Journal of Psychosocial Nursing and Mental Health Services

Original Article Open Access

Open Dialogue Approach: Exploring and Describing Participants' Experiences in an Open Dialogue Training Program

Ritva Kyrrø Jacobsen, MSc, RN; Ellen Karine Grov, PhD, MScN, RN; Tiril Østefjells, PhD; Bengt Karlsson, PhD, MSc, RN

  • Journal of Psychosocial Nursing and Mental Health Services.
  • https://doi.org/10.3928/02793695-20210107-03
  • Posted January 14, 2021

Abstract

Open dialogue (OD) is a family-oriented approach that has demonstrated good outcomes in treatment of first-episode psychosis. OD focuses on communication as a joint process of constructing meaning among patients, their social networks, and professionals. The current study investigates how 42 participants experienced a training program in OD. The study comprises a cohort with a longitudinal design. Data were collected by means of semi-structured questionnaires and contained quantitative and qualitative data. Descriptive analysis was performed to analyze quantitative data and thematic analysis for qualitative data. Findings show that participants' learning outcomes and confidence with using OD with patients, social networks, and professionals increased significantly throughout the training program. Reflection and role play were essential learning methods. Participants defined themselves as in-progress and considered the training program educational, engaging, and varied. Three main themes arose from the data: Developing an OD Training Program, Competence Development “From Novice to Expert,” and Participation and Commitments. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Abstract

Open dialogue (OD) is a family-oriented approach that has demonstrated good outcomes in treatment of first-episode psychosis. OD focuses on communication as a joint process of constructing meaning among patients, their social networks, and professionals. The current study investigates how 42 participants experienced a training program in OD. The study comprises a cohort with a longitudinal design. Data were collected by means of semi-structured questionnaires and contained quantitative and qualitative data. Descriptive analysis was performed to analyze quantitative data and thematic analysis for qualitative data. Findings show that participants' learning outcomes and confidence with using OD with patients, social networks, and professionals increased significantly throughout the training program. Reflection and role play were essential learning methods. Participants defined themselves as in-progress and considered the training program educational, engaging, and varied. Three main themes arose from the data: Developing an OD Training Program, Competence Development “From Novice to Expert,” and Participation and Commitments. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Open dialogue (OD) is a family-oriented, early intervention approach that has demonstrated good outcomes in the treatment of first-episode psychosis (Aaltonen et al., 2011; Bergstrøm et al., 2017; Seikkula et al., 2006; Seikkula et al., 2011). The first OD approach appeared in Western Lapland, Finland, with the primary goal to create a comprehensive, psychotherapeutically oriented model of treatment within the public mental health sector to address the real and changing needs of first-contact schizophrenia patients and their families (Aaltonen et al., 2011). The principles of OD are now incorporated in all psychiatric treatment in the region, regardless of diagnoses (Seikkula, 2003). The OD approach eases the accessibility of mental health services by creating a low-threshold and family-oriented treatment system that promotes reciprocal OD among patients, their social networks, and mental health workers (Seikkula et al., 2006). In companion, these individuals create a forum where meanings of experience and identity are constructed, understood, and negotiated through dialogue to gain a joint understanding about individuals' experiences during episodes of psychotic symptoms (Seikkula & Arnkil, 2013). The group of professionals participating is responsible for the entire treatment process, and work with patients in inpatient and outpatient settings (Seikkula, 2003). Studies evaluating OD indicate that the total recovery rates are better than those with treatment-as-usual (Aaltonen et al., 2011; Bergstrøm et al., 2017; Gordon et al., 2016; Seikkula et al., 2006; Seikkula et al., 2011).

Over the past 4 decades, OD has evolved into a social movement, enlightening and providing alternatives to conventional psychiatric treatment, and has been adopted in several places other than the origin sites in Finland (Buus et al., 2017). In Denmark, a retrospective register-based cohort study was conducted where researchers compared a group of youth treated with OD and youth offered treatment-as-usual. OD was significantly associated with reduced risks of using health care services (Buus et al., 2019). An English randomized controlled study is ongoing and examines professionals training in OD compared to professionals learning treatment-as-usual (Razzaque & Stockmann, 2016). OD is practiced in various regions/counties around the world, such as Scandinavia, Germany, the Netherlands, Austria, the United Kingdom, the United States, Australia, and Japan (von Peter et al., 2019).

