Positive mental health - from what to how A study in the specialized mental healthcare service
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Abstract Background: The reorientation of the health services in a health promotion direction has been requested since 1986 when the Ottawa charter (WHO) was launched. A theoretical framework based on salutogenesis is recommended for health promotion development. This study emanated from a mental health hospital, where it was relevant to know how people with mental disorders perceive positive mental health and mental health promotion. Service user involvement in health research has been argued to hold the potential to make research more relevant to clinical practice, and further that it might result in effective improvements in the healthcare services. Aims: The purpose of the study ‘Positive mental health – from what to how’ was to contribute to the knowledge base of health promotion by exploring experiences of persons with mental health disorders. The present study evolved into two parts. The first aim was to explore how mental health and mental health promotion are experienced by adults affected by severe mental disorders. The next aim was to explore former inpatients’ experiences of mental health promotion in a mental healthcare hospital setting. In the second part of the study, the aim was to explore the applied process of involving mental healthcare service users in the entire research process of the study, in our case as part of an advisory team. Thereafter, how service user involvement may contribute to the development of the methodology Interpretative Phenomenological Analysis (IPA), and in turn enhance the research quality, was examined. Methodology: In the first part of the study, IPA was used to explore lived experiences of twelve participants. These former inpatients with mental disorders were interviewed in-depth. Analysis of the data was case focussed and then cross case focussed. As part of the study design service user involvement was applied in all stages of the research process. In the second part of the study, a case study design was used to explore the process of collaboration between five members of the advisory team and the researcher. Research data was collected from documentation, by multi-stage focus group interviews, and participant observations.Important concepts, insights and common opinions were identified by the advisory team and the researcher in analytical discussions, and further developed into understandings formulated in texts and illustrations that helped display and present our findings. Findings: The first of four papers included in this thesis shows how mental health is perceived as a dynamic phenomenon and an ever-present aspect of life. Mental health is perceived as a process, a constantly ongoing movement, like walking up or down a staircase and expressed through body language and everyday spoken language. The movement is nourished by experiences in the emotional, physical, social and spiritual domains of life, and accompanied by a sense of energy. The second paper focuses on the prominent finding of an appetite for learning. The participants perceive the learning processes that occur in the healthcare settings as health promoting. They are craving knowledge in order to cope with the mental disorder and to increase their mental health and wellbeing in daily life. The third paper discusses the applied service user involvement process. The level of involvement was dynamic and six features facilitated contributions from service users; role clarification, a predictable meeting structure, a safe and supportive setting through leadership, focus on possibilities, being a team member and being seen and treated as a whole person. These features helped the service users see themselves as valuable and competent. The fourth paper argues that the multiple perspectives of service users and researchers gave more insightful interpretations of nuances, complexity, richness and ambiguity in the participants' accounts. The power of multiple perspectives in service user involvement reinforced the IPA methodology and vice versa. Conclusions: This thesis shows that lived experiences by persons with severe mental disorders, constitute a rich and important source of knowledge to the field of health promotion. According to the participants, mental health is a dynamic, ever present aspect of life, with improvement or deterioration in their condition being likened to moving up or downa staircase. The learning processes that occurred in the hospital, including both salutogenic and pathogenic knowledge, were perceived as mental health promoting. The participants support the development of educational activities to complement the curative focus in mental