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Best Practices: To Lock or Not to Lock Patients'Rooms: The Key to Autonomy?
Netta Shoenfeld; Anne-Marie Ulman, M.D.; Mordechai Weiss, M.D.; Rael D. Strous, M.D.
Psychiatric Services 2008; doi: 10.1176/appi.ps.59.10.1100
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The authors are affiliated with the Beer Yaakov Mental Health Center, Yaakov, Israel. Dr. Ulman, Dr. Weiss, and Dr. Strous are also with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Send correspondence to Dr. Strous at Beer Yaakov Mental Health Center, P.O. Box 1, Beer Yaakov 70350, Israel (e-mail: raels@post.tau.ac.il). William M. Glazer, M.D., is editor of this column.

Many patients with schizophrenia experience prominent negative symptoms. Functional impairment often results in patients who remain in their rooms for most of the day. It has thus become common practice in many psychiatric wards to lock patients' rooms during much of the morning and afternoon hours to encourage participation in ward activities and treatment modalities. Within the context of a quality control evaluation, two self-report surveys were conducted among patients (N=20) and staff members (N=9) in Beer Yaakov, Israel: the first survey was given when the rooms were locked at certain times, and the second survey was given after the rooms had been unlocked for one week. Patients and staff members expressed differing views both before and after the week-long open-door policy (patients enjoyed the policy, whereas many staff did not). Behavior during the period of the open-door policy varied among patients. The authors discuss the ethical grounds of locking doors and whether it is a best practice in keeping with rehabilitation interests. (Psychiatric Services 59: 1100—1102, 2008)

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Negative symptoms often feature prominently in schizophrenia and are associated with dysfunction in many areas of behavior, including lack of motivation, anhedonia, and social withdrawal (1). Furthermore, because of disabling positive symptoms (for example, delusions and hallucinations), patients often minimize external stimuli to escape uncomfortable psychotic features and isolate themselves from the external world. The assumption has therefore often been that in the context of inpatient hospitalization, this functional impairment will result in patients' remaining in their rooms, so they can rest or sleep for most of the day.

Although no official figures exist, personal communication from practicing inpatient psychiatrists in several countries, including the United States, and our own observations in Israel, lead us to conclude that in many psychiatric wards, patients' rooms are locked during some of the morning and afternoon hours for the presumed purpose of encouraging participation in ward activities and treatment modalities. In addition, several psychiatry wards lock patients' rooms during much of the day as a safety precaution, to ensure that no violence or assault by patients on themselves or others occurs in rooms when staff cannot observe. Although the benefits of such a practice may seem obvious to staff, to our knowledge no studies in professional literature have examined the subject. Investigation of the practice is important because many patients do not necessarily want to rest or sleep away their day. The ward serves as home for the patients, and many in their rehabilitation process do take responsibility for their lives (2) and might be interested in having free access to their rooms, private bathrooms, and belongings.

Within the context of a quality control evaluation, we conducted two self-report surveys among patients (N=20) and staff members (N=9) in Beer Yaakov, Israel: the first survey was given in January 2007 when the rooms were locked during much of the morning and afternoon, and the second survey was given after the rooms were unlocked for one week. In doing so, this study explored the effects of a short-term intervention that challenged the practice of locking patients' rooms on a regular basis.

Of the 30 patients on the unit, 20 responded to the survey, three declined to participate, and seven were not able to participate because of language difficulties or because they had temporarily left the unit for a vacation. Of the nine staff members who participated, two were psychiatrists, four were nurses, one was a psychologist, one was a social worker, and one was a cleaning staff member.

In a ward where long-standing policy says that rooms should be locked in the morning and during part of the late afternoon, patients and staff were asked voluntarily and informally to provide their opinion before and after the doors were kept unlocked for one week. Patients and staff were informed that for this week the rooms would be open at all times, with entrance allowed at all hours. In addition, patients were informed that staff would not insist that patients leave their rooms, if the patients were reluctant to do so. The patients would not be encouraged (over and above what is normally extended) to participate in daily activity groups. Thus patients would be free to determine whether they wanted to spend time in activities, in the yard, or in their rooms.

