Least restrictive practices in acute mental health wards including consideration of locked doors: Facilitated forums and options for the future

Abstract

This report brings together research literature and stakeholder perspectives, to inform recommendations for achieving the least restrictive practice in Queensland’s acute inpatient mental health services. It presents qualitative data gathered via consultation with Queensland stakeholders with direct experience of acute inpatient units. The data from the facilitated forums address issues related to the acceptability and applicability of a set of recommendations developed from a review of Australian mental health policy documents and relevant research literature. Based on these data, the report synthesises and integrates the results of the research team’s investigation and concludes with options related to the key themes of: recovery-oriented practice, policy and procedure, routine and environment, and staffing. Much of the literature about reducing coercive and restrictive practices in acute inpatient environments tends to focus on individual patients; however this report relates to the whole ward environment. Thus the decision to keep the doors of wards locked or unlocked is particularly important, and our purpose has been to assist in informing decision-making on this issue through the gathering of research evidence and key informant perspectives. We have found that the research evidence is relatively sparse; there have been very few research efforts in this area. However there is considerable interest and support for improved decision making, reducing restrictive practices and improving the environment and culture of wards. This interest is given particular momentum in the context of a shift to recovery-oriented practice and greater respect for the human rights of people with mental illness. Our report reaffirms that these are complex issues. The human rights of patients in wards is extremely important, as is ensuring that wards offer a safe place for vulnerable people and for staff, while also meeting community expectations about managing risk. Five consultations were held across two locations: consultations with a group of people with lived experience, a group of carers and a group of staff on the Gold Coast; consultations with people with lived experience and with staff in Rockhampton. These consultations involved 35 individuals who ranged in age from 23 – 73 years, two thirds of whom were female and two of whom identified as being of Aboriginal or Torres Strait Islander descent. The options presented here, in the form of refined recommendations under each of the key themes, provide guidance for future policy and practice in Queensland. We identify that the recommendations had varying levels of support from stakeholders, but that each recommendation has potential to improve current systems and practices towards the goal of achieving less restrictive practices in acute inpatient services in Queensland. The report suggests that there are multiple ways forward. One relies on an approach of universal precaution, resulting in routinely locking the doors of wards; another begins with keeping the wards open. In keeping the wards open, our investigation suggested that there was still support for having a tiered or discretionary approach that enabled some areas of a ward to be locked, or for the whole ward to be locked for particular time-limited purposes. At this stage, we conclude that the goal of having wards unlocked at all times is aspirational and contingent on significant system change.