Most of the practitioners in the study scored high on fidelity during the study, which indicated that they used IMR according to the manual. However, the practitioners expressed views and concerns that might challenge the sustainability of the program in their services, both in terms of maintaining high fidelity levels and in terms of organizational facilitation. Four themes described these challenges: Prioritization dilemmas despite high autonomy, the practitioners’ experiences of leader engagement, uncertainty about long-term priorities, and that practitioners are guided by the patients’ reception of IMR.
Prioritization Dilemmas Despite High Autonomy
The practitioners in all the participating services expressed a high degree of perceived control regarding how they work. Hanna stated: “I believe that we can choose our methods ourselves. There is no control of details here.” Dagny said: “Our working environment is such that our leader is confident that we are sensible and independent in work, and that we prioritize in a way that benefits the service. We have relatively free reins when we believe in something.” The practitioners chose their own schedule and followed up with their patients according to their clinical competence and their judgement of what was best for their patients. This included their participation in IMR training: All but one of the practitioners, who was requested to do so, chose to attend the training themselves.
Despite feelings of being highly autonomous, the practitioners expressed differences regarding what they believed they could decide for themselves. In terms of reading the IMR manual and preparing for group sessions, some believed that this should be done during their spare time. Faye stated: “We were told to read it, and I did that at home cause I cannot use working hours for that.” Others were determined to not use their spare time. Dagny said: “If I should manage this, I cannot use my spare time. I must use working hours.” The practitioners differed in their prioritizing of IMR. Two practitioners expressed that they had no trouble with this. Hanna stated: “I spend 45 min on every session, so I might as well use it on IMR than something else.” However, most of the practitioners seemed to be torn between IMR work and their other responsibilities. Brit stated:
We can control it ourselves, in a way. It’s up to me to let them know that I have too many responsibilities, because I need to work on IMR and that takes time. In the beginning it was like that. I felt the leader was sympathetic. But gradually there has been no need to be considerate toward it. And actually, maybe this has affected the preparation a bit. It has become a bit unstructured.
Although the practitioners showed a faithful use of IMR during the implementation period, they continuously dealt with priority dilemmas throughout their workday. Often IMR was given a lower priority, which might hinder the further use of the model.
In Service C, autonomy was expressed differently. As Carl described it: “This (IMR) has been a priority from Day One, and I have to say the time and free rein we have been given. We don’t feel that we are less prioritized.” The practitioners perceived that they made independent decisions regarding their IMR use, but they seemed to have clarified the work allocations with their staff. They experienced few priority dilemmas between their IMR work and their other responsibilities.
Leader Engagement
Most practitioners expressed that they felt supported by management in their implementation of IMR. They perceived the leaders as having positive attitudes and showing goodwill toward the program. Brit stated: “She [department leader] has been positive to us, spending enough time to prepare [for IMR sessions]. And the organizational manager, to the extent he understood the content of it, he was also positive toward it.” Service H lacked a leader for most of the period, so Hanna worked as an IMR champion and motivator for her colleagues. When explaining the content of IMR to the new leader, she perceived that he was positive toward it. Thus, positive leaders were receptive of the practitioners’ need to discuss IMR, but did necessarily not bring IMR up themselves. However, practitioners in two other services expressed a lack of leader support. In Service E, although the leader did not demonstrate negativity toward the program, Erik felt that: “they were not backed up properly”. Service G was the opposite; the leader was negative, but trusted the practitioners’ choices. Gina said: “My leader hasn’t been very positive. I had to justify it a little, but at the same time she showed me confidence: If you believe in this, then do it”. Thus, leaders that showed lack of support were unavailable for discussing the content of IMR or the challenges of implementing it.
Despite support from the leaders, there were few indications of them being especially engaged in the implementation process, such as giving proactive attention to reducing barriers, taking responsibility, and following up with the practitioners. As Freya explained: “They [leaders] have arranged for us to receive it [IMR training], and given us the responsibility and a free rein. Yeah, there is really nothing more to say about it.” In most services, the practitioners took the primarily responsibility for facilitating IMR use and solving implementation barriers, without questioning the leaders’ role in this. In some services, the practitioners were clearly dissatisfied with the leaders’ lack of involvement. A few expressed that they were frustrated. Dagny stated: “If this should last, I believe that [strategy plan] is what is required. And then someone must want it. It is very tiring when you all the time [have] to work bottom-up. It has to be top-down.”
In Service C, however, the practitioners gave a clear vision of an engaged, dedicated leader who listened to the practitioners’ wishes, followed up with them regularly, and facilitated implementation in the service. The leader was hands-on in the selection of practitioners to attend the IMR training and considered the practitioners’ capacity beyond the use of IMR. The practitioners expressed gratitude for this engagement. Accordingly, there were differences between leader support and engagement in the services.
Uncertainty About Long-Term Priorities
The practitioners in the services differed regarding their goals and visions for implementing IMR in their organizations. From the beginning, Service C was goal-oriented toward sustaining the program in the organization. The selection of practitioners to participate in the training was a joint decision between the leaders and the practitioners, and was based on their willingness and the service’s structure. The staff had regular meetings to discuss barriers, their progress, and how to obtain support from several municipality levels. IMR was continually used and talked about in the service. The other services were less prepared for the implementation of IMR. The majority of practitioners were randomly selected; they were often asked by a leader or colleague in passing, which sometimes resulted in sending practitioners at the expense of future prospects. David said:
For me it was a question whether it was a point, since I’m soon retiring. I considered it back and forth. But then I thought it’s alright to try something new at the end of my career, and I decided to go for it. I hope I can give something back of what I’ve learned before I leave this place.
