Toward a New Open-Door Model for Psychiatric Wards

Pura C. Roy

September 21, 2022

If isolated, patients with mental disorders may end up having higher levels of social impairment. This has led several hospitals in Spain to set up open-door departments that are more accessible.

The purpose of the open-door model is to help remove the stigma from individuals who need to be admitted to a psychiatric ward because they have a mental disorder.

Traditional Locked Wards

According to the World Health Organization (WHO), in 2019, 1 in every 8 people were living with a mental disorder. Having the least restrictive type of mental health care is one of the 10 basic principles listed in a 1996 reference document from the WHO.

Among people suffering from severe psychiatric disorders, there is a high probability of being involuntarily admitted to a psychiatry ward with locked doors (PWLD). Admission to a PWLD involves the application of a set of measures that restrict the individual's freedom.

The main argument for keeping the doors locked is that it prevents suicides and self-harm behavior, as well as abscondment. But in recent years, efforts have been made to apply a model called open-door policy psychiatry wards (ODPWs).

Open Wards Model

Experiments were undertaken in various countries, including the United Kingdom, Australia, Switzerland, and Germany. Investigators found that the new forms of hospitalization led to a reduction in conflictive events; self-harm behavior; restrictive measures, such as seclusion, mechanical restraints, and chemical restraints; as well as forced medication. On the basis of these findings, ODPWs were launched.

Univadis Spain spoke with Ignacio García Cabeza, MD, psychiatrist and coordinator of the Department of Psychiatry at Madrid's Gregorio Marañón General University Hospital. "The open wards model is founded on the idea of respecting the patient and their autonomy. In addition, it advocates a reduction in coercive measures," he said.

"We wanted our department to be the same as the other departments in the hospital, with patients going in and out, receiving treatment, and being able to have family visits," he explained. "A patient's diagnosis should not factor into these things. People with schizophrenia, people with any type of mental disorder, should be able to enjoy this minimally restrictive environment."

Use of open wards constitutes a paradigm shift in hospitalization toward a person-centered psychiatry. The goal of this new paradigm is to prepare the individual so that he or she can live in harmony with the usual environment and participate in it to the same extent as everyone else in the community.

This model also implies fundamental changes in the interaction between healthcare professionals and patients. The implementation of new nursing care models, among which the Safewards model stands out, is a key element for the success of the project.

Based on a set of tools for preventing and managing conflict, the Safewards model seeks to modify the factors that regulate the relationship between staff and patients. Using this model brought about a 15% reduction in the rate of conflictive events and a 23% reduction in the rate of coercive interventions, in comparison with a control group.

One of the major debates is about whether every patient should be able to choose this open-door system. For García Cabeza, the answer is yes, but with one caveat. "There's a certain group of patients who perhaps need to be in locked wards, who perhaps require greater means of control — patients whose conditions put them at a high risk of suicide or of self-harm behavior or of absconding."

He had no hesitation in saying that an open-door ward increases the patient's self-esteem. It helps promote autonomy and a sense of control and of normalcy with respect to a community. "The idea is to get to the point where we've got an atmosphere, a climate, that serves to benefit the therapeutic actions that are going to continue to influence the patient's future progress and their treatment."

That's why it's important to bring about the kind of healthcare activities that can prevent the patient from experiencing some of the negative psychological effects, such as distrust and feeling removed from normalcy. "In traditional locked wards, the patient feels incapable of making decisions. They feel that they have very little to do with [and have] no say in the decisions made, and a lot of times, this leads to a situation where, after discharge, the patient ends up giving up on the treatments. If we can manage to break this perception held by the patient," García Cabeza suggested, "it's quite likely that we'll manage to improve the course of their disorder in general."

What the Literature Says

The effect of ODPW has been investigated through comparative studies with PWLD and research of the transition from PWLD to ODPW, both from a therapeutic and safety a point of view.

A 15-year observational study published in The Lancet Psychiatry found that, with respect to abscondment, suicide attempts, and suicide, there were no significant differences between hospitals with open-door policies and those without.

A subsequent study that was published in 2017 found that on open wards, any aggressive behavior and restraint or seclusion were less likely than on closed wards.

The Spanish Situation

This system is already at work in some Spanish hospitals, among them Inca Comarcal Hospital (Palma de Mallorca), Elda General University Hospital (Alicante), Germans Trias i Pujol Hospital in Badalona, and Gregorio Marañón General University Hospital in Madrid.

"At Gregorio Marañón, we started the experiment just before the pandemic hit. We're up and running now, but still with some limitations; the patient can go in and out, but not with the flexibility we'd like," explained García Cabeza. "An open ward plays a clinical, patient-care role and a symbolic one as well. Locking the doors has a lot to do with the fear felt toward these patients. It's a stigma that they've had to deal with and that they continue to have to deal with. In terms of the symbolic role, there's also the fear that comes with giving these patients some rights."

While the experiment at Gregorio Marañón's psychiatric ward "is still very much in the early stages," there have been no recorded incidents related to its open-door policy. García Cabeza is aware of the challenges of such a policy, "starting with assistance when conflictive events arise. Challenges faced by the staff — especially the nursing staff, as they're the ones who are with the patients 24 hours day — and challenges faced by those in charge of providing care. In all of this, there are new things to learn and be aware of, new ways of understanding and looking at the patient-physician relationship. The fears are still there — they haven't been done away with. But the way we conduct ourselves should be adjusted, matching how we act toward other patients. Although the differences have to be taken into account, we have to try to normalize, as much as possible, the environment where patients with mental disorders receive treatment."

García Cabeza himself has no doubts. "The most sensible and reasonable decisions need to be made at these sites so as to allow the broadest applicability to cases. Anyone who needs psychiatric hospitalization and who is competent to consent to admission and who voluntarily agrees to be admitted — they can and must be placed in an open ward."

The hope is that in the future, the number of open wards will increase and the number of locked wards — which have more stigma attached to them — will go down. The involvement of the staff and appropriate institutional support are essential to making this a reality.

This article was translated from Univadis Spain.


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