What these countries have in common is empowering all users in processes making research and clinical performance relevant, particularly individuals in need of health care services (Crowe et al., 2015). However, OD's practical implementation has only been investigated to a limited degree (Buus et al., 2017; Schubert et al., 2020). According to Buus et al. (2017), studies focusing on implementation imply that the approach often generates resistance from practitioners, whose positions were challenged in different ways. A study from Australia sheds light on how psychologists and psychiatrists working with young people construct their professional identities through othering themselves from dominant professional paradigms or discourses (Schubert et al., 2020).

Over the past 20 years, Norway has seen an increase in the development and implementation of practices inspired by OD (Bøe, 2016; Brottveit, 2013; Holmesland, 2015; Jacobsen et al., 2018; Lidbom et al., 2014, 2015; Ulland et al., 2013). These studies have shown that changes can develop on individual and organizational levels during the implementation of new mental health practices; however, more research is required. We therefore established a research cooperation across different units of public mental health care in Akershus University Hospital and its catchment area and formed a research study where the OD approach was offered as a training program to a group of professionals to examine how their OD practice evolved over time.

Few studies have documented psychotherapy training programs, but according to Ditton-Phare et al. (2017), the heterogeneity of communication skills training is a barrier to evaluating the efficacy of different training programs. They recommend studies examining specific models and frameworks, which can advise support and stronger evidence base for communication skills training in psychiatry. There are some studies describing professionals' experiences with the implementation process of OD (Aaltonen et al., 2011, Bergström et al., 2017; Buus et al., 2017; Florence et al., 2020; Hopper et al., 2020; Schubert et al., 2020; Seikkula et al., 2006; Seikkula et al., 2011; Ulland et al., 2013), but as far as we know, no studies have described participants' experiences with an OD training program. Therefore, the current article aims to explore and describe participants' experiences in an OD training program. Research questions included: (1) How do participants experience the content and structure of the OD training program?; (2) Are there any differences between participants' ratings from the first to the final training day?; and (3) How do participants describe their experiences of learning outcomes and evaluation of the training program?

Method

Design

The current study is an explorative cohort study with a longitudinal design (Kvale & Brinkmann, 2015).

Study Context

We followed 40 professionals and two user representatives participating in an OD training program. The training program was conducted over a 6-month period, from January to June 2019, and consisted of 6 days/42 hours in total. The training program was designed as a mixed variation of classroom teaching, training skills with supervision, reflections in small groups, and plenum discussions. The program intended to stimulate participants to interact with each other and create good learning processes (e.g., by training together). The program encompassed learning core techniques and principles in OD. OD skills training was based on the 12 fidelity criteria (Olson et al., 2014) and key markers (Eiterå et al., 2014). Some skills and principles that were focused on in the training program were reflective conversation, active listening, listening without agenda, managing own uncertainty, refraining from coming up with solutions, and inviting all voices to be heard in the network meeting. This structure was chosen to make participants capable of leading network meetings. The training program followed the three fundamental outcomes in learning processes highlighted in the National Qualifications Framework for Lifelong Learning: knowledge, skills, and competence (European Communities, 2008). We chose reflection and mastery as components to operationalize the content of the term “competence.”

Recruitment/Selection

Unit leaders informed staff about the study. Participation was voluntary. Those with interest in participating were asked to contact the project member located in the unit for more information and registration. The maximum number of participants was capped at 45 to give participants the possibility of a proper and interactive training program. Forty-two participants joined the training program and all agreed to participate in the study.

