research paper about open door policy

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Requirements for the implementation of open door policies in acute psychiatry from a mental health professionals’ and patients’ view: a qualitative interview study

1 Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Alexandrinenstr. 1-3, 44791 Bochum, Germany

2 Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstr. 258a, 44799 Bochum, Germany

J. Vollmann

Associated data.

The data sets generated and analyzed during the current study are not publicly available due to individual privacy, but are available from the corresponding author upon reasonable request.

Treating legally committed patients on open, instead of locked wards is controversially discussed and the affected stakeholders (patients, mental health professionals) have ambiguous views on the benefits and disadvantages. The study aims to assess the opinions and values of relevant stakeholders with regard to the requirements for implementing open wards in psychiatric hospitals.

Semi-structured interviews were conducted with 15 psychiatrists, 15 psychiatric nurses and 15 patients, and were analyzed using qualitative content analysis.

The interviewees identified conceptual, personnel and spatial requirements necessary for an open door policy. Observation and door watch concepts are judged to be essential for open wards, and patients appreciate the therapeutic value they hold. However, nurses find the door watch problematic. All groups suggest seclusion or small locked divisions as a possible way of handling agitated patients. All stakeholders agree that such concepts can only succeed if sufficient, qualified staff is available. They also agree that freedom of movement is a key element in the management of acutely ill patients, which can be achieved with an open door policy. Finally, the interviewees suggested removing the door from direct view to prevent absconding.

Conclusions

For psychiatric institutions seeking to implement (partially) open wards, the present results may have high practical relevance. The stakeholders’ suggestions also illustrate that fundamental clinical changes depend on resource investments which – at least at a certain point – might not be feasible for individual psychiatric institutions but presumably require initiatives on the level of mental health care providers or policy makers.

People suffering from severe and acute psychiatric disorders are at an increased risk of being involuntarily detained on a locked ward, especially in situations in which they pose a threat to themselves or to others. Although research by Rittmannsberger and colleagues [ 1 ], conducted in Austria, Hungary, Romania, Slovakia and Slovenia, showed more than 10 years ago that involuntarily committed patients are not necessarily referred to locked wards, it is still common practice in most European countries to treat acutely ill psychiatric patients who pose a danger to themselves or to others, at least initially on wards whose doors are permanently locked. Data from the United Kingdom even reveals that the proportion of locked wards has risen over the last decades, resulting in more than 90% locked wards out of all wards visited by the Care Quality Commission in 2015/2016 [ 2 , 3 ].

In Germany, there are two legal regimes – the guardianship law (which is a federal law) and the mental health laws of each of the 16 German federal states – under which patients can be involuntarily admitted to a psychiatric hospital. About 10% of the admissions to a psychiatric hospital are involuntary, and the absolute number of involuntary admissions has increased significantly under both legal regimes since the 1990s [ 4 ]. Traditionally, legally committed patients are admitted to locked wards. However, in recent years, several clinicians and bodies advocated for stronger efforts to implement open door policies in psychiatry, which means to treat legally committed patients on open, rather than locked wards [ 5 – 8 ]. Such approaches are discussed controversially; however, some psychiatric hospitals have quite a long tradition of open door policies [ 9 – 11 ].

Legally, it is assumed that the treatment of legally committed patients on open, rather than locked wards, is permissible as long as hospitals take appropriate measures to guarantee that the respective patients do not abscond from the commitment [ 12 , 13 ]. In North Rhine-Westphalia, which is the German federal state with the highest number of inhabitants, on 1 January 2017 a new mental health law came into force which even explicitly states that “legal commitments shall be performed in an open setting as far as possible” (Sec. 10 of the North Rhine-Westphalian PsychKG). All such demands and provisions aim to ensure the safety of the patients or others as best as possible while limiting the patients’ freedom as little as possible. There is data that opening the doors might lead to less aggressive incidents [ 14 , 15 ] and that absconding and suicide rates are not higher compared with closed settings [ 15 , 16 ].

However, previous studies revealed that mental health professionals’ and patients’ attitudes towards open wards are quite ambiguous and that different stakeholders tend to not only see benefits but also certain disadvantages of open wards, such as the loss of resources due to the observation of the open door or a decrease in security and control [ 2 , 17 – 20 ]. Open door policies challenge those who are directly involved in clinical routines and have to transform theoretical concepts into daily clinical practice. While these previous studies have primarily investigated the effects of open door policies, there is no research that we are aware of that has explored how such concepts can be newly implemented and what organizational requirements may be necessary for putting them into practice.

The present study is part of a larger mixed-methods study on clinical effects and ethical aspects of open door policies. The mixed-methods study consists (1) of a prospective cohort study, which aims to investigate – amongst others – the effects of open compared to locked doors on coercive interventions and serious incidents in a sample of all patients who were involuntarily committed to five different psychiatric hospitals during a specified 6 months period, and (2) of a qualitative interview study with mental health professionals and patients. With the interviews, we aim to explore the experiences and attitudes of different experts of psychiatric practice with the implementation of open doors in an acute psychiatric hospital. In this article, we only present results of the qualitative interview study. We intend to identify requirements for the treatment of legally committed patients on open instead of locked wards by taking into account the practical and personal knowledge of those who are needed when such fundamental changes such as an open door policy are introduced into clinical practice.

Between February and June 2016, four members of the research team conducted 45 qualitative, open-ended, semi-structured interviews (15 interviews with patients, 15 interviews with psychiatric nurses and 15 interviews with psychiatrists). Psychiatrists and psychiatric nurses were chosen because they are directly involved in the decision making around legal commitments of psychiatric patients and in putting those into practice (amongst others by determining whether the ward’s entrance door should be opened or locked). The patients were chosen because they are personally affected by the legal commitment and restricted in their freedom by the locked door.

