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Nurses Experiences on Using Open Dialogue Approach in a Local Mental Health Service: an Interpretative Phenomenological Analysis

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Nurses Experiences on Using Open Dialogue Approach in a Local Mental Health Service: an Interpretative Phenomenological Analysis Nurses experiences on using open dialogue approach in a local mental health service: An interpretative phenomenological analysis Professional Doctorate in Advanced Healthcare Practice Thomas Mark Jones 2019 School of Healthcare Sciences Cardiff University HCARE – Doctor of Advanced Healthcare Practice/ CM20002637 ACKNOWLEDGEMENTS Thank you to all those people who have kept me on the path during this entire course. Thank you to Cardiff and Vale UHB for their ongoing support and backing – I could not have done it without the fantastic teams supporting me. Thanks to Cardiff University for an excellent course – in particular to Dr Jane Harden and to my very dedicated supervisors Dr Nicola Evans and Dr Steve Whitcombe and Dr Michelle Huws-Thomas (I hope this work reflects the amount of support you have given me): along with my research review supervisors. During this course I was fortunate to secure a travel scholarship from the Florence Nightingale Foundation. My travels took me across the world and finally to Finland that allowed me to focus and specify on my chosen topic, which I am very grateful for. Finally, thank you to the ongoing support from my wife Georgina, my son Benjamin and my daughter Menna – I ensured we had plenty of playtime and play days; but sleepless nights for me! cariad mawr xxxx Ac i mam, diolch am bopeth a cariad mawr xxxx Word Count: 69000 I HCARE – Doctor of Advanced Healthcare Practice/ CM20002637 ABSTRACT NURSES EXPERIENCES ON USING OPEN DIALOGUE APPROACH IN A LOCAL MENTAL HEALTH SERVICE: AN INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS Background Open Dialogue Approach (ODA) is a collaborative intervention and framework for using with service users with complex mental health such as psychosis. Aims To explore nurses’ experiences when using ODA and in particular how ODA culture compares to other mental health cultures within a local health board. Method Through the qualitative approach of Interpretative Phenomenological Analysis five members of staff were purposively sampled and participated in the research. Findings The participants discussed ideas and concepts that developed into the following themes: the first theme was based on learning ODA skills and concluded that experiential learning and more formalised teaching is beneficial for ODA roll out, however, having a more experienced clinician partnered with a novice is crucial. The second theme focussed on participants perception of impact: all participants/ clinicians agreed that ODA was an effective approach for the service users they worked with, due to the therapeutic relationship, service user empowerment and openness and transparency. The third theme identified ‘barriers’: the ODA principle of tolerance of uncertainty was a barrier that was encountered by the participants. Participants felt they must take positive risks and use minimal recording and not communicate about the service user without their presence, which is not in keeping with current legislation (UK and