Data Collection

Data were collected by use of semi-standardized questionnaires, which contained quantitative and qualitative data. Participants completed a questionnaire in the beginning and at the end of the training program (i.e., the first and final training day). The questionnaire included sociodemographic items, including age group (20 to 30, 30 to 40, 40 to 50, or ≥50), gender, profession, and educational level. Participants were asked to complete Likert scale ratings of whether their workplace facilitated their participation, and to what degree OD was perceived useful by their leaders, their colleagues, and themselves (ratings ranged from 1 = completely disagree to 5 = completely agree). With the same scoring structure, participants rated their confidence in how to work with OD with patients, their families, and other professionals. At the end of each training day, participants were given two questionnaires. One questionnaire related to learning outcomes as measured in the categories of knowledge, reflection, skills, and mastery (numeric rating scales [10 cm] with opposing anchor statements; correct – incorrect), and the second questionnaire related to participants' evaluations of the day measured with four statements: “I was understood and respected”; “I found the topics interesting”; “The training program had a form that suited me”; and “The training program was useful to me” (numeric rating scales [10 cm] from “No, to a small extent” to “Yes, to a large extent”). Questionnaires were designed so that participants had the possibility to add freely worded comments and descriptions to their ratings.

Data Analysis

Quantitative data were analyzed using IBM SPSS version 25, using 0.05 as alpha level for all analyses. Data were not normally distributed (all Kolmogorov-Smirnov tests p < 0.005), and pre- to post-training program outcome measures were therefore compared using related-samples Wilcoxon signed rank test (Field, 2013). Missing responses were excluded from analyses. Qualitative data were analyzed and systematized using thematic analysis as outlined by Braun and Clarke (2006). Qualitative data were participants' freely worded descriptions in the pre-named categories “Learning Outcome” and “Evaluation” in the questionnaires. The first and last authors (R.K.J., B.K.) read each transcript to familiarize themselves with the dataset. Both researchers completed an initial coding and searched for themes based on this coding before reviewing the themes together to ensure their alignment. The first author then defined and labeled the themes and wrote the report before a final review by both researchers.

Ethical Considerations

On behalf of The Norwegian Social Science Data Services, the Data Protection Officer at the Hospital approved the study. The Regional Ethical Committee considered the study to be outside their domain. Participants received written and oral information about the study prior to participating and provided written consent before completing questionnaires. Risk and opportunity analyses were performed, and questionnaires were collected and stored in accordance with the Data Protection Officer's instructions. In consideration of confidentiality, identifying characteristics were changed and de-identified.

Results

Participants

A total of 40 professionals and two patient and family representatives attended the training program. No days were full. Participation for the six training days ranged from 24 to 37 of the expected 42 participants. Absence from the training program was reported as illness, work pressure, vacation, and early leavers (the questionnaire was circulated at the end of the day). One participant reported leaving their job and therefore dropped out of the training program. Pre-training measures were based on questionnaires completed after the first training day (N = 37), and post-training assessment was completed after the sixth and final training day (N = 28).

Participants in the study were predominantly women (40 of 42), and mostly ≥50 years of age (range = 20 to 79 years). A majority had a 3-year health care–related degree and additional formalized professional training beyond the original degree. Table 1 presents participants' characteristics.

Participant Characteristics (N = 37)

Table 1:

Participant Characteristics (N = 37)

Three of 37 participants reported no previous knowledge of the OD approach. A total of 22 participants reported that they had need of the training program, 12 reported that they needed the training program to some degree, two to a small degree, and one reported no need at all. When participants were asked who recruited them into the study, 26 answered the leaders, three answered themselves, and eight answered other people (i.e., colleagues). Comparing pre- and post-training respondents, post-training respondents were significantly younger (median ages between 40 and 50 and ≥50 years [p < 0.05]), and they held higher formal education (median Master's degree, p < 0.001) than pre-training respondents.

Quantitative Findings Related to Confidence Working With Open Dialogue

Levels of perceived practical support from leaders to take part in the training program, and perceived use of the training by leaders, colleagues, and participants themselves did not differ significantly between pre- and post-respondents (all comparisons p > 0.05). However, when it came to participants' perceptions of “how their leaders can utilize what they have learned,” results showed that the threshold value tended toward significance where the median decreased from 5 to 4 (p < 0.05). This finding could, with increased sample and the same trend (type II error), indicate that leaders' use of their learning skills decreases from the first to the final day of training.