Many of the practitioners experienced a minimum amount of initial briefing on the content of IMR, and some were overwhelmed by the workload it caused. The practitioners implementing it in Service B had not considered whether they had patients who met the inclusion criteria or whether they had the capacity to follow patients on a weekly basis for a year. In Service F, IMR was to be offered to all the patients, but there was no implementation plan for how to facilitate this. Many services thematized IMR at personnel meetings without strategic and regularly examination of the challenges involved in its implementation. Accordingly, choices were made without considering how it would affect the sustainability of the services. Overall, most services seemed to have moved hastily into implementation, without having a long-term plan.
The services’ lack of goals and visions for IMR during the implementation process gave the practitioners mixed signals on what effort they were to put into the program. The practitioners of Services A and F had been told that the program was to be expanded, but they did not know the details of this expansion. The practitioners in Service G were waiting for signals regarding whether or not they were allowed to continue using it. In the remaining services, the practitioners were responsible for deciding whether they would continue to use it. Practitioners in two of the services were pessimistic about the further implementation of IMR in their services. Dagny explained:
I have told the leader that we have been offered something that is really unique [IMR training]. And this should be sustained so that we can offer it to the patients in our service. But I think that takes an effort, and that’s where I believe it takes more than two stakeholders to stay forward.
Others were more eager or hopeful. Frida said: “I feel I have come to a point where I’m curious about what will happen next, and how training should be arranged, and where.” The mixed signals concerning the amount of effort they were expected to dedicate to IMR caused many of the practitioners to be idle and to wait for further instructions. Since the practitioners had to dedicate their own efforts to sustaining the use of the practice, this seemed to increase a risk of their IMR use to drift.
Guided by Patient Reception
The majority of practitioners had positive experiences with IMR after using it for 12 months. The practitioners emphasized the program’s clear structure, which allowed them to discuss difficult, but important topics. The practitioners in Service A discussed this as follows (sequence):
Asta: “They [patients] get ownership.”
Ann: “It is not said, but they are the tools themselves. And at least I see that, by getting this chance [to receive IMR], it is like an abscess that they haven’t, whether that’s because they haven’t dared or had the time, or been able to see that even though they have an illness, they can still live a good life. So there is a lot of hope in this IMR. And I think that, it gives me much hope too, as a practitioner.”
Asta: “It is inspiring to work with.”
The practitioners perceived that IMR helped to promote shared decision-making with the patients. With regard to treatment, it enhanced the patients’ self-determination to set their own goals and work toward them. However, at the same time, most of the practitioners described the program as comprehensive and time-consuming. Some thought this was beneficial, since it covered many topics that were central to the patients’ everyday lives. This allowed the patients to practice what they had learned, and to achieve long-term goals. However, a few practitioners experienced the program as time-consuming to the extent that it demotivated the further use of it.
The practitioners’ experiences with the program were described in relation to how they perceived their patients as benefitting from the treatment. Grete explained:
You get inspired when you are working with a group and experience that it works. And you see progress in the group participants. When you get positive energy afterwards, it is inspiring to make use of it and form a new group. I have already thought of who I would like to recruit the next time.
The practitioners who expressed positive patient experiences described active patient engagement and a clear progression toward recovery. However, one third of the practitioners expressed some difficulties with using IMR in relation to the patients’ reception of it. In Service C, two of the practitioners discussed the challenges that they experienced (sequence):
Carl: “I believe most of them have taken steps. But the lasting change, to experience the benefit of taking steps toward something. But maybe you are ill the next time, and then it is all wasted in a way.”
Cate: “But I think that every time I bring up recovery goals and what steps you should take for next time, it is like they don’t understand what I’m talking about.”
Carl: “No, they are so low-functioning.”
The practitioners did not see any patient changes, and suggested that the program may be too demanding for low-functioning patients. Accordingly, the practitioners’ initial experience with IMR guided their further use of the program. Those with positive patient experiences expressed that they wanted to continue to use the program in their services. However, the practitioners who experienced small or no visible changes in their patients were more reserved toward the program. Some talked about only making use of parts of the program, particularly the first module, which seemed appropriate for most patients. Bob stated: “I’ve been thinking about using parts of IMR. Different modules for different problems. […] Then it doesn’t seem too discouraging for those who maybe perceive it like that in the beginning. To use it on behalf of the patients.” Other practitioners wanted to change the program, for example, by removing the home assignments. In addition, a few had stopped using it as they perceived that their patients did not benefit from it.
The evaluations of whether the patients benefited from the program were based on either the patients’ feedbacks or the practitioners’ own subjective and professional observations, rather than on systematic assessments. Service F described their observational experiences as decisive in terms of what kinds of patients they would recruit. Frida stated: “when we get experience, we know better who will utilize the program”. The practitioners in a couple of services expressed that they were tired of systematic evaluations. Arve said:
I’m so tired of evaluations. Because, I think that we are continuously considering which initiatives are useful for this group we are working with. […] But to repeatedly assessing what the patients think and stuff like that. Yeah, there is so much that claims our time, and we don’t get any resources for it.
None of the practitioners considered systematic monitoring as tools for evaluating IMR.