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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 Øste ells, PhD; and
Bengt Karlsson, PhD, MSc, RN
ABSTRACT
Open dialogue (OD) is a family-oriented approach that has demonstrated good
outcomes in treatment of rst-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 par-
ticipants’ learning outcomes and con dence with using OD with patients, social net-
works, and professionals increased signi cantly throughout the training program.
Re ection and role play were essential learning methods. Participants de ned them-
selves as in-progress and considered the training program educational, engaging,
and varied. Three main themes arose from the data: Developing an OD Training Pro-
gram, Competence Development “From Novice to Expert,” and Participation and Com-
mitments. [Journal of Psychosocial Nursing and Mental Health Services, 59(5), 38-47.]
Open dialogue (OD) is a fam-
ily-oriented, early inter-
vention approach that has
demonstrated good outcomes in the
treatment of fi rst-episode psychosis
(Aaltonen et al., 2011; Bergstrøm et
al., 2017; Seikkula et al., 2006; Seik-
kula et al., 2011). The fi rst OD ap-
proach appeared in Western Lapland,
Finland, with the primary goal to cre-
ate a comprehensive, psychotherapeu-
tically oriented model of treatment
within the public mental health sec-
tor to address the real and changing
needs of fi rst-contact schizophrenia
patients and their families (Aaltonen
et al., 2011). The principles of OD
are now incorporated in all psychiat-
ric 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 recip-
rocal OD among patients, their social
networks, and mental health workers
(Seikkula et al., 2006). In compan-
ion, these individuals create a forum
where meanings of experience and
identity are constructed, understood,
and negotiated through dialogue to
gain a joint understanding about in-
dividuals’ experiences during episodes
of psychotic symptoms (Seikkula &
Arnkil, 2013). The group of profes-
sionals participating is responsible
Ms. Jacobsen is PhD Candidate, Dr. Øste ells is Clinical Psychologist and Researcher, and Dr. Karls-
son 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. Øste ells is also
Clinical Psychologist and Researcher, Department of Child and Adolescent Mental Health, Akershus Uni-
versity 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.
Disclosure: The authors have disclosed no potential con icts of interest, nancial or otherwise.
© 2021 Jacobsen, Grov, Øste ells, & Karlsson; licensee SLACK Incorporated. This is an Open Access ar-
ticle 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 re-
mix, 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 Special-
ized 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
doi:10.3928/02793695-20210107-03
38
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; Seikku-
la et al., 2006; Seikkula et al., 2011).
Over the past 4 decades, OD has
evolved into a social movement, en-
lightening and providing alternatives
to conventional psychiatric treat-
ment, and has been adopted in several
places other than the origin sites in
Finland (Buus et al., 2017). In Den-
mark, a retrospective register-based
cohort study was conducted where re-
searchers compared a group of youth
treated with OD and youth offered
treatment-as-usual. OD was signifi -
cantly associated with reduced risks
of using health care services (Buus
et al., 2019). An English random-
ized controlled study is ongoing and
examines professionals training in
OD compared to professionals learn-
ing 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, Austra-
lia, and Japan (von Peter et al., 2019).
What these countries have in
common is empowering all users in
processes making research and clini-
cal performance relevant, particu-
larly individuals in need of health
care services (Crowe et al., 2015).
However, OD’s practical implemen-
tation 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 in-
spired 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 lev-
els during the implementation of new
mental health practices; however, more
research is required. We therefore estab-
lished a research cooperation across dif-
ferent units of public mental health care
in Akershus University Hospital and its
catchment area and formed a research
study where the OD approach was of-
fered as a training program to a group of
professionals to examine how their OD
practice evolved over time.
Few studies have documented psy-
chotherapy training programs, but ac-
cording to Ditton-Phare et al. (2017),
the heterogeneity of communication
skills training is a barrier to evaluating
the effi cacy of different training pro-
grams. They recommend studies exam-
ining specifi c models and frameworks,
which can advise support and stron-
ger 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’ ex-
periences with an OD training program.
Therefore, the current article aims to
explore and describe participants’ expe-
riences in an OD training program. Re-
search 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 fi rst to the
fi nal training day?; and (3) How do par-
ticipants 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 teach-
ing, training skills with supervision, re-
fl ections 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
fi delity 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 refl ec-
tive conversation, active listening, lis-
tening 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 partici-
pants capable of leading network meet-
ings. The training program followed the
three fundamental outcomes in learning
processes highlighted in the National
Qualifi cations Framework for Lifelong
Learning: knowledge, skills, and compe-
tence (European Communities, 2008).