Figure 1 shows changes in participants' self-reported confidence levels related to working with OD with patients, families, and other professionals from the first to the final day of training. The scoring range on “feeling more confident in working with OD with users” increased from 3 to 5 (p < 0.02), representing improvement for this part of the course from the first to the final day. The same pattern is shown for “feeling more confident in working with OD with relatives” and “feeling more confident in working with OD with other professionals,” revealing significant improvement from the first to the final training day (p < 0.001).

Participants' changes in confidence practicing the open dialogue (OD) approach.Note. T1 = first training day; T2 = final training day.

Figure 1.

Participants' changes in confidence practicing the open dialogue (OD) approach.

Note. T1 = first training day; T2 = final training day.

Quantitative Findings Related to Learning Outcomes and Evaluation

Figure 2 shows changes in learning outcomes from the first to the final training day. The sixth day prepared for the next phase in the project, and focused on other topics than the days before, and therefore, learning outcomes were assessed the sixth day and data from the fifth day were used to calculate learning outcomes at the final training day. The scoring range for knowledge increased from the first to the final training day: median 6.5 to 8.0 (p < 0.01), interpreted as knowledge improvement from participating in the course. The same pattern is shown for reflection, skills, and mastery, with significant improvement from the first to the final training day (p < 0.001).

Changes in learning outcomes from the first (T1) to the final (T2) training day.

Figure 2.

Changes in learning outcomes from the first (T1) to the final (T2) training day.

Levels of participants' scores (numeric rating scales [10 cm]) in evaluating the contents of the training program were high throughout all 6 days. For “I was understood and respected,” the median was 9 for all 6 days; for “I found the topics interesting,” the median was, from Day 1 to 6, respectively: 8, 8, 8.5, 8, 8, 9; for “The training program had a form that suited me,” the median was, from Day 1 to 6, respectively: 9, 8, 9, 9, 9, 9; and for “The training program was useful to me,” the median was, from Day 1 to 6, respectively: 9, 9, 9, 9, 8, 9.

Qualitative Findings Related to Learning Outcomes and Evaluation of the Training Program

Qualitative findings were systematized in the pre-named themes in the questionnaire: Learning Outcomes and Evaluation.

Learning Outcomes. This theme is presented in two subgroups that evolved through thematic analysis: (1) reflection and role play gives learning outcomes, and (2) in process. Table 2 provides an example of the thematic analysis process.

Example of the Thematic Analysis Process

Table 2:

Example of the Thematic Analysis Process

Reflection and Role Play Gives Learning Outcomes. Participants highlighted reflection and role play as crucial learning methods. Through the reflection settings in the training program, participants learned reflection skills, which are important for practicing as network leaders. Reflection sessions enabled participants to consider ethical dilemmas, cases from practice, theoretical themes, and the network meeting itself. One participant wrote: “It is good with reflection around different aspects of the network meetings, such as difficulties, roles, and expectations in the meeting.” Another participant wrote: “The session after the role play today, where we defined and reflected over what the reflection is and stands for, was very good and educational.” Participants wrote that role play in network meetings was an area where they could learn to facilitate network meetings as network leaders. One participant wrote: “The role play gave high learning outcomes.” Another participant wrote: “It's a lot of learning outcomes in role playing network meetings.” One participant highlighted the role playing but commented that role play in smaller groups could be better for those who struggled with role play in plenum. The participant added that several role play sessions at the same time would facilitate choices of practical training in OD skills. One participant enjoyed role playing that was based on cases from reality.

In Process. During the program, participants acquired insight and understood more of the OD approach. Participants experienced development and progress in OD skills, such as being in a process. Participants became more confident in using the approach. One participant described: “I experienced greater understanding of what this is all about. A lot is falling into place.” Some participants wrote about increased motivation for working with the OD approach. One participant, who had competence in OD from earlier practice, wrote about gaining new motivation for the approach through participating in the training program, for example: “I love listening to my inner dialogue when learning.” Another participant wrote: “It has been a process-learning séance through the whole period of the training program.”