Before the doors were unlocked, a majority of patients surveyed (N=18, or 90%) felt that conditions would be much better if rooms were to be unlocked throughout the day. All claimed that they would not spend all their time in their rooms if they were left unlocked; rather, they would attend therapy groups and wander the yard. They did not see benefits in locking rooms at defined hours, and they reported that the practice caused them considerable unease.

In contrast to patients' positive sentiments, the ward staff was against this anticipated change in general. A majority (N=6, or 67%) of staff members surveyed indicated that keeping doors unlocked was not in the best interests of patients, because they assumed that if patients were given the option to stay in their rooms, the patients would not attend treatment sessions or take medications. Furthermore, many (N=7, or 78%) felt that patients would stay up all night after sleeping more than necessary in the afternoon. Moreover, it was proposed that locking doors at certain hours functions as an important boundary framework for patients. Thus staff felt that locking doors reflects an important rehabilitative aspect of the ward treatment program that helps patients to become accustomed to a routine of activities during specified hours.

After the doors were left unlocked for the week, a majority of patients (N=17, or 85%) reported that they enjoyed the "open-door" week and supported a policy of unlocking rooms. All reported not having spent all their time in their rooms; instead they attended therapy groups at least some of the time. They also reported that they appreciated having full access to rooms and belongings at all times (N=18, or 90%), something one patient reported as "true freedom and privacy." However, a few patients (N=2, or 10%) complained of property theft (although it may not necessarily have been related to the open-door policy). Because rooms were open with general access, several patients (N=3, or 15%) believed others were stealing their food, drinks, and cigarettes. Nevertheless, patients summed up the week as being successful overall (N=19, or 95%); however, one patient (5%) felt that there was no need for rooms to be open during the morning hours, because that is when therapy groups meet. Instead, it was suggested that rooms be open only in afternoon hours.

In contrast, nursing and paramedical staff responded more negatively than patients to the week-long open-door policy. Although there was no denying that some patients had cooperated, proving that the change was justified, others had not. Some patients slept more than necessary in the afternoon, which led to their having difficulties in falling asleep and spending the nights wandering uncharacteristically. Moreover, some patients did not leave their rooms, and their communication was significantly diminished. The cleaning staff also reported key difficulties. With the rooms open, the cleaning staff member often found patients in their beds when staff went to clean the rooms. She reported that all cleaning staff had concerns that patients would slip on floors wet after cleaning and injure themselves. She also reported that staff would sometimes encounter rude and aggressive patient reactions when patients were asked to vacate the rooms temporarily so they could be cleaned.

One of the principal goals of a rehabilitation unit is to enable patients to progress into independent living infrastructures, such as halfway houses or group homes. The requirements for patients within the context of such semi-independent living is for patients to be able to eat by themselves, make their beds, take medications, bathe and dress independently, and be motivated to engage in vocational function. These independent living skills that are facilitated by social skills training are critical for patients' progress to recovery (3). With these requirements, many mental health staff members maintain that ward boundaries, such as locked doors at certain times for treatment purposes, are crucial. If a patient learns that certain hours are for working and others are for sleeping, it may assist the patient in more independent living. However, because the goal of mental health treatment is to encourage autonomy and good decision making, enforcing locked doors limits decision making over an important aspect of one's life, such as when one can stay in one's own room. With this in mind, the standard operating practice of locking patients' doors at certain times should be reexamined. Such a reconsideration kindles issues regarding unexamined aspects of hospital treatment in patients' lives.