We chose refl ection and mastery as com-
ponents 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
39
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 59, NO. 5, 2021
were asked to contact the project mem-
ber located in the unit for more infor-
mation 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 train-
ing 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 question-
naire in the beginning and at the end of
the training program (i.e., the fi rst and
fi nal training day). The questionnaire
included sociodemographic items, in-
cluding 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 lead-
ers, their colleagues, and themselves
(ratings ranged from 1 = completely dis-
agree to 5 = completely agree). With the
same scoring structure, participants rat-
ed their confi dence 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 re-
lated to learning outcomes as measured
in the categories of knowledge, refl ec-
tion, skills, and mastery (numeric rat-
ing scales [10 cm] with opposing anchor
statements; correct – incorrect), and the
second questionnaire related to partici-
pants’ evaluations of the day measured
with four statements: “I was understood
and respected”; “I found the topics in-
teresting”; “The training program had a
form that suited me”; and “The training
program was useful to me” (numeric rat-
ing 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 descrip-
tions to their ratings.
Data Analysis
Quantitative data were analyzed us-
ing 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 out-
come measures were therefore compared
using related-samples Wilcoxon signed
rank test (Field, 2013). Missing respons-
es were excluded from analyses. Qualita-
tive 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 fi rst and last
authors (R.K.J., B.K.) read each tran-
script 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 fi rst author then defi ned
and labeled the themes and wrote the
report before a fi nal review by both re-
searchers.
Ethical Considerations
On behalf of The Norwegian Social
Science Data Services, the Data Protec-
tion Offi cer at the Hospital approved
the study. The Regional Ethical Com-
mittee considered the study to be out-
side their domain. Participants received
written and oral information about the
study prior to participating and provided
written consent before completing ques-
tionnaires. Risk and opportunity analy-
ses were performed, and questionnaires
were collected and stored in accordance
with the Data Protection Offi cer’s in-
structions. In consideration of confi den-
tiality, identifying characteristics were
changed and de-identifi ed.
RESULTS
Participants
A total of 40 professionals and two
patient and family representatives at-
tended 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 cir-
culated at the end of the day). One par-
ticipant reported leaving their job and
therefore dropped out of the training
program. Pre-training measures were
based on questionnaires completed af-
ter the fi rst training day (N = 37), and
post-training assessment was complet-
ed after the sixth and fi nal training day
(N = 28).
Participants in the study were pre-
dominantly 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 for-
malized professional training beyond the
original degree. Table 1 presents partici-
pants’ characteristics.
Three of 37 participants reported
no previous knowledge of the OD ap-
proach. A total of 22 participants re-
ported that they had need of the train-
ing program, 12 reported that they
needed the training program to some de-
gree, two to a small degree, and one re-
ported no need at all. When participants
were asked who recruited them into the
study, 26 answered the leaders, three an-
swered themselves, and eight answered
other people (i.e., colleagues). Compar-
TABLE 1
PARTICIPANT
CHARACTERISTICS (N = 37)
Characteristic n
Nurse 17
Social worker 8
Psychologist 4
Physician 3
Patient/family
representative
2
Other 3
40
ing pre- and post-training respondents,
post-training respondents were signifi -
cantly younger (median ages between
40 and 50 and ≥50 years [p < 0.05]), and
they held higher formal education (me-
dian Master’s degree, p < 0.001) than
pre-training respondents.
Quantitative Findings Related to
Con dence Working With Open Dialogue
Levels of perceived practical sup-
port from leaders to take part in the
training program, and perceived use of
the training by leaders, colleagues, and
participants themselves did not differ
signifi cantly 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 signifi cance where the median
decreased from 5 to 4 (p < 0.05). This
fi nding could, with increased sample
and the same trend (type II error), in-
dicate that leaders’ use of their learning
skills decreases from the fi rst to the fi nal
day of training.
Figure 1 shows changes in partici-
pants’ self-reported confi dence levels
related to working with OD with pa-
tients, families, and other professionals
from the fi rst to the fi nal day of training.
The scoring range on “feeling more con-
fi dent in working with OD with users”
increased from 3 to 5 (p < 0.02), repre-
senting improvement for this part of the
course from the fi rst to the fi nal day. The
same pattern is shown for “feeling more
confi dent in working with OD with
relatives” and “feeling more confi dent in
working with OD with other profession-
als,” revealing signifi cant improvement
from the fi rst to the fi nal training day
(p < 0.001).