Before starting the sampling process, the research project was presented to all psychiatrists and psychiatric nurses in their regular team meetings. The sampling process was purposive in order to obtain a diverse selection of psychiatrists and psychiatric nurses to represent a range of professional experience, hierarchical positions, ages and genders. The interviewees could get in touch or were contacted directly by the members of the research team. With regard to the patients, we contacted all patients who met the inclusion criteria and appeared in the hospital’s outpatient or inpatient department during the course of the study.

The inclusion criterion for psychiatrists and psychiatric nurses was to have working experience on both open and closed acute psychiatric wards. As for the patients, the inclusion criteria were (1) having a psychiatric disorder according to ICD-10, (2) having experiences with involuntary commitments in the hospital before and/or after the implementation of the open door policy and (3) preserved mental capacity at the time of the informed consent process and the interview. In case the patient had a legal guardian, the latter also had to give informed consent.

The study was approved by the ethics committee of the Medical Faculty of the Ruhr University Bochum (Reg. No. 15-5452). Before conducting the interviews, the interviewers were trained by an experienced sociologist with the help of mock interviews.

The semi-structured interviews focused on thematic aspects, such as personal experience with the open door policy, challenges and barriers as well as suggestions for improvement. The guideline was developed based on our literature review and refined further after the first interviews, giving the interviewers the opportunity to add relevant questions to the set. The average length of an interview was 41 min (range: 21–64 min). All interviews were audio-taped, anonymized and transcribed verbatim. All transcripts were read and reread to ensure familiarity with the data. The analysis was conducted by five members of the research team, who were not involved in the treatment of the patients. The coders followed the principles of qualitative content analysis, a method that provides useful access to the large amount of data by preserving the advantages of quantitative content analysis and complementing them with qualitative-interpretative steps of analysis [ 21 , 22 ]. During the analysis, using AtlasTi 6.2 software, the data was repeatedly coded, moving from concrete passages to more abstract levels of coding, from codes to categories and finally to three overarching themes. This process was both inductively deriving themes from the data and searching for repeating concepts [ 23 ], as well as deductively analyzing the data on the grounds of previously conducted literature research and the current research question. These steps were repeated as coding guidelines for each interviewee group were gradually developed. All findings were critically tested and discussed among the researchers who had different disciplinary backgrounds (sociology, psychiatry, psychology, nursing and medical ethics). Any disagreements were resolved by discussion. Since the coding system remained the same for the last interviews and the findings did not add anything significantly new to the interviews conducted previously, we concluded that we had reached theoretical saturation.

As Table  1 demonstrates, the participants varied in their age and professional background or diagnosis respectively. One psychologist was included in the group of the psychiatrists. That particular psychologist carries out many tasks of the doctors in the clinic and is therefore referred to as part of the psychiatrist group for the remainder of this article.

Clinical and socio-demographic characteristics

We identified three overarching themes in which changes are seen as necessary for the implementation of open door policy in an acute psychiatric hospital: conceptual, personnel and spatial requirements.

Conceptual requirements

Two concepts which are often implemented in open door policies are intensive forms of observation and a door watch. The continuous or intermittent observation (e.g. 1:1 or 2:1 observation) of patients intends to ensure their safety and that of others and at the same time is a therapeutic intervention to engage the patient in a positive interaction. The door watch consists of a staff member being positioned near the door in order to prevent patients from absconding.

Observation

Both professional groups are in favour of observation because it is less disruptive of the patients’ freedom in comparison to a locked door or mechanical restraint. However, the nurses note that it is very exhausting to constantly be with a patient for lengthy periods of time. Furthermore, psychiatrists and nurses are aware that continuous observation may actually increase tension in certain patient groups. All interviewee groups acknowledge that observation is personnel intensive. Patients greatly appreciate continuous observation as it seems to achieve the right balance of feeling cared for while still remaining autonomous.

I’ve had it a few times that a nurse offered me to talk a little or that I could reach out to them for a chat and I liked that very much. In general, that there are people around you and don’t harass you and don’t want anything but just have a look at what you’re doing, how you are. […] I’ve always found that pleasant. (Patient 3)

While psychiatrists and patients judge the door watch as largely positive, the nurses find the concept problematic. According to the nurses, the door watch poses a big challenge for several reasons. Firstly, they find it mentally draining to watch the door. Many experience stress because so much is happening in the entrance area and they have to be continuously alert. They report it is very difficult to make sure no patient absconds when they have to interact with other patients at the same time. They also experience stress because they are afraid of being attacked and getting harmed when a patient tries to abscond. Finally, some nurses report stress due to feeling responsible when a patient absconds and even being made responsible by their superior. The role of watching the door and ensuring that patients do not abscond thus comes with a lot of emotional distress.

For a nurse, that’s not exactly a comfortable situation because you can’t assume that you can make the patient, who absolutely wants to leave the clinic now, a benevolent, therapeutic offer - rather, you have to mechanically prevent him from something. That’s always a negative experience to the point of quarrelling scenarios, which happen; with sounding the alarm and all that. (Nurse 9)

Secondly, many nurses see a role conflict in being a “guard” for the door. Nurses view themselves as a caring profession whose primary concern is to support the patient. They are thus averse to the idea of having a task that puts them in a position of a guard. Moreover, they report that the door watch prevents them from being able to fulfill their role as a nurse. They can no longer assist patients because they cannot leave their spot or have therapeutic conversations with them because privacy is not given in the entrance area. For this reason, the nurses judge the door watch to be too resource intensive as an entire person’s capacity is taken up by a non-nursing task. Lastly, the nurses point out that repeatedly having to tell patients that they cannot leave, fosters aggression and sometimes strains the therapeutic relationship.