Locking doors is not only a way of limiting withdrawal from social and treatment activities, it also may become an active way of asserting staff control. Locking doors can be seen as part of the power struggle between the "keepers" and the "kept." Therefore, it would not be surprising that staff would be unwilling to give up some of this control and that they would base this reluctance on clinical grounds, rather than on other, less socially acceptable reasons. The International Code of Medical Ethics (4) clearly states that patient interests are primary. Thus management of patients on a psychiatric ward, while ensuring safety, should be for optimal convenience of patients and not simply that of the staff. Although there can be no "one policy fits all" for whether doors should remain open at all times or locked during certain times, this issue should be closely examined, because it seems to be associated with the development of independent living skills. The question remains whether locking a door helps or interferes with the development of such skills. On the basis of our findings, the practice should be revisited and challenged. Staff should be engaged in a discussion of the negative consequences of locked doors, and staff need to consider and develop other ways of encouraging patients to participate in activities.

The week-long open-door policy may have been too short for patients or staff to appreciate the potential benefits of the change in policy. Because of the novelty, patients may have chosen to stay in their rooms, knowing that the privilege would later would be denied. Had the period been any longer, patients may have developed a stable routine without necessarily remaining in their rooms. Often, whether a patient stays or does not stay in his or her room depends on the disease profile. If negative symptoms are significant, with resulting impairment in drive and initiative, patients would use rooms for resting, sleeping, and withdrawing whenever possible. Other patients who are considerably active and look to occupy themselves may not.

The observations from our quality assurance evaluation were interesting, although more studies are needed. The best practice may be to individualize the treatment for all patients on a case-by-case basis, which means opening the door for some and locking it for others. This could be determined by examining the clinical state of the patient. Some patients are more independent and have less severe negative symptoms. This subgroup may benefit from having a key to their room. However, this would open up issues of fairness and differential treatment. Although it may be suggested that having different levels of privilege is unfair, within the context of an individualized treatment plan with clear boundaries and limits, this practice may have value and legitimacy. The decision to lock or not lock a patient's room should be seen as an important part of a patient's treatment plan.

Many advocates may propose that hospital staff never have the right to lock rooms, because it delineates a deprivation of patients' rights (5). This concern has been dealt with by the prevailing approach that because patients voluntarily agree to hospitalization, they have consented to treatment conditions, including a locked-door policy several hours a day for treatment purposes. Nevertheless, even within the context of this policy, staff should always be available to open rooms upon patients' request. Although the policy in many psychiatric hospitals continues to prevail on the basis of consideration for patients' best interests, this policy needs to be reexamined. At the least, the locked-door policy should be limited to times while ward activities are taking place—that is, activities oriented toward direct patient benefit and the rehabilitation process. At the time of admission, this should be made clear within the context of informed consent for voluntary institutional treatment. It becomes critical for clinicians to reassess unexamined assumptions, even if staff perceive the changes as initially being uncomfortable and unpopular. Long-suffering patients with psychiatric illness deserve nothing less.

Freedman R: Schizophrenia. New England Journal of Medicine 349:1738—1749, 2003
 
Diamond RJ: Recovery from a psychiatrist's viewpoint. Postgraduate Medicine 54—62, 2006
 
Kopelowicz A, Liberman RP, Zarate R: Recent advances in social skills training for schizophrenia. Schizophrenia Bulletin 32(suppl 1):S12—S23, 2006
 
International Code of Medical Ethics. World Medical Association Bulletin 1:109—111, 1949
 
Quill TE, Brody H: Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Annals of Internal Medicine 125:763—769, 1996
 
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References

Freedman R: Schizophrenia. New England Journal of Medicine 349:1738—1749, 2003
 
Diamond RJ: Recovery from a psychiatrist's viewpoint. Postgraduate Medicine 54—62, 2006
 
Kopelowicz A, Liberman RP, Zarate R: Recent advances in social skills training for schizophrenia. Schizophrenia Bulletin 32(suppl 1):S12—S23, 2006
 
International Code of Medical Ethics. World Medical Association Bulletin 1:109—111, 1949
 
Quill TE, Brody H: Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Annals of Internal Medicine 125:763—769, 1996
 
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