Quantitative Findings Related to
Learning Outcomes and Evaluation
Figure 2 shows changes in learn-
ing outcomes from the fi rst to the fi nal
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 out-
comes were assessed the sixth day and
data from the fi fth day were used to
calculate learning outcomes at the fi -
nal training day. The scoring range for
knowledge increased from the fi rst to
the fi nal 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
refl ection, skills, and mastery, with sig-
nifi cant improvement from the fi rst to
the fi nal training day (p < 0.001).
Levels of participants’ scores (nu-
meric rating scales [10 cm]) in evaluat-
ing the contents of the training program
were high throughout all 6 days. For “I
was understood and respected,” the me-
dian 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 fi ndings were system-
atized 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) refl ection
and role play gives learning outcomes,
and (2) in process. Table 2 provides an
example of the thematic analysis pro-
cess.
Refl ection and Role Play Gives
Learning Outcomes. Participants high-
lighted refl ection and role play as crucial
learning methods. Through the refl ec-
tion settings in the training program,
participants learned refl ection skills,
which are important for practicing as
network leaders. Refl ection sessions en-
Figure 1. Participants’ changes in con dence practicing the open dialogue (OD)
approach.
Note. T1 = rst training day; T2 = nal training day.
Figure 2. Changes in learning outcomes from the rst (T1) to the nal (T2) training day.
41
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 59, NO. 5, 2021
abled participants to consider ethical di-
lemmas, cases from practice, theoretical
themes, and the network meeting itself.
One participant wrote: “It is good with
refl ection around different aspects of the
network meetings, such as diffi culties,
roles, and expectations in the meeting.”
Another participant wrote: “The session
after the role play today, where we de-
fi ned and refl ected over what the refl ec-
tion 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 meet-
ings.” 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, par-
ticipants acquired insight and under-
stood more of the OD approach. Par-
ticipants experienced development and
progress in OD skills, such as being in a
process. Participants became more confi -
dent in using the approach. One partici-
pant described: “I experienced greater
understanding of what this is all about.
A lot is falling into place.” Some partici-
pants wrote about increased motivation
for working with the OD approach. One
participant, who had competence in OD
from earlier practice, wrote about gain-
ing 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. Par-
ticipants appreciated the opportunity of
practicing OD skills through case train-
ing as it could be part of a treatment
session. One participant wrote: “I liked
the practical training sessions on the
training days.” Participants described re-
fl ection sessions as educational. Ethical
dilemmas were relevant for participants
to refl ect on because these dilemmas
made them understand how to better
approach patients and their social net-
works in a different way. Refl ection ses-
sions were presented as a major theme
in learning OD skills. Some partici-
pants 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
refl ection and tuition.”
Engaging and Variety. Participants
found the training program useful, en-
gaging, and well composed. Participants
were satisfi ed 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 oth-
ers’ experiences with the approach.”
Another participant wrote: “There
is always a lot to learn, refl ect on, and
have a conversation about.” Partici-
pants described their new understand-
ing of how OD can be a useful tool in
the treatment process. One participant
wrote that the training program was en-
gaging and clarifying. Another wrote:
“For each training day I become more
and more convinced that OD is a use-
ful approach for the patients and their
social network.” Another wrote: “A lot
of different aspects in network meetings
TABLE 2
EXAMPLE OF THE THEMATIC ANALYSIS PROCESS
Pre-Named Category Theme Condensate Summary
Learning outcomes Re ection and role play
give learning outcomes
Re ection and role play are crucial
learning methods. Through re ection,
we learn skills, which are important
in practicing as network leaders.
Re ection 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.
Re ection and role play
as teaching methods
throughout the training
program give learning
outcomes
42
[are] brought up during the training pro-
gram.” Feedback such as “great,” “nice
day,” “good and open,” and “engaging”
appeared in the text. Some participants
found it challenging that other partici-
pants 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 partic-
ipants 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’ expe-
riences 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 fi ndings: (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 imple-
ment 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 ef-
forts in standardizing the approach have
been made. In Norway, Vigrestad and
Hellandshølen (2012) have written a
book on how to conduct network meet-
ings based on their own experiences
with practicing OD in network meet-
ings. Olson et al. (2014) presented 12
fi delity criteria for practicing OD. Un-
like fi ndings from the Collaborative
Network Approach (CNA) study and
Parachute projects, in which the authors
pointed to a resistance of the OD model
to fi delity criteria and standardization
(Florence et al., 2020; Hopper et al.,
2020), participants in our study found
the 12 fi delity criteria to be helpful el-
ements in the training program. To-
gether 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 fi ndings
show that participants found the train-
ing program interesting, useful, and suit-
able. These fi ndings may indicate that
the construction of the conducted train-
ing 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 fi delity
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 Para-
chute project (Hopper et al., 2020). Im-
plementation science in general shows
that implementation projects are most
effective when tailoring a program fi t for
the exact context (Flottorp & Aakhus,
2013). This tailoring supports the varia-
tion 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 supervi-
sion need to be carefully planned and be
protected as intrinsic to the approach.