You always had a bit of a bouncer feeling. You technically were rather a bouncer and not a nurse, but had to watch that he wouldn’t abscond, and this one, he can leave. Well that’s not really what we’ve studied for. (Nurse 13)

Psychiatrists are in favour of having a nurse watch the door. They view a constant eye on the door as essential for the success of the open door concept. Psychiatrists think that when a patient leaves the ward, a fast reaction using the presence of numerous staff members is often very effective in preventing absconding. A prerequisite for this is a constant watch of the door.

That would be, I’d say, a justifiable restriction of the respective person’s freedom. He would be brought back by nurses or an alarm would be sounded and everybody comes running. That usually is sufficient in getting the patient to return to the ward, and the other patients aren’t restricted one bit in their freedom of movement. (Psychiatrist 9)

At the same time, psychiatrists acknowledge that nurses cannot be expected to verbally prevent all, especially aggressive patients, from absconding.

Patients experience a nurse paying attention to the door as largely positive. They appreciate that it gives them someone on the floor who they can talk to. Some patients feel like they are being closely monitored, which they dislike, while others mention that they do not have a feeling of being watched. Generally, patients think that by watching the door, nurses can keep a better eye on patients who are at risk of harming themselves or others which enables them to respond faster to escalating situations.

Another one, two more would maybe be better because then maybe it would be a little more compact, right? Maybe one could leave the door open more often […] that staff sits there and pays special attention to those who are particularly at risk. (Patient 12)

All groups agree that the majority of the patients can be easily convinced to stay on the ward by using verbal communication but that some patients cannot be reached by these means and have a strong urge to repeatedly try to leave the ward. The challenge of an open door policy is to find a way of managing this latter group of patients. The interviewees have various ideas of how this might be accomplished. All groups agree that a successful door watch requires more staff. Psychiatrists suggest that all wards should be built in a way that the door can be viewed from the nurses’ room. Another idea for managing challenging patients in an open setting involves seclusion.

Patients, nurses and psychiatrists unanimously would like to have the option of seclusion in the clinic. Patients reported finding seclusion less traumatic than mechanical restraint.

Hence the rest room, the padded room. So they can go in there and let off steam without end and when they’re calm again, they can come out again; instead of being mechanically restrained. Because when you get mechanically restrained, it rather causes more frustration. (Patient 1)

Professionals view a locked door as less coercive than mechanical restraint but they critically note that it affects many patients. By having a seclusion room, nurses highlight that a situation can be effectively de-escalated without having to mechanically restrain the patient or lock the ward for many unaffected patients.

If the locked door can result in the de-escalation of a patient, or bring the situation as a whole under control, the locked door is preferable to mechanical restraint. But I would do it on a small scale […]. In my opinion, there should be an option to put the patient in a room, however that looks like, to lock the door and have a controlled area. I’d prefer that instead of having it affect so many patients. (Nurse 11) For rather physically agitated and restless patients, if you can somehow create special options for them which lead to a reduction of this urge to move; well if you think beyond pharmacological stuff […] possibly a sort of rage room or soft room […] that aggression can also be released without injuries to themselves or others. (Psychiatrist 12)

An overview of the identified conceptual requirements can be found in Table ​ Table2 2 .

Perceptions about conceptual requirements

+: positive; −: negative

Personnel requirements

More staff and strong therapeutic relationships.

All interviewee groups agree that open-door policies can be implemented more successfully with more staff. Both professional groups critically note that the present staff number is insufficient when there are several acute patients on the ward or when staff members are ill. Especially continuous observation and the door watch, both of which are often carried out when the door is open, are very personnel-intensive and result in too little resources for the remaining patients. The patients are also aware of this issue.

Worst-case-scenario would be being assigned to a shift with four of us. We have 32 patients who need to be cared for, then one of us drops out because of 1:1, then the door stays open so we need to establish a door watch, then the third nurse goes out on the floor. Then we only have two people who need to support the remaining 31 patients. That’s difficult. (Nurse 8) The nurses are only humans, they can’t keep an eye on everything. They’ve also got paperwork, they also have to treat other patients and so the chance to abscond is easy. No that doesn’t work, it doesn’t work out. (Patient 1)

Patients and nurses critically note that having too little time to engage in activities or conversations with patients gives patients the feeling that they are not being taken seriously. As a result, tension builds up. All three groups agree that building a strong relationship between staff and patient is crucial for an open door policy.

Psychiatrists and nurses suggest that by having more staff, even students, who can engage in continuous observation or watch the door, the other nurses have more time to manage the needs of patients and form stronger therapeutic relationships. Psychiatrists and nurses highlight that a strong relationship can prevent absconding because patients have a better understanding of why they are in the clinic and that staff want to help them. Moreover, the staff have a better understanding of how exactly they need to engage and communicate with the individual patient to calm them down or prevent them from leaving the ward.

I for one had the feeling I often had too little time to engage in adequate relationship building with the patient, that I had the feeling relationship-wise things were running smoothly, so that patients on this basis could be prevented from absconding. And speaking from my medical point of view, I think there was too little of that. I would’ve preferred to talk more to the patients in order to clearly and explicitly discuss with them why they are here, so that on that basis of trust, I maybe would have accomplished more, that patients don’t abscond. (Psychiatrist 3)

Patients and nurses suggest fixed opportunities for conversations with the staff. Patients report that it is important to them that they can talk to the nurses, to know that the staff regards them with benevolence and that the staff is open to make arrangements. Nurses stress that supporting patients, actively engaging and spending time with them can be effective in preventing tension from building up, which may have otherwise resulted in absconding or aggression.

