FURTHER WORK AND DISSEMINATION The future work from this study:

1/ The dissemination of this data with regard to the themes from this study – for peer review and scrutiny.

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2/ This pilot site should make contacts with other UK pilot sites with regard to how ODA research in the UK is being developed; potentially looking at joint research studies. Also this could further facilitate our understanding of the ‘mechanics’ and complexities of what might make ODA work in the UK setting and how ODA ‘impacts’ upon service users and. In the future, ethnographic studies can be used locally to conduct further research into this approach. Such studies could observe network meetings first hand to explore and record what is happening and what the subtleties of the discussions are having on the service user (and the clinicians). The context of this study was only from the

viewpoint and perceptions of participants (health care professionals in this case); a study looking at how power ‘friendly’ and equitable the meetings were conducted would be of great benefit (Gobo 2011). Additionally, this research needs to encapsulate a wider cohort of staff from different specialties along with those from different health boards to ensure we have as full a picture as possible of how views, opinions and the underlying culture pervades psychiatry in the UK. To conduct this research will pose ethical obstacles to the researcher although these are not insurmountable especially if an approach is made to the service user movement to come on board with this so that the rationale and objectives of the research is made transparent and open. It is vital that nurses rather than medical staff take the lead on such initiatives when there is some evidence that UK nurses may be opposed to such power levelling practices (Raboch et al 2010).

3/ There is a requirement for a business case prepared to bid for governmental monies to pay for staff training to a wider staffing group; and look into developing trainers to deliver training locally. This could be to expand on the pilot and conduct further research. Such data could generate a model that will demonstrate whether ODA is a sustainable model for Wales and the UK, i.e. economically feasible and effective in other parts of the mental health service. (This has already been achieved due to successfully securing Welsh Government funding £90,000 for ODA training.)

4/ In addition to the above develop a greater understanding of the power relationship with in psychiatry for clinicians and concentrate on the learning methods required for implementation in the UK. This could help develop evidence for a wider audience of the potential benefits of moving away from a diagnostic model and into a more therapeutic approach, that encapsulates a watchful waiting approach; but at the same time has a proactive stance.

5/ If ODA is demonstrated to be effective in the UK through further pilots then mental health services must lobby government for policy changes to fully implement tolerance of uncertainty; this will require the generation of ‘gold standard’ evidence in order to convince a wider audience of ODAs potential efficacy following the implementation of wider research within the UK setting.

8.4 SUMMARY

Experiential learning and more formalised teaching and learning is beneficial for ODA roll out,

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implemented in an ad hoc way in that clinicians had varying degrees of previous ODA knowledge or psychosocial intervention knowledge and experience. The latter undoubtedly provided clinicians with a smoother transfer into ODA; however, a clinician reported that having that lack of knowledge allowed him to experience the network meetings in genuine and meaningful way.

All clinicians were in agreement that ODA appeared to be an effective approach for the service users they worked with. It is not wholly clear from this study whether a pioneer effect resulted in those clinicians overcoming initial anxieties that ultimately resulted in them seeing the benefits they found in the service users they worked with. That is, future implementation must take into account that this effect may not be there to sustain staff through early stages and adequate support and training must be available to them.

The local evidence is such that all service users who engaged in this process appeared (to the

clinicians/ participants) to have benefitted from it. There is some subjective evidence in how it affected confidence in service users but also some objective reports in bed days and use of as required

medication.

The power relationship is critical as it appears to be the central and core intervention mechanism within ODA. However this power transfer can be perceived as a barrier by some staff and

professional groups who feel threatened by this. Tolerance of uncertainty was another barrier that was encountered by the participants and the role they felt they must follow of taking positive risks and using minimal recording and communication about the service user without their participation; which is in direct contrast to the legislative processes that currently state and assume that correct safeguards are in place for service users within the UK. This could be difficult with medical staff due to the element of risk and for medical staff who have responsible clinician status over their service users; there may be potential accountability and litigation if things go wrong. Therefore, government support would be required to change the policies surrounding mental health legislation. It could be argued that currently clinicians are not going to embark on implementing full ODA principles without senior support and direction from WG. Ironically WG are only going to make these policy changes with evidence; if ODA is effective and deemed to be implementable and safe then ODA could be promoted as core mental health services. However, clinicians within this study overcame this issue by not implementing all of the ODA principles; tolerance of uncertainty was ameliorated so that clinicians did record in case notes and had discussions with colleagues without the service user being present, however, these occurred in exceptional times of risk and probably most importantly they occurred with the service user having knowledge that these conversations would occur. This indicates a contrast to current

psychiatric care where discussions happen and records kept that are not explicitly done with the service user’s knowledge. However, all participants reported the positive effect that using ODA’s other principles had on their service users. The mechanism for this may be the fact that clinicians are being open and transparent with the service user despite having to have conversations with other clinicians without the presence of the service user and documenting risks clearly for others to see. The fact that

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this openness is there may act to preserve the therapeutic relationship by maintaining trust between the clinicians and the service user.

