The problematisation process
The initial problematisation: a lack of future perspective
The topic of the 'recovery-oriented care' project had been defined before the project went ahead. We entered stage at the starting conferences of the first round of the project, at which faculty introduced their ideas concerning problematisation. Their problematisation owed much to the recovery movement as initiated by former mental health care clients who described their recovery as a process of regaining control over their own lives, often leading to reintegration in society [25, 26].
In line with the goals of the recovery movement, the main aim of the project was giving clients more space to govern their own lives and to make their own decisions. Many clients living in mental health care institutions were facing a bleak future, as faculty said. "The lives of clients within long term mental health care are characterized by routine, boredom, marginalization, and a lack of perspective," a former client who was part of the expert team said. As faculty saw it, one of the reasons for this situation was the "mental health care regime" in which clients are approached in a "stigmatizing" way or receive scant attention. This speaker added that many care givers do not have faith in the possibility of change in clients' conditions and skeptically asked "if this perception has changed now that mental health care has discovered the concept of recovery". "Do they [mental health care professionals] really believe that clients can [...] live a complete life?"
The proposed solution: reducing the role of professionals
Hence faculty defined the problem as follows: mental health care clients lack perspective owing to the way in which professionals approach them. Inherent to a problem definition is the question who should tackle the problem and what roles these actors should take up [27]. Interestingly, many teams in this project mainly consisted of professionals. However, through its focus on clients' recovery, the recovery movement does not define a very clear role for professionals [25, 26].
Even faculty of this project struggled with this discrepancy. "It is an illusion to think that mental health care professionals can recover their clients," said one of the experts. The program leader moreover said that an improvement project is "a tricky thing" because it suggests that under certain conditions clear advances could be made within a year. The truth is we had no clear interventions available beforehand that would directly lead to clients' recovery, she said in an interview.
Still the faculty team had ideas for improvement. In order to support the clients' recovery process, professionals should be less dominantly involved in their lives. Ideally, as faculty said, professionals should restrict themselves to creating the essential preconditions for recovery to occur. For example, by removing those elements that are thought to be in the way of recovery, such as "restraining" home rules.
So this was how the faculty team saw the problem: many clients in mental health care institutions lack perspective because professionals do not show faith in their clients and do not give them much room for their wishes and plans. The improvement teams were therefore advised to step back.
The improvement actions: different ways of performing the project
Following faculty's problematisation process allowed us to analyze if and how the teams adopted this problematisation. Many teams recognized the picture sketched of clients lacking a future perspective. Also, they agreed they were too dominantly present in clients' lives. "Nurses often want to know everything, want to control everything, want to be in the lead," one project leader said. In an informal talk at a conference a team member said that while clients were often institutionalized, professionals were institutionalized as well.
So the teams seemed to adopt faculty's problematisation in the first instance. But how did they go ahead? As the recovery concept itself was seen as quite "abstract", many teams first set out to create a vision on what constituted recovery-oriented care. Furthermore, some teams discussed their approach to clients in line with the problematisation of faculty. One example concerned a client who changed clothes three times a day. Her bedroom door used to be locked to prevent her from doing so. The discussants wondered whether it was actually a problem that she changed clothes that often. They concluded it was not, unless this client was in "a manic period" and locking her door would calm her down. So this discussion indeed led to a proposal for reducing the professional role.
Another improvement action involved asking clients what hindered them in the way professionals approached them. One team invited clients to write down the home rules they disliked. This resulted in "a wall full" of post-its, said this team's project leader. One by one the post-its were taken from the wall and discussed. One client for example wanted a better arrangement for use of the washing machine. Another client disagreed with the lock on the refrigerator. This approach of asking clients what hinders them, in fact, is quite the reverse of the one in which professionals think up what might be hindering clients. It also has consequences for clients' role in their own recovery process; being either recipients or co-inventors of this new approach.
As another improvement action, clients were offered choice options in meals and snacks. "Despite being very psychotic, he is fully aware that he likes treacle wafers best," a team member said about a client who now chose treacle wafers every day. Yet many clients "do not know anymore what choosing means," a project leader said. One client, for example, even did not know what she would like to eat, although she expected the meals to be the best part of her holiday trip.
Many teams struggled with the question how to get clients to know and to state their wishes and how to get them into the recovery process, seeing that they "are often not easily mobilized and cannot mobilize and motivate themselves either", as a project leader told. "Some of my clients still think they are Napoleon," said another project leader to illustrate that clients may lack sense of reality. For these reasons, some team members told that recovery was not a suitable concept for their client group.