healthcare hospitals. When it comes to service user involvement in the present study, the levels of involvement were dynamic and varied throughout the research process. The research advisors experienced certain features of the collaboration process as essential to facilitating their contributions to the research and to seeing themselves as competent. The power of multiple perspectives came across in the collaboration process and this gave us more insightful interpretations of nuances, complexity, richness or ambiguity in the interviewed participants’ accounts. The advisory team became ‘the researcher’s helping hand’.Sammendrag Levde erfaringer hos personer med alvorlig psykisk lidelse kan være en rik og viktig kilde til kunnskap om helsefremming. Tidligere innlagte personer ble intervjuet om hvordan de erfarte psykisk helse og helsefremming. Psykisk helse blir opplevd alltid tilstedeværende i livet, en pågående bevegelse eller prosess, beskrevet som å bevege seg opp eller ned en trapp. Erfaringer knyttet til psykiske, sosiale, åndelige og fysiske sider av livet påvirker bevegelsen, som samtidig blir ledsaget av en opplevelse av energi. Erfaringer fra opphold i psykisk helsevern viste at læringsprosessene som foregår under innleggelse er helsefremmende. Deltakerne hadde en appetitt for kunnskap. Læringen var motivert av et ønske om å takle hverdagen med en psykisk lidelse, samt få bedre psykisk helse og økt velvære. Den anvendte brukermedvirkningen i forskningsprosjektet ble også undersøkt. Erfaringene til fem personer med brukererfaring, forskjellig fra de intervjuede deltakerne, viste at nivået av involvering varierte gjennom forskningsprosessen, fra konsultasjon til samarbeid. Seks kjennetegn ble opplevd å legge til rette for bidrag fra brukerne; a) avklart forståelse av rollene, b) forutsigbar møtestruktur, c) tydelig ledelse, d) fokus på muligheter og løsninger, e) å være en av et team, og f) å bli sett og behandlet som hele mennesker med erfaringer fra helse, sykdom og livet for øvrig. Disse særtrekkene ved samarbeidet ble trukket frem som viktig for en trygg og støttende atmosfære som ga brukerne en følelse av å være kompetente og at deres erfaringer var verdifulle for forskningen. De ulike perspektivene brukerne brakte inn i studien var en styrke. Mangfoldet i erfaringskompetanse og perspektiv bidro til mer innsiktsfulle fortolkninger av nyansene, tvetydigheten og kompleksiteten i de intervjuede deltakernes erfaringer. Brukermedvirkning bidro til økt forskningskvalitet. Siden helsefremming ble lansert i Ottawa charteret i 1986, har helsetjenestene blitt oppfordret til å fokusere mer på helsefremming og forebygging. Denne studien har hentet inspirasjon fra klinisk praksis i et helseforetak som tilbyr spesialisthelsetjenester innen psykisk helsevern. Salutogenese benyttes om et teoretisk rammeverk for helsefremming, her forstått som å fremme mental helse som noe positiv tilstede, noe kvalitativt annet enn fravær av psykisk sykdom. Fortolkende fenomenologisk analyse (IPA) ble benyttet for kvalitativt å undersøke levde erfaringer hos tolv deltakere og fem brukere. Forskningsdata ble samlet ved hjelp av dybdeintervju, fler-stegs fokusgruppeintervju, fra lydopptak av analytiske og fra dokumenter produsert under samarbeidsprosessen. Viktige meninger og forståelser ble fortolket til funn formulert gjennom tekst og illustrasjoner.
Består avPaper 1: Mjøsund, Nina Helen; Eriksson, Monica; Norheim, Irene; Keyes, Corey L.M.; Espnes, Geir Arild; Vinje, Hege Forbech. Mental health as perceived by persons with mental disorders - an interpretative phenomenological analysis study. International Journal of Mental Health Promotion 2015 ;Volum 17.(4) s. 215-233 - Is not included due to copyright available at http://dx.doi.org/10.1080/14623730.2015.1039329
Paper 2: Mjøsund, N. H., Eriksson, M., Espnes, G. A. and Vinje, H. F. (2016) Reorienting Norwegian healthcare services: listening to patients’ craving for learning. - Is not included due to copyright
Paper 3: Mjøsund, N. H., Vinje, H. F., Eriksson, M., Haaland-Øverby, M., Jensen, S. L., Kjus, S., Norheim, I., Portaasen, I.-L., and Espnes, G. A. (2016) Salutogenic service user involvement: experiences from collaboration in a mental health research project. - Is not included due to copyright
Paper 4: Mjøsund, Nina Helen; Eriksson, Monica; Espnes, Geir Arild; Haaland-Øverby, Mette; Jensen, Sven Liang; Norheim, Irene; Kjus, Solveig Helene Høymork; Portaasen, Inger-Lill; Vinje, Hege Forbech. Service user involvement enhanced the research quality in a study using interpretative phenomenological analysis - the power of multiple perspectives. Journal of Advanced Nursing 2017 ;Volum 73.(1) s. 265-278 http://dx.doi.org/10.1111/jan.13093 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License