Wales). Also of significance is the fact that the service user is empowered within ODA to lead and direct the conversation which could be perceived as a barrier by some staff and professional groups who may feel threatened by this. This was evident in managing staff emotions within initial network meetings, managing risk and maintaining professional boundaries. In order to overcome this, the principle of tolerance of uncertainty was relaxed by participants in order to manage risk and for them to comply with current legislation. The empowered relationship in ODA is critical (through clinicians being open and truthful), as it appears to be the central and core intervention mechanism within ODA. Conclusion ODA is reported as being effective by the participants within this study, but it will require further research to demonstrate this effectiveness within the UK to the wider clinical body and policy developers. The study also indicates a mechanism for ODA effectiveness: control and empowerment of the service user and openness/ transparentness from clinicians. If this is employed then it appears that the principle of tolerance of uncertainty can be ameliorated to fit with UK legislation. II HCARE – Doctor of Advanced Healthcare Practice/ CM20002637 CONTENTS NURSES’ EXPERIENCES ON USING OPEN DIALOGUE APPROACH IN A LOCAL MENTAL HEALTH SERVICE: AN INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS ACKNOWLEDGEMENTS I ABSTRACT II CONTENTS III 1. INTRODUCTION 1 1.2 LAYOUT OF THESIS 2 1.3 REFLEXIVITY 3 2. BACKGROUND 5 2.1 HISTORICAL UNDERPINNINGS OF MENTAL ILLNESS 5 2.2 DEFINITIONS AND BACKGROUND TO PSYCHOSIS AND SCHIZOPHRENIA 5 2.3 TRANSFORMATION – INSTITUTIONALISATION OR 6 TRANS-INSTITUTIONALISATION, REHABILITATION AND RECOVERY 2.4 BIOPSYCHOSOCIAL MODELS OF SMI – 9 HISTORICAL AND CURRENT BIOMEDICAL TREATMENTS 2.5 EARLY INTERVENTION SERVICES 11 2.6 OPEN DIALOGUE APPROACH 13 2.7.1 THEORY AND CONCEPTUAL UNDERPINNINGS 13 2.7.2 BACKGROUND TO DEVELOPMENTS AND RESEARCH 14 2.8 RECENT DEVELOPMENTS 21 2.9 SUMMARY 23 3 SYSTEMATIC REVIEW OF THE LITERATURE 24 3.1 APPROACH METHOD 24 3.2 REVIEW FINDINGS 28 3.2.1 QUANTITATIVE PAPERS 29 3.2.2 QUALITATIVE PAPERS 33 3.2.3 ODA INFORMATION SOURCES 39 3.2.4 OUTCOME STUDIES 40 3.2.4.1 QUANTITATIVE STUDIES 40 3.2.4.1.1 FINLAND STUDIES 40 3.2.4.1.2 OTHER STUDIES 46 3.2.4.2 QUALITATIVE 47 3.2.4.2.1 FINLAND STUDIES 47 3.2.4.2.2 OTHER STUDIES 49 3.3 REVIEW SUMMARY 51 III HCARE – Doctor of Advanced Healthcare Practice/ CM20002637 4 THEORETICAL FRAMEWORK 54 4.1 ONTOLOGICAL AND EPISTEMOLOGICAL POSITION 54 4.2 THEORETICAL LENS 55 4.3 METHODOLOGICAL AND STUDY ALIGNMENT 56 4.4 SUMMARY 57 5 METHODOLOGY 59 5.1 RESEARCH DESIGN 59 5.1.1 CHOICE OF METHODOLOGY 60 5.1.2 RATIONALE FOR CHOOSING IPA 63 6 METHOD 65 6.1 THE RESEARCH QUESTION 65 6.2 OBJECTIVES 65 6.3 RESEARCH DESIGN 67 6.3.1 REFLEXIVITY 67 6.3.1.1 THEORETICAL ENGAGEMENT 68 6.3.1.2 PRACTICAL ENGAGEMENT 69 6.3.1.3 ROLE AS A RESEARCHER AND A SERVICE MANAGER 70 6.3.1.4 REFELXIVITY SUMMARY 71 6.3.2 SAMPLING 71 6.3.3 RECRUITMENT 72 6.3.3.1 INCLUSION AND EXCLUSION CRITERIA 72 6.3.3.2 PARTICIPANTS 73 6.3.4 DATA GENERATION 74 6.3.5 DATA ANALYSIS 75 6.3.5.1 INDIVIDUAL CASE ANALYSIS 76 6.3.5.2 EMERGENT THEMES 78 6.3.5.3 CROSS CASE ANALYSIS 78 6.3.5.4 RIGOUR - TRUSTWORTHINESS AND QUALITY 79 6.3.5.4.1 SENSITIVITY TO CONTEXT 79 6.3.5.4.2 COMMITMENT AND RIGOUR 79 