Evaluation. This theme is presented in two subgroups that evolved through thematic analysis: (1) educational, and (2) engaging and variety.

Educational. Participants found role playing useful and educational because it gave them training in concretization of OD skills. Some participants wrote that they found role play challenging because they did not like to play roles, but understood the usefulness of it. Participants appreciated the opportunity of practicing OD skills through case training as it could be part of a treatment session. One participant wrote: “I liked the practical training sessions on the training days.” Participants described reflection sessions as educational. Ethical dilemmas were relevant for participants to reflect on because these dilemmas made them understand how to better approach patients and their social networks in a different way. Reflection sessions were presented as a major theme in learning OD skills. Some participants expressed that they wanted more training in network meetings and OD skills. One participant wrote: “I want more focus on the dialogue in network meetings.” Another participant wrote: “...appreciated educational days with practical training in combination with reflection and tuition.”

Engaging and Variety. Participants found the training program useful, engaging, and well composed. Participants were satisfied with the variation of the learning methods and highlighted the interaction with other participants as inspiring and engaging. One participant wrote: “Very helpful to hear about others' experiences with the approach.” Another participant wrote: “There is always a lot to learn, reflect on, and have a conversation about.” Participants described their new understanding of how OD can be a useful tool in the treatment process. One participant wrote that the training program was engaging and clarifying. Another wrote: “For each training day I become more and more convinced that OD is a useful approach for the patients and their social network.” Another wrote: “A lot of different aspects in network meetings [are] brought up during the training program.” Feedback such as “great,” “nice day,” “good and open,” and “engaging” appeared in the text. Some participants found it challenging that other participants had different starting points in the OD approach, creating the possibility of misunderstandings. Some participants described concerns of other participants that they assumed could not grasp what the project leaders talked about. They were worried about participants with the least knowledge. Could these participants miss the message of the learning process? Yet, no participants actualized this matter in written feedback.

Discussion

The aim of the current study was to explore and describe participants' experiences with the training program “Open Dialogue in Network Meetings.” In the following section we will discuss three main themes related to our research questions and findings: (a) Developing an OD Training Program, (b) Competence Development “From Novice to Expert,” and (c) Participation and Commitments.

Developing an OD Training Program

There are no standardized programs or manuals that describe how to conduct a training program in OD and this might be a challenge to those trying to implement the OD approach (Florence et al., 2020). Despite this challenge, local implementation practices have been developed in different contexts around the world (Buus et al., 2017). Some efforts in standardizing the approach have been made. In Norway, Vigrestad and Hellandshølen (2012) have written a book on how to conduct network meetings based on their own experiences with practicing OD in network meetings. Olson et al. (2014) presented 12 fidelity criteria for practicing OD. Unlike findings from the Collaborative Network Approach (CNA) study and Parachute projects, in which the authors pointed to a resistance of the OD model to fidelity criteria and standardization (Florence et al., 2020; Hopper et al., 2020), participants in our study found the 12 fidelity criteria to be helpful elements in the training program. Together with the key markers developed by Eiterå et al. (2014), these “manuals” helped participants get a grip on the OD approach.

Our training program was designed as a dialogical program, expecting and motivating for dialogical processes and interactions between participants. This process contradicts a set standard, manual-based program. Our findings show that participants found the training program interesting, useful, and suitable. These findings may indicate that the construction of the conducted training program was successful. The essence of a dialogical approach, with its lack of set standard manuals, might prevent high-level comparisons. According to Buus et al. (2017), most of the fidelity criteria constructed for OD were not designed in such a way that they could be used in standardized measurements. Seikkula and Arnkil (2013) point out that context is an important factor in research studies, as does the CNA study (Florence et al., 2020) and the Parachute project (Hopper et al., 2020). Implementation science in general shows that implementation projects are most effective when tailoring a program fit for the exact context (Flottorp & Aakhus, 2013). This tailoring supports the variation of learning programs in OD around the world. Buus et al.'s (2017) scoping review indicates that it is challenging to adopt and implement OD, and suggests that OD teaching, training, and supervision need to be carefully planned and be protected as intrinsic to the approach. These findings coincide with our project, where the importance of training and supervision as a major part of our training program were highlighted. Participants in our study also pointed out the importance of training sessions.