A change in problematisation: stimulating clients
These questions led to a change in problematisation. Improvement teams focused more on stimulating clients than on reducing their own roles in the lives of clients. The dilemma many team members faced was that they wanted to create a future perspective for clients but that clients themselves did not even have ideas about what they would like to eat, let alone what activities they wanted to undertake during their days or what life goals they had. Therefore some teams decided not to wait until clients could mobilize themselves, and to invent a program of activities themselves.
One team said that in the beginning of the project recovery looked like a figment to them. Clients could have been living for fourteen years within the institution and yet never have come up with the idea of breakfasting earlier than the set time, although they sometimes woke up at six o'clock. So the team proposed alternative meal times to clients. By the time of the closing conference these clients could have meals at variable times like in a hotel.
So during this project some teams shifted their focus from reducing their own role to stimulating clients. As faculty proposed it, the teams should strive for taking up as small a role as possible. However, some teams said that then nothing would happen and adopted a more active role in order to make clients more active as well.
Analysis of the problematisation process
To summarize, the 'recovery-oriented care' project was characterized by different problematisations. Faculty defined the main problem to be a lack of perspective for clients, and thought this was partly caused by a 'negative' approach from professionals. Faculty therefore advised teams to step back and to support the recovery process mainly by not hindering it. Some teams nevertheless took up a more dominant role in stimulating clients to become more active so as to improve their future perspective. This shift in the problematisation process also had consequences for "who has the right and who has the obligation" to do something about the problem [27], for example which actions from professionals were allowed and which actions were not.
So the problem on which an improvement project focuses may change during the course of the project. The exact problematisation depends on both the expert knowledge and the local knowledge of improvement teams. The improvement actions could not be directly deduced from the topic of the collaborative or from the way faculty proposed the problem, but had to be analyzed by following the actors.
The changes in problematisation were clearly notable in this improvement project because improvement teams were given much leeway. They had to state their own goals as a means to endorse the actions undertaken by them. At the same time faculty of the projects still tried to control the improvement actions by their own presentation of specific solutions. Another way of directing teams, intertwined with the problematisation process, is found in the measurement practice(s), illustrated in the next section by focusing on the 'social participation' project.
The measurement practices
The 'social participation' improvement project
The two purposes of the 'social participation' project were to strengthen clients' social networks and, interrelated, to make them feel less lonely. Many clients have unfulfilled needs on the social domain, said the program leader at the starting conference. While he did some suggestions for improvement, he urged teams especially to adjust the improvement actions to the wishes and needs of clients themselves and to ask clients what they would like. The problematisation therefore was the following: although clients have many unfulfilled needs on the social domain, professionals do not always know and/or do not inform after these needs.
Consequently, many of the teams first set out to map the needs of clients, in order to see what improvements were possible in this regard. They often did so by using the network circle, which was an obligatory measurement instrument in this project and was meant to map all the contacts of clients. Options for improvement actions included contacting the persons important to clients or directing clients' attention to new contacts. For example, one client started to go to church; another regularly visited the sauna and there they met (new) people.
This project's central indicators for success were decided somewhere between the starting conference and the first working conference. The program leader proposed that social participation had "a subjective and an objective side", and teams were advised to direct their attention to either one of these pillars, or, ideally, to both. Teams were asked to measure both the subjective and the objective side at the beginning and the end of the project. The subjective side was measured in terms of the degree of loneliness clients experienced. The objective side was measured by the aforementioned network circle instrument, which is discussed in the next sections.
Shaping the actors: the assumptions within the instrument
The network circle is an instrument consisting of five concentric circles. The innermost represents the client himself or herself. The client's so-called anchors are placed in the next ring: "One can hardly imagine living without these people," one of the experts typified this circle. The third ring includes friends, "who enable you to do things you normally would not be doing". Then there are the acquaintances, "with whom you share one thing such as being part of the same tennis club". The outermost circle represents the professionals, who are getting paid to help clients. Professionals completed the network circle together with the client by informing after clients' contacts and where to place them. This approach was thought to bring up many unfulfilled needs and thus to open avenues for improvements aligned with clients' needs.