Beneficial here is without question the communication you can have here; that you’re not put off but rather that you can directly interact with the nursing staff, […] in the locked setting it’s rather that they withdraw, and with this observation there is a kind of care, you get attention and warmth and feel social proximity, and that’s very conducive to your health . (Patient 2)

Trained staff

Nurses and psychiatrists emphasize that training staff adequately is very helpful in the implementation of open-door policies. Psychiatrists critically note that many staff members lack detailed knowledge on the legal aspects of coercive measures and legal commitments to a psychiatric hospital. Psychiatrists also admit that coercive measures, including the locked door policy, should be reviewed more regularly, because oftentimes short periods of a locked door are sufficient to de-escalate a situation. Psychiatrists suggest that there should be more standards and that the given standards regarding coercive measures should be more strictly adhered to. Nurses suggest regular supervisions or inter-professional reevaluation sessions in which the challenges and ideas for the implementation of the open door policy can be discussed.

Technically, we are obliged to review every four hours, and also when a situation has de-escalated earlier, you should always check that you can quickly open the door again. And sometimes you become a little negligent with that. (Psychiatrist 1)

An overview of the identified personnel requirements can be found in Table ​ Table3 3 .

Perceptions about personnel requirements

+: positive

Spatial requirements

Increased freedom of movement and outdoor activities.

Both nurses and patients stress the importance of being surrounded by or in nature. They highlight that activities in nature have therapeutic and de-escalating effects. Patients would like to have more outside excursions with staff. Nurses express their wish to have more time to go for a walk with patients.

That you get to do more with the group, go somewhere or go for a walk in the park, experience more nature, go for a jog or so. (Patient 11)

Psychiatrists and nurses find a garden enclosed in the ward very valuable as patients can be outside, have a smoke and more space to move around. Patients appreciate it, too, but point out that the garden should not be too small.

The problem was that I had to walk all the time because, due to the antipsychotics I got, I had restless legs symptoms. So somehow walk all the time, and so I constantly walked in a circle in this courtyard garden and was annoyed that I couldn’t get further out. (Patient 3)

All three groups agree that it would be favourable to have a bigger space which patients can move in. However, psychiatrists note that a bigger space makes it hard to keep an overview and thus comes with safety risks.

No visible freedom restraints

Related to an increased freedom of movement is the suggestion of moving the actual border within which patients should remain. Both nurses and psychiatrists proposed that patients should be kept on the open ward through verbal communication and that there should only be a lock system outside the ward. This system may be an alarm that automatically goes off, a door further on in the clinic which automatically locks when an alarm button is pressed or special security staff who could be called.

If you secure the outer borders, you could have plenty of latitude to possibly let the patient abscond because then you would find him on the way to the main reception so to speak. So really a mechanical process, that you kind of move the security aspect further outside distance-wise. To present the open here so to speak, which, I find and I stand by that, holds a therapeutic quality for the patient. But the security aspect, that no one absconds who’s going to run out in front of a car or who is going to kill someone or things like that. (Nurse 9)

Another suggestion put forward by the nurses is the idea that it could be helpful to put the (open or locked) door out of line of sight for the patients. By moving the door around a corner which is not visible from the usual movement on the ward, the open door may not create such a big temptation to abscond while the locked door may not create so much frustration. Both these ideas attempt to make the freedom restraints less visible to the patient so that they are not constantly at the top of their minds.

Small locked divisions

Another compromise which is proposed by patients and nurses is to generally have an open setting in the clinic with an additional small locked ward or division. This locked area should have very few beds and only be for acutely dangerous patients. Furthermore, it should be highly staffed with experienced and trained personnel to ensure intensive care. Patients and nurses agree that such a ward would keep the other patients safe. The acute patients would also benefit because they could stabilize in a small, low-stimulus environment. Once they are stable again, they can return to their respective open ward.

Maybe I would really stow them away in an extra space, well only at risk, strongly at risk […] that you can take them out in the acute phase but then also reintegrate them back into the community because they do belong to us, we are a community after all. (Patient 15)

An overview of the identified spatial requiremenst can be found in Table ​ Table4 4 .

Perceptions about spatial requirements

The interviewees identified several requirements for an implementation of open door policies which pose a challenge to the current mental health care system. These include – amongst others – door watch and special observation measures as conceptual requirements, a higher number of well trained staff as personnel requirements and more freedom of movement as well as making the door less visible as spatial requirements.

Special observation measures are well-established in many psychiatric institutions and an integral part of existing clinical guidelines [ 24 ]. Besides observational aspects, they entail therapeutic elements which are valuable for the management of suicidal or aggressive patients. If one opens a locked entrance door on a psychiatric ward, one has to replace the former “mechanical” with a “human” barrier to guarantee that the staff members always know who is on the ward and who is not. This requires measures with a strong focus on observation, and such measures may contradict the professional self-conception of nurses. Moreover, such observational measures can cause emotional distress among nurses (which was described as “anxious vigilance” by Muir-Cochrane et al. [ 19 ] several years ago) and come along with a feeling of having too much responsibility. Against this background, it seems desirable to 1. clearly assign responsibilities among the multi-professional teams, especially in situations in which it comes to absconding, 2. periodically change the observing nurse to prevent emotional distress and 3. strengthen the therapeutic elements in the implementation of a door watch which means using the time of the door watch procedure to engage patients in positive contact instead of merely focusing on the observational aspect.

The psychiatrists’, psychiatric nurses’ and patients’ call for seclusion seems to be quite contradictory at first sight, as it would merely replace one locked door (the ward’s entrance door) by another (the seclusion room’s door). Given that seclusion is rarely used in Germany, in comparison to other countries, and many German psychiatric hospitals do not even possess seclusion rooms (but use mechanical restraint instead [ 4 ]), this claim seems even more astonishing. Furthermore, the claim for seclusion apparently contradicts the international efforts to eliminate all coercive interventions [ 25 – 29 ] and seems to ignore the existing literature on negative effects of seclusion [ 30 – 32 ].