The training program in the CNA study (Florence et al., 2020), and the Parachute project (Hopper et al., 2020) included experienced trainers from Europe, which was deemed necessary but costly. Our hospital and surrounding municipalities have invested in educational OD courses for decades, but participation has been limited by costs. Still, because of years of sending professionals to external courses, we have gained some experienced and competent professionals using OD. Therefore, we invited local forces to conduct our training program as an attempt to train more professionals in OD at a lower cost. Our findings show promising results in this regard.

Competence Development “From Novice to Expert”

Data show that participants' confidence in working with OD and their learning outcomes increased significantly during the training program. This result implies that most participants needed the training program. Implementation of OD was described as an ongoing process in the CNA study (Florence, 2020). This description corresponds well with findings from our study in which professionals described themselves as in process. This ongoing process, from novice to expert, was first studied and described by Benner (1984). Her research, based on Dryfus and Dryfus' model of skill acquisition, revealed that students pass through five levels of proficiency: novice, advanced beginner, competent, proficient, and expert (Benner, 1982). Although our conducted training program lasted for only 6 days, competence increased significantly. This increase may have been possible because there were no real novices among participants in our training program. Most participants were professionals with several years of practice. Our findings show that the median age of participants was between 40 and 50 and ≥50 years at post-training and the median educational level was Master's degree. The OD approach is a new therapeutic approach, but participants in the current study had previous therapeutic skills, which enabled them to understand and incorporate OD skills faster than actual novices. According to Benner (1982), advanced beginners have coped with enough real situations to note the recurrent meaningful situational components or aspects. Participants' former education and practice might classify them as advanced beginners, competent professionals, or proficient practitioners (Benner, 1982), and a reason for increased competence through our relatively compressed training program. Although the training program shows improved skills, the findings show that participants still need more training. Participants are joining a learning process, which is still progressing after the training program has been completed. Twamley et al. (2020) found that the importance of ongoing training and supervision for practitioners was strongly endorsed, a finding supported by our study.

Participants with different levels of preexisting OD skills enrolling in the same training program could have differing learning needs; however, this might also provide a beneficial learning process for everyone. Novices will learn by watching and simulating cases with more experienced participants, whereas experienced participants can learn through novices' questions about the approach, which enables even the most skilled participants to learn something new. One of the success factors of implementation is learning from peers, as a colleague (Flottorp & Aakhus, 2013). In our study, the significant increase in median scores confirms this idea, and may indicate that all participants improved and moved closer to a more expert level. We had no indication of drop out during the training program; however, several participants were absent the last day of training. Attendance might represent a challenge when evaluating a compressed and demanding program at the end of the last day. Our findings show that post-training participants were significantly younger and more highly educated than pre-training participants. This finding might be a coincidence, or it may indicate that less educated participants skipped the last session or the last training day, whereas the highly educated attended. An explanation could be that highly educated personnel appreciated the challenging and intensive training program and therefore wanted to complete the whole program.

Participants highlighted role play as an important learning method, which is a demanding approach where previous clinical experience and/or higher education might be an advantage. Role play or simulation training are well known methods for building competence (Motola et al., 2013). Role play provided participants in our training program with confidence to test their skills in their own work setting. Simulating cases provides the courage to seek situations in practice (Valen et al., 2019). Findings also show that training in core/key principles was highlighted by participants, which corresponds with research from the United Kingdom showing that OD principles may offer a useful framework to develop services in a clinically meaningful way (Razzaque & Wood, 2015). Buus et al. (2017) point to a resistance of the OD model to fidelity criteria and standardization. This resistance was also the case in the CNA project (Florence et al., 2020), where fidelity was seen as a barrier to a more organic process of incorporating the CNA into dayto-day work in the agencies. This was not the case in our study. Participants pointed out the importance of fidelity criteria as a manual to understand what the OD approach contained. This view may change when participants increase their OD skills and become more highly trained practitioners. Disentangling from a manual might be easier when individuals are more experienced (Benner, 1982).

