The Lovisenberg study of Open-door policies in acute mental healthcare: developing and evaluating a service innovation to minimize coercion

Unnecessary coercion can cause patients to lose hope and undermine their engagement in treatment. The Lovisenberg Open Acute Door Study (LOADS) aims to reduce unnecessary coercion in acute psychiatric wards at the Lovisenberg Diaconal Hospital in Oslo, Norway by implementing a new service model, ?open door policy?. In open-door policy, the main door to the acute ward is open by default to prevent tension among admitted patients. The open door also enables patients to remove themselves from provoking situations that could have resulted in violence. One aim of LOADS is to enhance trust in the health services and counteract the image of acute mental health care as synonymous with coercion. Staff in LOADS will be trained in finding alternatives to coercion while continuously assessing the safety of each patient. LOADS will start by developing a version of open-door policy adapted to Lovisenberg's setting: acutely admitted patients with serious mental health problems living in the inner-city boroughs of Oslo, Norway. Development is based on experiences at hospitals in Germany and Switzerland, as well as input from patients and staff at Lovisenberg. The open-door policy will affect both how we work with patients at the hospital, how we train to maintain and improve staffs coercion prevention skills, and how patients engage with outpatient services before and after admission. After development is finished, two acute psychiatric departments will apply the open-door policy for one year. After 12 months, LOADS will evaluate satisfaction and use of coercion in the open-door policy wards compared to 'best practice' wards. If the evaluation is positive towards open-door policy, two more wards will start using the open-door policy. Evaluation and development will continue for a further three years focusing on coercive measures, in-house drug use, and comparison with neighboring hospitals.

Freedom of movement is a fundamental human right that is systematically restricted in acute psychiatry to address safety, prognosis and/or staffing concerns. The legitimacy and therapeutic impact of the current state-of-the art ‘locked door’ practice has recently been called into question by the United Nations, the WHO, user organisations, and the Norwegian Government. Lovisenberg Diaconal Hospital wishes to implement and test a new service model, open-door policies, to increase patient freedom and reduce coercion in their inner-city acute psychiatric wards. The Lovisenberg Open Acute Door Study (LOADS) RCT will randomly assign admitted acute psychiatric patients to two open-door policy wards or state-of-the-art locked-door wards for 12 months. The RCT will be followed by a 4-year observational period to report on data beyond the RCT. The hypothesis is that open-door care will be equivalent to - or better than locked-door care. The risk of insufficient involvement of staff and management is addressed via an action-based implementation model: The Clinic Director retains the psychological ownership of the project, and invests considerable resources and time in engaging and listening to the opinion of staff, users, and external collaborators in dialogue on the design and implementation of the open-door service model. This also reduces the risk of insufficient research management, as the project manager for the research component need not constantly pressure staff and management to contribute but can focus on study design, results analyses and dissemination. Ordinary risk of insufficient inclusion (selection bias) and incomplete data are addressed by the designation of LOADS as a health services research project that will utilise routinely collected data from all admitted patients rather than being based on acutely ill patients providing informed consent. The RCT addresses the risk of selection bias in comparing old and new service models.