In the focus groups, the researchers and participants explored the five elements of CHIME from Leamy et al. (2011), within the context of enhancing the employees’ abilities to support patients’ recovery process. The participants expressed increased reflection on their actions, which seemed to be a tool they used to guide themselves towards a more recovery-oriented pathway.
Reflections on Actions and Attitudes
The participants expressed increased knowledge and reflection about the term recovery and positive attitudes to this paradigm. However, the reflection is on what they already do and how that fits into the CHIME framework, rather than on alternative ways of working. In their reflections, they communicate a dissonance that they feel they should do more but are unsure what.
The participants expressed the importance of elements such as patient involvement, ability to reflect critically and the process of building relationships (Mathisen 2016; Norwegian Directorate of Health 2012). Such terms are not thoroughly described on a governing level, which leaves the different local services to define the content, causing variations of the same term and leading to uncertainty of what terms may imply in practice. Furthermore, the participants explained that they have not experienced a definite change in the concrete tasks they do. However, increased reflection and the resulting increased awareness can be the first step to a dynamic change. As Knutagård (2014) states, employees may think that diffuse changes do not differ from what they already do, even though there may be small differences in nuance that have the potential for significant meaning. For example, it may be complicated for the staff to comprehend the change and difference in moving from a patient-centred approach, which traditionally has meant offering professional assessments of where the important areas of focus are, to an approach that involves working together with the patient.
After searching the existing literature, including the scientific literature and government guidelines, we did not find recourses that we felt offered concrete actions on how to support a recovery-oriented approach in local community services. This may be one explanation for why employees are unsure about what exactly they should do differently.
Uncertainties, as described in the section above, can hinder patients’ participation in their treatment.
Not Participating in Meetings
The lack of patient participation in team meetings is a habit that is seemingly accepted, despite the fact that for a long time, patients have demanded a ‘nothing about me, without me’ approach to their care (Slade et al. 2012). The participants argued that the patients may not handle the professional setting in such meetings and that the presence of patients may restrict their professional reflections on their practice, which may lead to less constructive meetings. They expressed a need to protect themselves and the patients. On the other hand, during the focus groups, participants expressed approval for the idea of including patients in meetings, but argued that the function and organisation of the meetings would have to change and effort exerted in order to make it feasible and safe for the patients.
The participants mentioned that they use (gallows) humour to cope and to vent and use the team meetings as an arena for this. This use of humour is a common phenomenon that helps healthcare professionals cope with patients in complex situations, a demanding workload and sleep deprivation, amongst other job frustrations (Aultman 2009; Wear et al. 2009). However, this kind of humour is also used in healthcare settings, deliberately or not, to ascertain dominance or position of power (Aultman 2009).
Patient participation seems to be a challenge, as the need for the employees to be in control of the opportunities they portray to patients may be a barrier to recovery implementation. Reasons for the discrepancy between intention and practice can be that the employees are working towards supporting a recovery orientation, but at the same time, they are afraid of doing something wrong, neglecting their professional responsibility or not doing their job well enough. Having the patients’ best interests at heart is a recurring theme in the focus groups, and the participants express a struggle to find balance. The participants argue that they give the patients choices and focus on what they believe to be the patients’ needs; however, rarely do they actually ask the patients.
Paternalism and Autonomy
The participants’ discussions indicated a tendency to continue acting in a paternalistic manner, even though they identified empowerment and autonomy as important elements. This highlights the difficult balance between paternalism and autonomy.
Although the participants acknowledged that the patients can have a rational conception about themselves, there seems to be an issue with trust and taking this autonomy seriously. Some participants fulfil their duty of ‘helping the patients’ in the way they personally feel is best and actually believe that the patients profit due to their well-intended actions. According to the definition presented in the introduction, recovery is what the person defines as a meaningful and satisfying life (Shepherd et al. 2008). Despite having this definition as a guideline, in practice, the participants do not allow the patients to define for themselves what they regard as important. A keystone to recovery-supporting care is to validate and respect self-determination and patient choice, reframing the treatment initiative from the professional’s perspective to the patient’s perspective (Davidson et al. 2006). Patients who oppose initiatives from the staff can be perceived as ‘difficult’ (Deegan and Drake 2006; Mathisen 2016). As demonstrated in the findings, the participants attempt to balance the power relations and give patients autonomy, which may lead to a retraction of the employees’ own responsibility, using the argument that patients can decide for themselves, despite their serious illnesses. As Manojlovich (2007) and Borg and Kristiansen (2004) describe, a trusting and collaborative relationship with their service provider and a willingness to share power can empower the patient. Thus, working towards patient empowerment and collaborative relationships without a retraction of responsibility may contribute to a better balance in power relations.
The CHIME framework, Connectedness, Hope, Identity, Meaning and Empowerment, provides useful information on what patients regard as being important in their own process and what issues the services should focus on. However, the elements are somewhat broadly categorised, with the consequence that a lot can fit into the categories—and into more than one category. For example, pursuing an education is highly relevant within all five categories.
Van Gestel-Timmermans et al. (2010) demonstrate that the CHIME elements influence each other. Raised hope can enhance confidence and thus strengthen the feeling of identity. However, we argue that more research is needed on CHIME processes and tools, especially on how to promote CHIME in everyday work, as there is seemingly a challenge regarding how to execute this framework within daily tasks. It is a weakness that such a relevant framework is difficult for the local community services as the unit in this study to enforce.
Brekke et al. (2018) illustrate the potential misuse of recovery approaches as the concept, which was developed by people with lived experience, is seized by the professionals. In the context of this study, this perspective may be expressed through the fact that participants understand the CHIME framework differently from how they attempt to help patients in practice. The health care organisation examined in this study needs to be aware of this pitfall and to continuously have in mind that recovery entails the patients’ processes.
Two of the researchers are employed in the same organisation as the participants, which can affect our perspective (Chenail 2011; Malterud 2002). However, we have chosen to conduct the study within our own services, as we can delve deeper into the material and understand what the participants are saying better than if it were an unfamiliar service. Since we had a mentor from the university and a co-researcher who had experiences with mental illness, we claim that we have examined the issue from the relevant perspectives.
In retrospect, we should have prompted the participants to expand on their statements in order to gain more detailed information.