locking of doors prevents deaths or serious injury in patients under compulsory care (Huber et al., 2016).

Attention may be drawn to alternatives to coercion in mental health care by using evidence-based strategies like Safewards and ‘six core strategies’. Safewards is a set of interventions to minimise conflict and containment in acute psychiatric wards (locked or unlocked) founded on an extensive programme of empirical research involving hundreds of acute inpatient units. Bowers et al. (2014) note that wards which are permanently locked are associated with reduced rates of absconding, but also increased incidence of aggression, self-harm and medication refusal controlling for other factors. They suggest that locked doors contribute to conflict through ‘. . . the sense of imprisonment and confinement, the identification of the ward as a prison by patients, increased resentment fueling non-cooperation, and plummeting self-esteem through social exclusion and stigmatization’ (Bowers et al., 2014: 357). The Safewards programme includes 10 interventions aimed at improving communication between staff and patients, de-escalation strategies, positive messages and ‘soft words’, and distraction and sensory modulation to manage agitation. Another set of interventions called ‘six core strategies’ emphasises that clear leadership and a specific plan that includes collaborative care with patients and carers reduces other coercive practices like seclusion (Huckshorn, 2004). Such evidence-based strategies would reduce the need for locking the wards at all times by adopting recovery-oriented approaches in acute mental health wards, which reflect local circumstances rather than a universal policy of locked doors (Queensland Mental Health Commission., 2017).

Conclusion

Mental health services must balance the rights and interests of patients, carers, staff and the broader public. We have shown that while Queensland Health’s locked ward policy constrains the rights of all patients admitted to mental health wards, there is little evidence that it reduces risks to patients or others, and some evidence that it may increase risks. Introduction of significant legislative or policy changes intended to improve outcomes for patients with mental illness should include a framework for evaluating impacts and unintended consequences. Entering the eighth year of the locked wards policy, we reflect that we would be in a much stronger position to assess its impact on patients and others if we could now review 8 years of annual reporting of the number of patients affected by the policy; the number of patients absconding from inpatient mental health wards; and the number and character of incidents of harm arising from patients absconding from wards relative to incidents of harm arising from related circumstances, such as failing to return from leave.

We argue that the most pernicious effect of the locked wards policy may be that it has prevented evidence-based approaches to management of the risk of absconding. We recommend a review of the locked wards policy in light of human rights principles and inter-national research, to consider evidence-informed, recovery-oriented alternatives to this policy.