These fi ndings coincide with our proj-
ect, where the importance of training
and supervision as a major part of our
training program were highlighted. Par-
ticipants 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 mu-
nicipalities have invested in educational
OD courses for decades, but participation
has been limited by costs. Still, because
of years of sending professionals to exter-
nal courses, we have gained some experi-
enced and competent professionals using
OD. Therefore, we invited local forces to
conduct our training program as an at-
tempt to train more professionals in OD
at a lower cost. Our fi ndings show prom-
ising results in this regard.
Competence Development
“From Novice to Expert”
Data show that participants’ con-
fi dence in working with OD and their
learning outcomes increased signifi -
cantly during the training program. This
result implies that most participants
needed the training program. Imple-
mentation of OD was described as an
ongoing process in the CNA study
(Florence, 2020). This description cor-
responds well with fi ndings from our
study in which professionals described
themselves as in process. This ongo-
ing process, from novice to expert, was
fi rst studied and described by Benner
(1984). Her research, based on Dryfus
and Dryfus’ model of skill acquisition,
revealed that students pass through fi ve
levels of profi ciency: novice, advanced
beginner, competent, profi cient, and
expert (Benner, 1982). Although our
conducted training program lasted for
only 6 days, competence increased sig-
nifi cantly. This increase may have been
possible because there were no real nov-
ices among participants in our training
program. Most participants were profes-
sionals with several years of practice.
Our fi ndings 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 thera-
peutic skills, which enabled them to
understand and incorporate OD skills
faster than actual novices. According
to Benner (1982), advanced beginners
43
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 59, NO. 5, 2021
have coped with enough real situa-
tions to note the recurrent meaningful
situational components or aspects. Par-
ticipants’ former education and prac-
tice might classify them as advanced
beginners, competent professionals, or
profi cient practitioners (Benner, 1982),
and a reason for increased competence
through our relatively compressed
training program. Although the train-
ing program shows improved skills, the
fi ndings show that participants still need
more training. Participants are joining a
learning process, which is still progress-
ing after the training program has been
completed. Twamley et al. (2020) found
that the importance of ongoing train-
ing and supervision for practitioners was
strongly endorsed, a fi nding supported
by our study.
Participants with different levels of
preexisting OD skills enrolling in the
same training program could have dif-
fering learning needs; however, this
might also provide a benefi cial learning
process for everyone. Novices will learn
by watching and simulating cases with
more experienced participants, where-
as 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 imple-
mentation is learning from peers, as a
colleague (Flottorp & Aakhus, 2013). In
our study, the signifi cant increase in me-
dian scores confi rms 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 com-
pressed and demanding program at the
end of the last day. Our fi ndings show
that post-training participants were
signifi cantly younger and more highly
educated than pre-training participants.
This fi nding might be a coincidence, or
it may indicate that less educated par-
ticipants skipped the last session or the
last training day, whereas the highly ed-
ucated attended. An explanation could
be that highly educated personnel ap-
preciated 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 previ-
ous clinical experience and/or higher
education might be an advantage. Role
play or simulation training are well
known methods for building compe-
tence (Motola et al., 2013). Role play
provided participants in our training
program with confi dence to test their
skills in their own work setting. Simu-
lating 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 King-
dom 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 fi delity criteria and standard-
ization. This resistance was also the
case in the CNA project (Florence et
al., 2020), where fi delity was seen as
a barrier to a more organic process of
incorporating the CNA into day-to-
day work in the agencies. This was
not the case in our study. Participants
pointed out the importance of fi del-
ity criteria as a manual to understand
what the OD approach contained. This
view may change when participants in-
crease their OD skills and become more
highly trained practitioners. Disentan-
gling from a manual might be easier
when individuals are more experienced
(Benner, 1982).