However, what concerns the psychiatrists and psychiatric nurses most is the management of individual agitated or aggressive patients without affecting many other patients by locking the door of the whole ward, and in this context, they regard seclusion rooms as helpful. These attitudes correspond – at least with respect to the patients’ and the staff members’ safety – to the results of a survey in which service users, carers and professionals to varying degrees (ranging from ca. 44 to 85%) hold the opinion that seclusion can increase the safety of service users or others [ 33 ].

The patients’ claim for seclusion rooms probably can be best understood in the context of their strong disapproval of mechanical restraint [ 34 ]. Patients might see seclusion as a less restrictive alternative compared to mechanical restraint [ 35 ].

In view of our results, alongside German guidelines which already recommend the provisioning of different types of coercive measures in psychiatric institutions (to be able to take into account the patients’ individual preferences [ 36 ]), psychiatric hospitals should consider providing seclusion rooms. This does not necessarily have to result in an increase of seclusion or coercive interventions in general. On the contrary, there is evidence that coercive interventions including seclusion can be significantly reduced by the introduction of an open-door policy [ 11 , 14 , 37 ]. Furthermore, there are less restrictive and voluntary alternatives to seclusion such as “soft rooms” which are already known from “Soteria” concepts [ 38 ]. Our interviewees suggested such facilities as helpful in the management of agitated patients.

All stakeholders unanimously share the view that ambitious conceptual changes, like the implementation of an open door policy, can only succeed if sufficient and well qualified staff are made available. However, most of the legal reforms and various demands for a reduction of coercion in psychiatry are not accompanied by the provision of higher financial resources. Taking the views of those who are directly involved in daily clinical routines seriously, initiatives to reduce coercion should include sufficient financial and personnel investments in order to avoid excessive demands on the part of the staff and to make such initiatives successful. At the level of mental health care providers and leaders of psychiatric institutions, strong support should be provided by internal guidelines and regular trainings which has already been identified to be a helpful and effective approach in the reduction of coercion in general [ 39 – 42 ].

Considering that legally committed patients are often tense and restless, an increased freedom of movement is presumably a key element in the management of patients in acute psychic crisis situations. Opening locked doors can both psychologically and factually increase the available space and help reduce crowding with all its negative effects on aggression and concomitant coercion [ 9 , 15 , 43 – 46 ].

With regard to the idea of moving the actual border out of sight of the patients, it is questionable whether an open door policy is still given when there is in fact a locked door further on in the building. However, the idea illustrates that professionals seek a compromise of reaping the therapeutic and ethical benefits of an open door while ensuring safety and abiding by the legal requirement of taking measures to keep the patient committed in the hospital.

Whereas such ideas would presumably require structural modifications in the hospital, this is all the more true for the idea of having small (locked) divisions for intensive care on a regular ward. The interviewees’ suggestions brings the Dutch “High and Intensive Care”- model to mind which entails special “Intensive Care Units”, in which patients can temporarily receive intensified care in acute crisis situations [ 47 , 48 ].

All these approaches indicate that conceptual changes, at least at a certain point, often have to be accompanied by architectural changes. This is in line with the already existing evidence that modifying a hospital’s architecture can contribute to a reduction of coercion [ 49 – 52 ].

Strengths and limitations

To our knowledge, this study is the first qualitative interview study on open door policies in acute psychiatry which includes psychiatrists, nurses and patients, hence all stakeholders who are primarily affected by such a far-reaching change in clinical practice. A key strength of this study is its use of a qualitative method to explore a multifaceted topic, enabling mental health professionals, alongside patients, to express their attitudes towards the implementation of an open door policy. Using a qualitative method such as semi-structures interviews allows participants to expand on their responses, ideally resulting in a rich data collection that provides depth and detail which could not be achieved using a quantitative method approach. However, selection biases due to the recruitment process are possible which could result in a bias towards the participation of mental health professionals who feel generally more positively towards this topic. Nevertheless, since we have (1) strictly respected confidentiality and anonymity and also (2) obtained a variety of distinct answers that are not limited to what would be expected to be socially desirable (e.g. very critical statements), it is safe to conclude that this bias remains small.

With regard to the participating patients, one major limitation is the fact that we did not systematically assess the patients’ disease severity at the time of the interviews and that some of their viewpoints might have been influenced by their current state of disease. Furthermore, not all patients we asked agreed to participate so that we possibly missed the views of those patients who would have been more critical.

A general limitation, which applies to most qualitative studies, is the issue of generalizability. However, the aim of qualitative studies is not generalizability or statistical significance, but rather, to gain a better understanding of social phenomena such as the effects of the implementation of open door policies. Since 1) the data was gathered from a good representation of various mental health professions and 2) theoretical saturation was reached within the number of conducted interviews, we are convinced that we have achieved this aim. Nevertheless, it is unclear whether the attitudes and beliefs presented here would be shared by participants from other settings in other areas or countries.

Based on their personal experiences, mental health professionals and patients point out several requirements which help to promote the process of implementing open door policies in acute psychiatric hospitals. Hence, for all psychiatric institutions which seek to (partially) open former locked wards, their insights into conceptual, personnel and spatial preconditions might have a high practical relevance. On a broader level, the suggestions also illustrate that fundamental clinical changes, such as the implementation of open door policies, depend on resource investments which, at least at a certain point, might not be realised on the level of an individual psychiatric institution but presumably require initiatives on the level of mental health care providers or policy makers.

Acknowledgments

We thank Johannes Bernard, Matthias Kühne and Marco Knoll for their support in the conduction of the study and Jan Schildmann for his methodological advice. Finally, we thank all patients and mental health professionals for their participation in our interview study.