In making the network circle an obligatory measurement instrument, faculty assured that teams asked after clients' needs in this respect. The network circle in that sense was both an indicator of what faculty thought the problem and the solution were. The problem was, among other things, not enough information about clients' needs and/or the needs not being point of discussion. The solution accordingly was informing after these needs. Faculty could use the measurement instrument then to (subtly) steer the teams towards the proposed problematisation and solution.
Also in another way the measurement instrument supported the problematisation of faculty. Faculty said that professionals were often too dominantly present in a client's social life. Completing the network circle would tell them who else they could mobilize in order to improve the networks of clients. The instrument then would directly point at possibilities for reducing their role. Indeed, at the closing conference one of the experts said that this project was successful in that professionals had learned to abandon the notion that they were the ones who should manage everything for clients. So here again the measurement instrument had its function in strengthening the problematisation of faculty.
The instrument does not only carry assumptions about the professional role; it also "co-defined and co-produced" [17] the clients involved by assuming a typical client. Thereby, the instrument also stimulated professionals to assume this typical client and to approach clients in a certain way. For example, one of the assumptions in the instrument is that clients are able and interested to discuss their social network. Yet this was not always the case in this project. Some clients were reported to stay in bed the whole day, and their world accordingly was very restricted, as a project leader said.
Furthermore, clients were expected to be able to distinguish between professionals, friends and acquaintances. Yet many of the clients placed professionals in the friends ring. "From whose perspective do we fill this in?" a project leaders asked. "I have clients who designate my colleagues as their friends, is that allowed or not?" Faculty responded that clients should become aware that professionals cannot be their friends. Furthermore, professionals themselves also ought to realize they were clients' caregivers and not their friends, faculty said. So here again the instrument strengthened the problematisation, and led to a situation that faculty of the project liked to see: clients placing professionals where they belong.
So although clients' wishes had to be leading in the improvement actions, their perspective was not taken for granted. Perceiving professionals to be friends was thought to be problematic. Some teams, therefore, were struggling with adapting improvement actions to their clients' wishes but at the same time had to confront clients with a picture of reality that was not the way clients perceived it. In this sense, the problematisation of faculty both strengthened and denied the perspective and wishes of some clients.
The effects of the instrument
Apart from strengthening faculty's problematisation, the instrument may have other effects. For one, it could heighten clients' awareness of their social networks. One client reported forty contacts at the start of the project, a number reduced to no more than twenty at the end. Faculty thought this might be due to more awareness of what really could be regarded as friends, and mentioned this awareness in general to be one of the successes of the project. For that matter, a project leader pointed out that the visual nature of the instrument makes the social situation of clients clear at a glance. Therefore clients could easily replace and relocate contacts. One client for example found out that a perceived friend was actually not a friend, and vice versa.
In some cases clients' heightened awareness of their social networks made improvement actions superfluous. For example, a client who always said he was very lonely was astonished to see how big his network was and how active he was. "Why complain about being lonely at all", he was reported to say. So the use of the network circle instrument led clients "to redefine the concept of loneliness", as this project leader said. Apart from its positive effects, however, the instrument could evoke more negative feelings when clients were confronted with their small networks.
In the above examples the instrument transformed the way in which the actors involved thought about and enacted the improvement situation, and their social life in general. These transformations may have been foreseen. Still, as a possible unforeseen side-effect, use of the instrument often improved relations between professionals and clients as well. Even clients who did not gain any new contacts enjoyed talking about their social networks, a project leader said. All this, however, was rather not in line with faculty's policy of strengthening the inner network circles instead of the outer ring consisting of professionals.
Analysis of the measurement practices
To summarize, in the 'social participation' project the measurement instrument selected by faculty had several roles. It not only measured results, but also steered improvement actions in the desired direction. Faculty's problematisation was that professionals tended to be unaware of what clients would like and also did not ask them. Moreover, clients themselves sometimes lacked awareness of their social situation. Having them to 'objectively' classify their relations was thought to be a solution for this shortcoming.
Furthermore, the instrument assumed a typical client, one willing and able to discuss social relations with professionals who could not be conceived as friends anymore. Faculty assured that clients had an active role; they needed to think about what they would like and discuss this with care givers. The instrument thus had a performative effect; i.e. it shaped reality as well [21]. As this example illustrated, measurement practices in improvement projects not only endorse faculty's problematisation but also carry (subtle) assumptions about who should be able and who has the obligation to do something about the problem. Measurement practices may change the improvement practices in foreseen and unforeseen ways.