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7.3.1 LEARNING/ AQUISITION OF NEW SKILLS

This first theme involves looking at how practitioners became involved with ODA and how they acquired the skills to become ODA practitioners. Some practitioners were provided with ODA information/ learning whilst others had been immersed into sessions without such information.

This first theme can be seen to have generated data that alludes to the fact that participants are supportive of both types of learning and there appears to be no consensus on what should happen first; experiential learning or classroom training. The merits of both have been observed; the exposure to ODA without prior knowledge is seen as a positive experience, along with having information beforehand. This is something that may need to be explored further as it is difficult to ascertain what has greater benefits due to the subjectivity of the respondents along with the bias that they have been exposed to, i.e. the way that they were initially exposed to ODA may have influenced their responses because they cannot undo how they were first exposed to the intervention.

7.3.2 FEASIBILITY OF ODA/ BARRIERS WITHIN HEALTH BOARD Barriers to implementing ODA were raised by all participants.

To recap on this theme, barriers to implementing ODA are as follows:

 The principle of tolerance of uncertainty – this is where no information is recorded or

discussed in between meetings; participants highlight the problem of this in that legislation in this country dictates that we must record notes fully.

 The clinicians who participated in this study felt that the NHS is not open and transparent like ODA is and this dichotomy makes it difficult for ODA to be fully implemented in our services.  Participants feel that they need appropriate clinical space in order to successfully hold ODA

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 Some participants can feel judged by colleagues about their clinical practice, especially during clinical reflective discussion.

 Participants feel that you have to give some of yourself to the process – to make it real and genuine.

 Participants felt stripped of their professional mask and therefore authority in the room. Less experienced participants found this more difficult.

7.3.3 PERCEPTIONS OF IMPACT

All the participants discussed in some way about their perceptions of ODA’s impact in their sessions with service users. This was experienced in a variety of ways.

To conclude this theme it is apparent that ODA clinicians feel that there is some merit in its

application. They felt that they could see the impact it had on the service users that they worked with. This positive effect was observed through a reduction in clinical acuity (use of medication and

hospitalisation), achievement of goals and direct feedback from service users.

7.3.4 POWER

This overarching theme explores the power relationship between clinicians and service users. ODA theory aims to promote and elevate service user authority, control and status in the clinical environment, and it became evident from the interviews that this aim had transferred to the local health board.

7.4 SUMMARY

The themes presented indicate that robust learning (experiential and classroom) is important to be able to equip staff with the skills required to undertake ODA interventions; although as mentioned by participants an experienced clinician working with an inexperienced clinician in partnership is vital. Power has a vital role in ODA in that part of ODA perception of effectiveness by the clinicians involved in this study is the empowerment of service users, although some participants can be affected by their perceived loss of power which may be seen as a barrier for some. Other barriers of ODA being successfully inculcated into the local health board is the tolerance of uncertainty principle which clinicians are expected to undertake. This may be difficult in a health board (and country) where risk is always minimised and standards assume that all safeguards are put in place. Finally, all clinicians are in agreement that ODA is effective. However to demonstrate this, further work will need to be undertaken to accurately measure whether ODA is effective or not.

131 8. DISCUSSION

The study research question was as follows:

What was the experience of mental health nurses in an inpatient and outpatient setting of using Open Dialogue Approach following its implementation in a local mental health clinical board?

This work has been achieved through conducting an IPA study using interviews with staff who have used ODA. In addition to this it has been informed by research from Western Lapland that purports the efficacy of ODA, and has been driven by the lack of evidence within the UK to demonstrate whether ODA is transferrable to the UK and whether it is as effective as its developers report.

During the finishing stages of this work, other research papers have been published, but in particular studies by Ellis (2018) and Tribe et al (2019). Ellis’ (2018) study used a qualitative narrative approach to interview staff of their experiences of using ODA; Ellis found that ODA had a positive experience on staff practice. However there were several organisational barriers faced in implementing ODA due to the medicalised approach embedded within the organisation.

Whilst Tribe et al (2019) looked at staff and service users experience of ODA using an inductive thematic analysis approach. They found that clinicians’ perceptions were that ODA was effective, a preferred choice, but a challenging way of working. Service users’ views were mixed, with some feeling reflective discussions were strange, but ultimately they mostly felt listened to and had developed a greater understanding between them and the clinicians. Interestingly, service users reported that network meetings were emotionally expressive and could feel overwhelming at times (one service user stated that they felt distressed by them), which implies that the correct support is required for staff and service users. Although the description within this paper as to why service users became overwhelmed is worrying because it relates to clinicians being open about their feelings, which made the service user wary; this appears to be a miscommunication between clinicians and service users. The service users should lead network meetings not the clinicians.

Similarly to the Tribe et al (2019) study, this doctoral study would also have included the views of service users, however, at the time it was felt too time consuming within the deadlines of this programme due to delays within the early stages of developing the proposal. Therefore, any future work is recommended to include the service user voice.

This chapter explores the themes that were raised in the previous chapter data findings. The layout of the discussion is as follows:

 ODA in a Complex System – practice and research settings

This section discusses the importance of a complex system perspective when employing change and implementing something as radical as ODA that challenges many of the pre- existing structures.

132 o Learning/ Acquisition of new skills

This subsection is related to how learning or experiential knowledge is preferred by the participants within this study. Dealing with professional boundary issues, increasing clinician confidence and clinician perceptions.

o Feasibility of ODA/ Barriers within health board

This subsection focussed on the potential barriers of adopting ODA from the study evidence and from other research sources. Issues found were that the NHS culture is not open and transparent, staff can feel judged/ threatened (at least initially) by ODA, staff felt reduced of their power/ control, the principle of tolerance of uncertainty was not fully implemented due to UK legislation which reinforces a power barrier or power imbalance in the relationships between clinicians and service users. Shared decision making collaborative practice barriers were explored as this could be replicated with the implementation of ODA. Staff need to be genuine/ authentic which could produce professional boundary issues.

o Perceptions of impact

This section focusses on the shift of control from the clinician to the service user, the therapeutic relationship and recovery.

o Superordinate theme – Power

The final theme is the superordinate (overarching) theme, which is interrelated to the previous themes and is discussed in each section. It looks at therapeutic relationship verses coercive practices, and the role of the clinician in empowering service users.  Further work, extrapolation and dissemination

Finally, the chapter provides an overview of further work that is required following this study and similar studies.

 Summary

This section reviews the previous work and highlights strengths/limitations of this research. It concludes that whilst the tolerance of uncertainty principle was not fully adhered to the approach still appears to be effective.