The Medical Faculty of the Ruhr University Bochum supported this study financially by a grant for the Department of Psychiatry, Psychotherapy and Preventive Medicine (Head: Georg Juckel; Awardee: Jakov Gather; FoRUM-award Clinical Research, K093-15).

Availability of data and materials

Abbreviations, authors’ contributions.

IO, JV, GJ and JG made substantial contributions to the conception and design of the study. IO and JG recruited and interviewed the participants. JK managed the data analysis and interpretation to which IO and JG contributed. JK wrote the first draft of the manuscript, JG was a major contributor in writing the manuscript. All authors read the manuscript and were involved in revising and finalizing it. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The study was approved by the ethics committee of the Medical Faculty of the Ruhr University Bochum (Reg. No. 15-5452). All participants gave written informed consent. In case the patient had a legal guardian, the latter also gave informed consent.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

J. Kalagi, Email: [email protected] .

I. Otte, Email: [email protected] .

J. Vollmann, Email: [email protected] .

G. Juckel, Email: [email protected] .

J. Gather, Email: [email protected] .

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The middle class as a large group within any society is an important category of interest, as it is the main driver of economic activity and an interest group that influences political and social life. This paper uses data of successive Household Income, Expenditure, and Consumption Surveys (HIECSs) conducted by Egypt’s Central Agency for Public Mobilization and Statistics (CAPMAS) for 2010/11, 2012/13, and 2015. The Egyptian middle class’s share of the country’s population reached 28 percent in 2015 (almost 25.6 million people). Both the lower- and upper-middle class is more represented in metropolitan areas and in Lower Egypt than elsewhere. Middle class households are likely to have heads with high education, permanent jobs, nonagricultural formal work, work in the government, other public, or private sector, and benefit more from social and health insurance compared to lower income households. Coverage of social and health insurance should be expanded all population specially the middle class. They need insurance or income stabilization interventions so that no newly poor are generated. On the other hand, the poor need structural changes in terms of their education, employment, health status, and assets. Cash transfers may alleviate their situation in the short-run, but the impact will be temporary unless they can build their human capacities to be able to maintain sustainable income, and hence get and stay out of poverty. Compared to those in poor groups, they spend a larger share of their consumption on education, and accordingly children in the middle and affluent classes are more likely to enroll in schools than those among the poor class. Food consumption constitutes nearly two-fifths of total consumption of poor households, while it is 36% percent and 33 percent among households in the lower- and upper-middle group, respectively. The number declines more to 25 percent among households in the affluent group. Subsidized food received via ration cards is considered a significant part of food consumption for the poor group (8.4 percent), and 6 percent for middle group. If food subsidies are removed, both middle class, especially lower middle class, have to be compensated in terms of more and better education services and more employment generating activities. If well targeted compensation mechanisms are adopted, the poor and middle class will not adopt stress or crisis coping strategies and hence their food security and human capital will not be affected. Government contributory pensions support the affluent class. Households in this class receive government pension at a rate more than six times higher than that for the poor, and three and two times higher than that for the lower- and upper-middle class, respectively. Moreover, the percentage of households receiving government transfers (government assistant) is progressive where the poor receive more benefits. However, fine tuning targeting is called for, as one out of eight effluents receives cash transfers.

Perrihan Al-riffai , Ahmed Kamaly

International Journal of Middle East Studies

Osama Hamed

Although some may assert that it is too early to assess the impact of Anwar al-Sadat's liberalization policies on the Egyptian economy, I believe there is enough evidence to measure the important trends that have arisen in their wake. And while the statistics and conclusions may be regarded as tentative, they delineate a picture.“There is a smell of money around this place.” With this sentence J. R. Frickers, head of Mobil Oil in Egypt, gives us a feeling for the atmosphere that prevailed in Egypt in 1974. The oil price hike of December 23, 1973, created billions of-dollars in surplus funds for Saudi Arabia and the other Arab oil-producing states.

Shireen Alazzawi

This paper provides a detailed analysis of the dynamics of moving in and out of poverty and inequality in Egypt, utilizing a recent, nationally representative panel survey. It studies the dynamics of poverty using both measures of income and measures of consumption. This provides an opportunity to compare poverty measures and dynamics using these two related, but not identical measures of economic well being. It also shows the difference between urban and rural families, and the use of region specific poverty lines. Regression methods are used to identify the determinants of chronic and transitory poverty over this period in Egypt, and the determinants of moving between and within income groups. The ultimate goal of this paper is to devise and recommend a set of high impact short term policies with immediate measurable results as opposed to grander schemes.

Third World Quarterly

Raymond Hinnebusch

Policy Research Working Papers

Elena Ianchovichina

SEKAI KASHAMBA

Angela Joya

Archives of Business Research

AbdelMonem Lotfy Mohamed Kamal

E-International Relations

Ahmed Elsayed

This content was written by a student and assessed as part of a university degree. E-IR publishes student essays & dissertations to allow our readers to broaden their understanding of what is possible when answering similar questions in their own studies.

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The Open Door Policy and China's Rapid Growth: Evidence from City-Level Data

MARC RIS BibTeΧ

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The open-door policy: good or bad for whom?

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Many new nursing leaders assuming deanships, assistant, or interim deanships have limited education, experience, or background to prepare them for the job. To assist new deans and those aspiring to be deans, the authors of this department, 2 deans, offer survival tips based on their personal experiences and insights. They address common issues, challenges, and opportunities that face academic executive teams, such as negotiating an executive contract, obtaining faculty lines, building effective work teams, managing difficult employees, and creating nimble organizational structure to respond to changing consumer, healthcare delivery, and community needs. The authors welcome counterpoint discussions with readers.