The implications for practice with this work is that it indicates there may be some flexibility in the way ODA is implemented in the UK. It appears that ODA can be contextualised to the cultures it is used within and the legislative frameworks that organisations must comply with. Additionally to ensure it is implemented successfully managers must be aware of their role in delivering and managing this. Staff need to feel empowered and supported to implement ODA as the initial period may be uncomfortable for new clinicians. A transformational leadership approach is more likely to provide the correct level of support and empower staff. Additionally this style provides a role model for how ODA should be delivered to service users and embraces the complexity surrounding health care processes and successful change management principles.

Finally this study is limited due to its size (n.5) and specificity i.e. only involved nurses who worked in the same service. Therefore, the transferability of the findings are limited. However, the transferability of some of the themes found here to other similar areas are positive and something others should consider.

162 9. CONCLUSION & RECOMMENDATIONS

9.1 THE RESEARCH QUESTION

This is a small scale study (n. 5) however the gap in knowledge about nursing staff adopting ODA has been lessened by this study adding to a growing body of knowledge that has recently developed within the UK. This study will serve to guide future work or add to already existing work.

Complexity theory and the qualitative approach of IPA have worked well together: IPA has provided this study with a rich source of data full of complexity with which a complex systems model has been used to view analyse and offer explanations/ insights.

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?

ODA was reported to be effective for service users by all of the participants over the 18-24 months study period. The participants were unanimous in their opinion that the intervention appeared to be effective for service users in that it empowered and created a sense of choice and control that in their previous experience had not existed. Learning methods need to be incorporated for the local area to ensure that staff wishing to use ODA can obtain safe, effective, consistent and purposeful education. Two things are required if the evidence declares that ODA is effective: Learning equipment and access to it for clinicians to undertake ODA and there needs to be support from policy drivers to ensure UK clinicians are directed to embed ODA into mental health services.

The ODA principle of tolerance of uncertainty is at odds with current UK mental health legislation and within this pilot it was not adhered to fully. Despite this ODA was reported to be effective to the service users according to the clinicians who used the approach. However, the clinicians were open and honest with the service user about when they did not adhere to it. This indicates that approach may be ameliorated and adapted to the locality it is implemented within and that the approach can be flexible in this regard.

ODA relies on clinicians devolving their power or sharing their power with service users. This may cause some anxiety within clinicians especially within the initial stages. The central element that appears to contribute to that perceived success was a change to the power dynamic or specifically a shift in control to the service user. Power was an enabler by empowering service users to take a more active role and have control over their futures. Through this it appeared give them confidence and control over their illness and lives. The clinicians involved in this study felt that this aspect of ODA was the effective part of the approach as it allowed service users to gradually develop confidence through the dialogical intercourse with clinicians, which in turn allowed them to connect with their own

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thoughts and develop a deeper and greater understanding of themselves and following this with others. Clinicians described how service users gradually became more confident in what they said and did. Clinicians allow service users to be afforded the basic dignity of equality and this fosters their independence and confidence, by respecting people as people and allowing them to develop and learn and move on. Psychiatry does not actively stop this development however, in the rush to treat people with medication and other treatments this may hinder growth and development, by focussing too specifically on one aspect of the service user’s symptomatology.

Therefore it appears that power, learning, effectiveness and barriers play a vital role in the process of participants using ODA within this local health board. Power, and its benefits through empowering service users is in contrast to the barriers clinicians feel, as they can feel threatened by this. Initially, clinicians found this change in control and power very uncomfortable, and only through witnessing the benefits to the service user did they perceive the significance of the approach. The power shift can be/ become a barrier to the successful implementation of the approach. It potentially requires legislation changes so that positive risks can be taken with service users by increasing their control without having the potential threat of legal or disciplinary ramifications onto the professional.

Power relationship needs to be explored with staff because as well as being a source of benefit to service users it can be viewed as a potential barrier to staff uptake of ODA. If staff feel threatened by such a phenomenon then this could prevent the intervention being undertaken by them. Staff require knowledge as well as support to guide them through this process. Interestingly in this study the participants who had longer clinical experience found the power difference to be less of an issue, this may be indicative of this study alone, however, subsequent clinicians should be mindful that length of clinical experience may play a role in this phenomenon being an issue for some clinicians.

Further research has been produced since work on this study began, in particular, Tribe et al (2019) which found ODA to be overall positive although there may be some further support required for both staff and service users. In addition, Ellis (2018) study found ODA to be positive but discovered an organisation that is founded on the medical model could be a barrier to successful implementation. It is very positive that these studies overlap with this work in the qualitative approaches taken and the inquiry into staff experiences which reported the positive effect they saw on service users - although this study could have been enhanced by service user experiences.