According to our findings, many participants highlighted reflective skills as important to the OD practice, and they found it to be the most difficult skill to acquire. Other studies show that professionals find it challenging to adapt to the expert role and establish a new type of expertise (Buus et al., 2017; Jacobsen et al., 2018). Reflective conversations between network leaders are important in network meetings, according to Seikkula and Arnkil (2013). It is professionals' opportunity to contribute their expertise to hopefully move patients and their social network to new understandings or new solutions of the problems occurred through mental crises (Seikkula et al., 2006). Reflective conversations lead to better professional practice compared with the usual treatment approaches in mental health services, and a new way of practicing professional expertise. This may be the cause of participants' uncertainty about how to manage reflective conversations (Seikkula & Arnkil, 2007). The findings of our study show that reflection skills increased throughout the training program. However, participants were still in need of more training in reflective conversation at the end of the training program, indicating that this is a demanding process.

Participation and Commitment

Although the training program was approved by leaders of the participating departments, participants varied in presence throughout the training program. Other studies also describe difficulties in conducting training days or sessions. Florence et al. (2020) describe difficulties such as finding time for staff to be trained and receiving approval from managers to participate. Turnover was also a challenge. Hopper et al. (2020) describe difficulties in turnover and institutional cooperation. They point out that transitioning counterhegemonic innovation from a curiosity to a contender requires political organization, which could parallel the commitment in the current project. Leaders are committed by their signatures, but how do they commit their departments and the leaders who are responsible for the professionals in their daily work? Based on knowledge from implementation strategies (Flottorp et al., 2013), the project group suggested supervision groups for leaders similar to professionals' supervision groups to commit leaders and provide them a better understanding of the OD approach. This idea was overruled by leaders, who argued that leaders had no time to participate in the implementation process. As a result, the commitment from management might have been lacking throughout the training program.

Our findings show decreased belief in leaders' perceived utility of participants' use of the training program (ratings decreased from the first to the final training day). The interpretation of this finding is difficult; however, one explanation might point toward participants' individual feelings of bearing the responsibility of the implementation themselves. Implementation of new approaches has advantages when anchored to leadership as well as staff. With lack of support from their leaders, implementation depends on an individual, which might be a difficult and lonely journey. Commitment from management was found to be crucial in the implementation of OD in the CNA study and the Parachute project (Florence et al., 2020; Hopper et al., 2020). However, commitment from each participant can also be investigated. Findings show that some participants did not know a lot about the approach before participating and might not have understood what they signed up for. Some participants reported no need of the training program. Although findings show that participants were satisfied with the content of the training program, there might be less positivity among participants who did not answer the questionnaires. These participants may have been less committed to participate and thus prioritized accordingly in disfavor of the training program. Rapid recruitment of professionals without assuring real commitment to the study might therefore be a present bias.

Flottorp and Aakhus (2013) point out the importance of incentives and recourses in an implementation process. Joining the implementation process actively could be a solution to help leaders encourage professionals to commit to the implementation of OD and the training program throughout the implementation period. One study notes: “Family work can only be implemented if this is considered a shared goal of all members of a clinical team and mental health service, including the leaders of the organization” (Eassom et al., 2014, p. 1). We experienced, during the training program, that obstacles in committing professionals to participate are multifactorial; leaders have to clarify professionals' interest in participating in a training program, and they have to make it possible to participate; working shifts have to be taken into account, and someone must take over professionals' urgent tasks. Without a strong commitment to implementing OD, the implementation will be difficult to manage. Generating dialogical practice requires shared understanding of OD and collaboration between professionals and among leaders (Ulland et al., 2013).