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• Negotiating Medicine & Life Sciences 100%
• Contracts Medicine & Life Sciences 96%
• Nursing Medicine & Life Sciences 69%
• Occupational Groups Medicine & Life Sciences 59%
• Education Medicine & Life Sciences 52%
• Delivery of Health Care Medicine & Life Sciences 50%
• Survival Medicine & Life Sciences 46%
• organizational structure Social Sciences 41%

T1 - The open-door policy

T2 - good or bad for whom?

AU - Kenner, Carole

AU - Pressler, Jana L.

AU - White, Joie J.

PY - 2008/3

Y1 - 2008/3

N2 - Many new nursing leaders assuming deanships, assistant, or interim deanships have limited education, experience, or background to prepare them for the job. To assist new deans and those aspiring to be deans, the authors of this department, 2 deans, offer survival tips based on their personal experiences and insights. They address common issues, challenges, and opportunities that face academic executive teams, such as negotiating an executive contract, obtaining faculty lines, building effective work teams, managing difficult employees, and creating nimble organizational structure to respond to changing consumer, healthcare delivery, and community needs. The authors welcome counterpoint discussions with readers.

AB - Many new nursing leaders assuming deanships, assistant, or interim deanships have limited education, experience, or background to prepare them for the job. To assist new deans and those aspiring to be deans, the authors of this department, 2 deans, offer survival tips based on their personal experiences and insights. They address common issues, challenges, and opportunities that face academic executive teams, such as negotiating an executive contract, obtaining faculty lines, building effective work teams, managing difficult employees, and creating nimble organizational structure to respond to changing consumer, healthcare delivery, and community needs. The authors welcome counterpoint discussions with readers.

UR - http://www.scopus.com/inward/record.url?scp=43149092486&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=43149092486&partnerID=8YFLogxK

U2 - 10.1097/01.NNE.0000299515.24012.7e

DO - 10.1097/01.NNE.0000299515.24012.7e

M3 - Article

C2 - 18317309

AN - SCOPUS:43149092486

SN - 0363-3624

JO - Nurse educator

JF - Nurse educator

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Key facts about U.S. immigration policies and Biden’s proposed changes

Since President Joe Biden took office in January 2021, his administration has acted on a number of fronts to reverse Trump-era restrictions on immigration to the United States. The steps include plans to boost refugee admissions , preserving deportation relief for unauthorized immigrants who came to the U.S. as children and not enforcing the “ public charge ” rule that denies green cards to immigrants who might use public benefits like Medicaid.

Biden has also lifted restrictions established early in the coronavirus pandemic that drastically reduced the number of visas issued to immigrants. The number of people who received a green card declined from about 240,000 in the second quarter of the 2020 fiscal year (January to March) to about 79,000 in the third quarter (April to June). By comparison, in the third quarter of fiscal 2019, nearly 266,000 people received a green card.

Biden’s biggest immigration proposal to date would allow more new immigrants into the U.S. while giving millions of unauthorized immigrants who are already in the country a pathway to legal status. The expansive legislation would create an eight-year path to citizenship for the nation’s estimated 10.5 million unauthorized immigrants , update the existing family-based immigration system, revise employment-based visa rules and increase the number of diversity visas . By contrast, President Donald Trump’s administration sought to restrict legal immigration in a variety of ways, including through legislation that would have overhauled the nation’s legal immigration system by sharply reducing family-based immigration.

The Biden administration has proposed legislation that would create new ways for immigrants to legally enter the United States. The bill would also create a path to citizenship for unauthorized immigrants living in the country.

To better understand the existing U.S. immigration system, we analyzed the most recent data available on federal immigration programs. This includes admission categories for green card recipients and the types of temporary employment visas available to immigrant workers. We also examined temporary permissions granted to some immigrants to live and work in the country through the Deferred Action for Childhood Arrivals and Temporary Protected Status programs.

This analysis relies on data from various sources within the U.S. government, including the Department of Homeland Security, Citizenship and Immigration Services, the Department of State, Federal Register announcements and public statements from the White House.

The Senate is considering several immigration provisions in a spending bill, the Build Back Better Act , that the House passed in November 2021. While passage of the bill is uncertain – as is the inclusion of immigration reforms in the bill’s final version – the legislation would make about 7 million unauthorized immigrants eligible to apply for protection from deportation, work permits and driver’s licenses.

Amid a record number of migrant encounters at the U.S.-Mexico border, Biden reinstated in December 2021 a Trump-era policy that requires those who arrive at the U.S.-Mexico border and seek asylum to wait in Mexico while their claims are processed. Biden had earlier ended the Migration Protection Protocols , or “Remain in Mexico” policy, and then restarted it after the U.S. Supreme Court upheld a lawsuit by Texas and Missouri that challenged the program’s closure. Asylum seekers do not receive a legal status that allows them to live and work in the U.S. until the claim is approved.

Overall, more than 35 million lawful immigrants live in the U.S.; most are American citizens. Many live and work in the country after being granted lawful permanent residence, while others receive temporary visas available to students and workers. In addition, roughly 1 million unauthorized immigrants have temporary permission to live and work in the U.S. through the Deferred Action for Childhood Arrivals and Temporary Protected Status programs.

Here are key details about existing U.S. immigration programs, as well as Biden’s proposed changes to them:

Family-based immigration

In fiscal 2019, nearly 710,000 people received lawful permanent residence in the U.S. through family sponsorship. The program allows someone to receive a green card if they already have a spouse, child, sibling or parent living in the country with U.S. citizenship or, in some cases, a green card. Immigrants from countries with large numbers of applicants often wait for years to receive a green card because a single country can account for no more than 7% of all green cards issued annually.