According to our fi ndings, many par-
ticipants highlighted refl ective skills as
important to the OD practice, and they
found it to be the most diffi cult skill to
acquire. Other studies show that profes-
sionals fi nd it challenging to adapt to
the expert role and establish a new type
of expertise (Buus et al., 2017; Jacobsen
et al., 2018). Refl ective conversations
between network leaders are impor-
tant in network meetings, according to
Seikkula and Arnkil (2013). It is profes-
sionals’ opportunity to contribute their
expertise to hopefully move patients and
their social network to new understand-
ings or new solutions of the problems oc-
curred through mental crises (Seikkula
et al., 2006). Refl ective conversations
lead to better professional practice
compared with the usual treatment ap-
proaches in mental health services, and
a new way of practicing professional ex-
pertise. This may be the cause of partici-
pants’ uncertainty about how to manage
refl ective conversations (Seikkula &
Arnkil, 2007). The fi ndings of our study
show that refl ection skills increased
throughout the training program. How-
ever, participants were still in need of
more training in refl ective conversation
at the end of the training program, indi-
cating that this is a demanding process.
Participation and Commitment
Although the training program was
approved by leaders of the participating
departments, participants varied in pres-
ence throughout the training program.
Other studies also describe diffi culties
in conducting training days or sessions.
Florence et al. (2020) describe diffi cul-
ties such as fi nding time for staff to be
trained and receiving approval from
managers to participate. Turnover was
also a challenge. Hopper et al. (2020)
describe diffi culties in turnover and in-
stitutional cooperation. They point out
that transitioning counterhegemonic in-
novation 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 com-
mit 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 com-
mit leaders and provide them a better
understanding of the OD approach. This
44
idea was overruled by leaders, who argued
that leaders had no time to participate
in the implementation process. As a re-
sult, the commitment from management
might have been lacking throughout the
training program.
Our fi ndings show decreased be-
lief in leaders’ perceived utility of par-
ticipants’ use of the training program
(ratings decreased from the fi rst to the
fi nal training day). The interpretation
of this fi nding is diffi cult; however, one
explanation might point toward partici-
pants’ individual feelings of bearing the
responsibility of the implementation
themselves. Implementation of new ap-
proaches has advantages when anchored
to leadership as well as staff. With lack
of support from their leaders, implemen-
tation depends on an individual, which
might be a diffi cult and lonely journey.
Commitment from management was
found to be crucial in the implementa-
tion of OD in the CNA study and the
Parachute project (Florence et al., 2020;
Hopper et al., 2020). However, commit-
ment 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
fi ndings show that participants were sat-
isfi ed 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 par-
ticipate and thus prioritized accordingly
in disfavor of the training program. Rap-
id 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 pro-
cess. Joining the implementation pro-
cess 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 imple-
mented if this is considered a shared
goal of all members of a clinical team
and mental health service, including
the leaders of the organization” (Eas-
som et al., 2014, p. 1). We experienced,
during the training program, that ob-
stacles 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 im-
plementing OD, the implementation
will be diffi cult to manage. Generating
dialogical practice requires shared un-
derstanding of OD and collaboration
between professionals and among lead-
ers (Ulland et al., 2013).
STRENGTHS AND LIMITATIONS
The current study was the fi rst to
explore and describe participants’ ex-
periences with a training program in
OD. The use of multi-methods (i.e.,
qualitative and quantitative approach-
es) 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 learn-
ing (European Communities, 2008) is
a strength. Collecting data on a group
level provides knowledge on partici-
pants’ experiences with the OD train-
ing 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 train-
ing program. Such an approach might
have provided a more robust analysis.
However, individual data raise ethical
considerations regarding identifi cation,
and in this sample the N would be lower
because of the variation of attendance
among participants (some participants
attended the fi rst training day and were
absent the last, and vice versa). Nev-
ertheless, group level analysis provided
data for designing training programs in
OD. There may be a displacement in
the positive direction of our fi ndings if
participants who stayed and answered
the questionnaires were only partici-
pants who provided positive responses.
However, we have no indication that
absence was caused by lack of motiva-
tion, but caused by illness, work pres-
sure, and other obligations. As most
participants in this study had a nurs-
ing education, it seems reasonable that
nurses may benefi t 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 cur-
rent study is the fi rst to systematically
explore and describe participants’ expe-
riences with an OD training program.
Findings show that participants gained
increased knowledge, skills, and com-
petence in the OD approach. Our study
also shows diffi culties regarding com-
mitment among participants through-
out the training program. Although
the training program shows increased
competence in OD, fi ndings show that
participants still need more practice
and knowledge. Participants are join-
ing a learning process, which is still in
progress after fi nishing the training pro-
gram, and further guidance and super-
vision 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.
45
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 59, NO. 5, 2021
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