Strengths and Limitations

The current study was the first to explore and describe participants' experiences with a training program in OD. The use of multi-methods (i.e., qualitative and quantitative approaches) allowed rich details in participants' experiences with the training program. A strong level of user involvement from the beginning and throughout the training program strengthens the study. The evaluation questionnaire was made particularly for this study and had no psychometric evaluation, which is a weakness. However, connecting the overall topics in the questionnaire to the international framework of learning (European Communities, 2008) is a strength. Collecting data on a group level provides knowledge on participants' experiences with the OD training program; however, this does not allow us to follow each participant individually. It might have been an advantage to have the ability to follow each participant throughout the training program. Such an approach might have provided a more robust analysis. However, individual data raise ethical considerations regarding identification, and in this sample the N would be lower because of the variation of attendance among participants (some participants attended the first training day and were absent the last, and vice versa). Nevertheless, group level analysis provided data for designing training programs in OD. There may be a displacement in the positive direction of our findings if participants who stayed and answered the questionnaires were only participants who provided positive responses. However, we have no indication that absence was caused by lack of motivation, but caused by illness, work pressure, and other obligations. As most participants in this study had a nursing education, it seems reasonable that nurses may benefit from OD training. However, in mental health practice, several professionals work together, so it might also be an advantage for other staff to join OD training as part of their collaboration.

Conclusion

To the authors' knowledge, the current study is the first to systematically explore and describe participants' experiences with an OD training program. Findings show that participants gained increased knowledge, skills, and competence in the OD approach. Our study also shows difficulties regarding commitment among participants throughout the training program. Although the training program shows increased competence in OD, findings show that participants still need more practice and knowledge. Participants are joining a learning process, which is still in progress after finishing the training program, and further guidance and supervision will be essential to preserve and develop further competence in OD. The program is considered successful and it shows that it is possible to develop a compressed training program designed to enable participants to practice OD in network meetings. Commitment from leaders is crucial to enable professionals to participate throughout the entirety of the training program.

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Participant Characteristics (N = 37)

Characteristicn
Nurse17
Social worker8
Psychologist4
Physician3
Patient/family representative2
Other3

Example of the Thematic Analysis Process

Pre-Named CategoryThemeCondensateSummary
Learning outcomesReflection and role play give learning outcomesReflection and role play are crucial learning methods. Through reflection, we learn skills, which are important in practicing as network leaders. Reflection sessions enable us to consider ethical dilemmas, cases from practice, theoretical themes, and network meetings. Role play is a learning arena where we learn how to facilitate network meetings as network leaders.Reflection and role play as teaching methods throughout the training program give learning outcomes
Authors

Ms. Jacobsen is PhD Candidate, Dr. Østefj ells is Clinical Psychologist and Researcher, and Dr. Karlsson is Professor, Department of Specialized Inpatient Treatment, Division of Mental Health Care, Akershus University Hospital, Lørenskog, Norway; and Dr. Grov is Professor and Head of the PhD Program in Health Sciences, Department of Health Sciences, Oslo Metropolitan University, Oslo, Norway. Dr. Østefj ells is also Clinical Psychologist and Researcher, Department of Child and Adolescent Mental Health, Akershus University Hospital, Lørenskog, Norway; and Dr. Karlsson is also Department Head, Center for Mental Health and Substance Abuse, Department of Health, Social and Welfare Studies, Faculty of Health and Social Sciences, University of Southeast Norway, Drammen, Norway.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

© 2021 Jacobsen, Grov, Østefjells, & Karlsson; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (https://creativecommons.org/licenses/by-nc/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.

Address correspondence to Ritva Kyrrø Jacobsen, MSc, RN, PhD Candidate, Department of Specialized Inpatient Treatment, Division of Mental Health Care, Akershus University Hospital, 1478, Lørenskog, Norway; email: ritva.jacobsen@ahus.no/ ritva@live.no.
Received: July 14, 2020
Accepted: September 16, 2020
Posted Online: January 13, 2021

10.3928/02793695-20210107-03

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