Biden’s proposal would expand access to family-based green cards in a variety of ways, such as by increasing per-country caps and clearing application backlogs. Today, family-based immigration – referred to by some as “ chain migration ” – is the most common way people gain green cards, in recent years accounting for about two-thirds of the more than 1 million people who receive green cards annually.

Refugee admissions

The U.S. admitted only 11,411 refugees in fiscal year 2021, the lowest number since Congress passed the 1980 Refugee Act for those fleeing persecution in their home countries. The low number of admissions came even after the Biden administration raised the maximum number of refugees the nation could admit to 62,500 in fiscal 2021 . Biden has increased the refugee cap to 125,000 for fiscal 2022, which started on Oct. 1, 2021.

The low number of admissions in recent years is due in part to the ongoing pandemic. The U.S. admitted only about 12,000 refugees in fiscal 2020 after the country suspended admissions during the coronavirus outbreak . This was down from nearly 54,000 in fiscal 2017 and far below the nearly 85,000 refugees admitted in fiscal 2016, the last full fiscal year of the Obama administration.

The recent decline in refugee admissions also reflects policy decisions made by the Trump administration before the pandemic. Trump capped refugee admissions in fiscal 2020 at 18,000 , the lowest total since Congress created the modern refugee program in 1980.

Employment-based green cards

In fiscal 2019, the U.S. government awarded more than 139,000 employment-based green cards to foreign workers and their families. The Biden administration’s proposed legislation could boost the number of employment-based green cards, which are capped at about 140,000 per year . The proposal would allow the use of unused visa slots from previous years and allow spouses and children of employment-based visa holders to receive green cards without counting them against the annual cap. These measures could help clear the large backlog of applicants. The proposed legislation also would eliminate the per-country cap that prevents immigrants from any single country to account for more than 7% of green cards issued each year.

Diversity visas

Each year, about 50,000 people receive green cards through the U.S. diversity visa program , also known as the visa lottery. Since the program began in 1995, more than 1 million immigrants have received green cards through the lottery, which seeks to diversify the U.S. immigrant population by granting visas to underrepresented nations. Citizens of countries with the most legal immigrant arrivals in recent years – such as Mexico, Canada, China and India – are not eligible to apply.

The Biden administration has proposed legislation to increase the annual total to 80,000 diversity visas. Trump had sought to eliminate the program .

In fiscal 2019, more than 188,000 high-skilled foreign workers received H-1B visas . H-1B visas accounted for 22% of all temporary visas for employment issued in 2019. This trailed only the H-2A visa for agricultural workers, which accounted for nearly a quarter (24%) of temporary visas. In all, nearly 2 million H-1B visas were issued from fiscal years 2007 to 2019.

The Biden administration is expected to review policies that led to increased denial rate s of H-1B visa applications under the Trump administration. In addition, Biden has delayed implementing a rule put in place by Trump that sought to prioritize the H-1B visa selection process based on wages, which would have raised the wages of H-1B recipients overall. Biden also proposed legislation to provide permanent work permits to spouses of H-1B visa holders. By contrast, the Trump administration had sought to restrict these permits. The Trump administration also created an electronic registration system that led to a record number of applicants for fiscal 2021.

Temporary permissions

A relatively small number of unauthorized immigrants who came to the U.S. under unusual circumstances have received temporary legal permission to stay in the country. One key distinction for this group of immigrants is that, despite having received permission to live in the U.S., most don’t have a path to gain lawful permanent residence. The following two programs are examples of this:

Deferred Action for Childhood Arrivals

About 636,000 unauthorized immigrants had temporary work permits and protection from deportation through the Deferred Action for Childhood Arrivals program, or DACA, as of Dec. 31, 2020. One of Biden’s first actions as president was to direct the federal government to take steps to preserve the program , which Trump had tried to end before the Supreme Court allowed it to remain in place . DACA recipients, sometimes called “Dreamers,” would be among the undocumented immigrants to have a path to U.S. citizenship under Biden’s immigration bill. Senators have also proposed separate legislation that would do the same.

Temporary Protected Status

Overall, it is estimated that more than 700,000 immigrants from 12 countries currently have or are eligible for a reprieve from deportation under Temporary Protected Status, or TPS , a federal program that gives time-limited permission for some immigrants from certain countries to work and live in the U.S. The program covers those who fled designated nations because of war, hurricanes, earthquakes or other extraordinary conditions that could make it dangerous for them to live there.

The estimated total number of immigrants is based on those currently registered, in addition to those estimated to be eligible from Myanmar – also called Burma – and Venezuela.

Immigrants from Venezuela and Myanmar are newly eligible for TPS under changes made after Biden took office in January 2021 by the Department of Homeland Security, which oversees the program. The government must periodically renew TPS benefits or they will expire. The department extended benefits into 2022 and beyond for eligible immigrants from nine nations: El Salvador, Haiti, Honduras, Nepal, Nicaragua, Somalia, Sudan, Syria and Yemen. In addition, the Biden administration expanded eligibility for immigrants from Haiti based on recent turmoil.

Biden and congressional Democrats have proposed granting citizenship to certain immigrants who receive TPS benefits. Under Biden’s large immigration bill, TPS recipients who meet certain conditions could apply immediately for green cards that let them become lawful permanent residents. The proposal would allow TPS holders who meet certain conditions to apply for citizenship three years after receiving a green card, which is two years earlier than usual for green-card holders. By contrast, the Trump administration had sought to end TPS for nearly all beneficiaries, but was blocked from doing so by a series of lawsuits.

Note: This is an update of a post originally published March 22, 2021.

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How Temporary Protected Status has expanded under the Biden administration

After declining early in the covid-19 outbreak, immigrant naturalizations in the u.s. are rising again, how the political typology groups compare, most americans are critical of government’s handling of situation at u.s.-mexico border, most latinos say u.s. immigration system needs big changes, most popular.

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