6.3.5.4.3 TRANSPARENCY AND COHERENCE 79 6.3.5.4.4 IMPACT AND IMPORTANCE 80 6.4 ETHICAL CONSIDERATIONS 80 7 DATA FINDINGS\ ANALYSIS 83 7.1 INTERPRETATION OF DATA 83 7.1.1 THEORY OF THEMES 83 7.1.2 IMPACT OF THE THEMES 84 IV HCARE – Doctor of Advanced Healthcare Practice/ CM20002637 7.2 RESEARCH PARTICIPANTS 86 7.2.1 RACHEL 86 7.2.1.1 LEARNING/ ACQUISITION OF NEW SKILLS 87 7.2.1.2 FEASIBILITY OF ODA/ BARRIERS WITHIN HEALTH BOARD 91 7.2.1.3 IMPACT AND POWER 93 7.2.2 COLLETTE 96 7.2.2.1 LEARNING/ ACQUISITION OF NEW SKILLS 97 7.2.2.2 FEASIBILITY OF ODA/ BARRIERS WITHIN HEALTH BOARD 98 7.2.2.3 PERCEPTIONS OF IMPACT 102 7.2.2.4 POWER 104 7.2.3 MIKE 106 7.2.3.1 FEASIBILITY OF ODA/ BARRIERS WITHIN HEALTH BOARD 108 7.2.3.2 PERCEPTIONS OF IMPACT 110 7.2.3.3 POWER 111 7.2.4 PATRICK 113 7.2.4.1 LEARNING/ ACQUISITION OF NEW SKILLS 114 7.2.4.2 FEASIBILITY OF ODA/ BARRIERS WITHIN HEALTH BOARD 115 7.2.4.3 PERCEPTIONS OF IMPACT 118 7.2.5 HEATHER 119 7.2.5.1 LEARNING/ ACQUISITION OF NEW SKILLS 121 7.2.5.2 FEASIBILITY OF ODA/ BARRIERS WITHIN HEALTH BOARD 122 7.2.5.3 PERCEPTIONS OF IMPACT 123 7.2.5.4 POWER 128 7.3 THEMES ANALYSIS 129 7.3.1 LEARNING/ ACQUISITION OF NEW SKILLS 129 7.3.2 FEASIBILITY OF ODA/ BARRIERS WITHIN HEALTH BOARD 129 7.3.3 PERCEPTIONS OF IMPACT 130 7.3.4 POWER 130 7.4 SUMMARY 130 8 DISCUSSION 131 8.1 ODA IN A COMPLEX SYSTEM – PRACTICE AND RESEARCH SETTINGS 132 8.2 THEMES DISCUSSION 134 8.2.1 LEARNING/ ACQUISITION OF NEW SKILLS 134 8.2.2 FEASIBILITY OF ODA / BARRIERS WITHIN HEALTH BOARD 137 8.2.2.1 SHARED DECISION MAKING BARRIERS/ ODA 138 POTENTIAL IMPLICATIONS 8.2.2.1.1 INCOMPATIBILITY WITH POLICIES/ 138 LEGISLATION & CURRENT SYSTEMS/ CULTURES V HCARE – Doctor of Advanced Healthcare Practice/ CM20002637 8.2.2.1.2 SDM NOT HERE TO STAY 140 8.2.2.1.3 MEDICAL PROFESSION IN CONTROL 141 8.2.2.1.4 PROFESSIONAL BOUNDARIES 142 8.2.2.1.5 PATIENTS ISOLATED 143 8.2.2.1.6 SDM TOO COSTLY 143 8.2.2.1.7 STAFF UNSKILLED AT SDM 144 8.2.2.2 BARRIERS TO ODA 144 8.2.2.2.1 REFLECTIVE DISCUSSIONS 144 8.2.2.2.2 TOLERANCE OF UNCERTAINTY 145 8.2.3 PERCEPTIONS OF IMPACT 145 8.2.3.1 SHIFTING CONTROL TO SERVICE USERS: 145 EQUALITY 8.2.3.2 THERAPEUTIC RELATIONSHIP & RECOVERY 146 8.2.3.3 RESEARCH PARTICIPANTS REFELCTIONS ON 147 IMPACT 8.2.3.4 IMPACT SUMMARY 149 8.2.4 POWER (OVERARCHING THEME) 149 8.2.4.1 POWER HISTORY AND IMPACT 150 8.2.4.2 POWER/ COERCION AND THERAPY 152 8.2.4.3 EMPOWERMENT: THE CLINICIAN’S ROLE 156 8.3 FURTHER WORK AND DISSEMINATION 158 8.4 SUMMARY 159 9 CONCLUSION & RECOMMENDATIONS 162 9.1 THE RESEARCH QUESTION 162 9.2 RESEARCH LIMITATIONS 163 9.3 FINAL THOUGHTS 164 9.4 FURTHER WORK AND DISSEMINATION 165 10 REFERENCES 167 11 APPENDIX 190 11.1 APPENDIX A 190 LITERATURE REVIEW SCREENING TOOL 11.2 APPENDIX B 191 LITERATURE REVIEW APPRAISAL TOOL 11.3 APPENDIX C 192 RESEARCH PROTOCOL 11.4 APPENDIX D 194 CONSENT FORM VI HCARE – Doctor of Advanced Healthcare Practice/ CM20002637 11.5 APPENDIX E 195 SEMISTRUCTURED INTERVIEW QUESTIONS 11.6 APPENDIX F 196 INTERVIEW TRANSCRIPTS WORD FREQUENCY SEARCH 11.7 APPENDIX G 198 INTERVIEW TRANSCRIPT CODED EXAMPLE 11.8 APPENDIX H 199 SUMMARY OF RESEACRH THEMES 11.9 APPENDIX I 205 RESEARCH LOG 11.10 APPENDIX J 215 ETHICS APPROVAL 11.11 APPENDIX K 218 CRITICAL SYSTEMS HEURISTICS TOOL VII HCARE – Doctor of Advanced Healthcare Practice/ CM20002637 1.
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