Our analysis and interpretation of the data culminated in identifying 18 impacts of implementing recovery innovations from the perspectives of diverse stakeholder groups. In our conceptual framework (Fig. 1), we grouped these 18 impacts conceptually into four overall categories of impact: ways of being, ways of interacting, ways of thinking, and ways of operating and doing business. Below we present our findings by category of impact (see Additional File 1 for Concept Maps which guided our write-up of the findings). Quotes from interviews in French were translated by authors into English. Quotes are identified by stakeholder group of the respondent and the innovation implemented at their site. Self-reported sociodemo-graphic factors such as participants’ gender, age, and cultural background were not taken into account in data analysis; our primary focus was on understanding and revealing participants’ perspectives based on their stakeholder group.
Impacts that fall completely within the grey rectangle contain data exclusively relating to the implementation of the selected recovery innovation. Impacts that fall completely within the blue rectangle with rounded corners contain data exclusively relating to the implementation process. Impacts overlapping the grey and blue rectangles contain data predominantly relating to the implementation of the selected innovations, but also some data segments related to implementation process.
We noted that participants occasionally not only spoke about the impact of implementing the recovery innovation but also the impact of the implementation or research process itself, that is, the experience of using implementation teams and having external facilitation from a research team. In one interview with a site that had to stop implementation of their innovation after only 2 weeks, we explicitly targeted interviewees’ perception of the impact of the process as a whole. We paid attention to this in all of the data by systematically identifying whether participants were talking about either the innovation, or the process. In Fig. 1, impacts that fall completely within the grey rectangle contain data exclusively relating to the implementation of the selected recovery innovation. Impacts that fall completely within the blue rectangle with rounded corners contain data exclusively relating to the implementation or research process, of which there were three impacts. And finally, impacts overlapping the grey and blue rectangles contain data predominantly relating to the implementation of the selected innovations, but also some data related to the implementation or research process. We provide our interpretation of this in the discussion section.
Ways of being
Ways of being is a category of impact that relates to how individuals can experience transformation at a personal level as a result of implementing a recovery-oriented innovation. In this case, this impact related predominantly to a sense of personal growth or wellbeing, either of service users, or of service providers (Fig. 1). This was especially the case, though not exclusively, in the sites that implemented innovations targeted towards service users, such as WRAP, peer support workers, and a family support group. Multiple stakeholder groups noted that one impact on service users they observed was a “coming out of one’s shell” (Service provider, peer worker innovation) that took the form of service users being better able to express their own needs, desires and emotions. A tenant in one of the sites that implemented peer support mentioned “ I see that some other residents in my house are basically um, like, they are able to discuss like how they feel and things like that. So, they can do it properly and all that kind of stuff. So, they’re able to do that. And also they have one on one conversations as well so it’s, it’s really good. Learning was also an important element of personal growth, either learning something about oneself and how to care for oneself, or learning specific tools that can be applied in everyday life. Three tenants who attended WRAP specified:
“…it’s helped me in identifying triggers, identifying when I go into crisis… I learned how to utilize coping skills” (tenant 1); “And the WRAP plan really helped me out. I was able to go to the hospital without the emergency line and able to get fixed up and taken care of without having to explain a lot….
I learned how to form a crisis plan” (tenant 2)”; “Yes, I’ve actually used the program in regards to listing and recognizing days when I’m better and days when I’m not, and days when I’m not, I know who I can reach out to in terms of my list, in terms of my step of things that I need to do. I’ve used that thing multiple times, multiple times. Oh yes, it’s great! It’s absolutely fabulous (tenant 3).
Personal growth was also characterised by an overall more positive outlook on life, increased self-esteem and confidence, emotional improvement in the sense of feeling happier, more positive, more hopeful, more relaxed and less stressed, and feeling stimulated in one’s life. A service provider described the impact on service users as follows:
I suppose I’ve seen in the last year, even in the last 6 months, a tremendous growth in their openness and willingness to share and engage with us. When I first came here, they just wouldn’t, they didn’t speak to me for a long time, and now they come in, pop in the door, engage me. (service provider, staff training innovation)
As for the personal growth of service providers, this took the form of staff having a sense of accomplishment, experiencing a personal sense of awakening and increased confidence in one’s work.
So, I would add that it’s an opportunity to learn and grow, right? Because learning is always fluid like you may, we can’t learn enough because from out of the blue, somebody may have a different perspective or deeper insight or whatever, so for me the impact of this for both service providers and service users, would be the opportunity for more growth and development. (Service provider, staff training innovation)
For a minority of service users and staff the implementation of a recovery innovation brought on a way of being that was hesitant about or resistant to change, particularly at the start of implementation. A manager, speaking of the impact on staff, described the following:
I think at the beginning they were a bit reluctant, they don’t necessarily have the time, the resources. There were some sticks in the wheels along the way, well not sticks, but, you know, the.
staff are so busy, so to add one more programme, one more task, they were hesitant. (Manager, family support group innovation)
Ways of interacting
The implementation of recovery innovations also impacted the way people interacted with one another, as did the implementation process itself. In the case of the impact of the recovery innovations, in the vast majority of cases, these were positive impacts such as new opportunities for building and strengthening relationships. These took the form of an improved sense of community and inclusivity, staff working together and supporting each other, improved interpersonal relationships in personal and home life, improved or increased connections between people and different service points, improved cohesion among service users and staff, and building relationships with external organisations and partners. For example, at the Québec site where peer support workers were implemented into housing services, multiple stakeholders noted how the group peer worker sessions helped to build relationships between tenants in positive ways. A tenant on the implementation team described how they learned about each other and could relate to one another in new ways.
He [fellow tenant] talks about his boats, where he travelled and everything. Everybody has a past here, not just the mental grounds, but everybody has a past, they had a family, they lived somewhere before, they travelled somewhere, you know? They are all different, but we all relate with each other. (Service user, peer worker innovation).
Another service user at the British Columbia site who participated in the WRAP programme being implemented highlighted the impact on the way they, as a service user, related to staff:
I would like to say that because of WRAP, and again just in my own personal demeanour and how I carry myself, that the interactions that I do have with the staff are just on a better level. (Service user, WRAP innovation)
Similarly, in the Manitoba 2 site that implemented a staff recovery training programme that was open for some tenants to participate in, a manager expressed how much they valued the opportunity to build relationships with service users:
And I really would also like to say that I value and honour having deeper relationships with some people that were part of the training, and that includes [service user’s name] and [service user’s name], and then maybe some other areas that I don’t normally get a chance to work with, other staff. (Manager, staff training innovation)
The implementation process, particularly the implementation team process, was also referred to as having impacted interactions among stakeholders by empowering members and shifting power. In particular, the implementation team process empowered stakeholders not typically at the decision-making table, including service users, family members, even staff, to participate. It was seen as a bottom-up approach, one where there was a sharing of power for decision-making, and one that could increase members’ confidence and pride in their work. The implementation team process also impacted service users by increasing their access to technology since participating organisations were asked to ensure access to a laptop, tablet or smartphone for service user members of the implementation team to enable their full participation. This need was reinforced when the COVID-19 pandemic pushed in-person meetings online.
Although the impact on ways of interacting were predominantly positive, there were also some examples given of increased interpersonal conflict, usually as a result of norms or power relations being questioned in the recovery-transformation process (see Ways of operating and doing business).
Ways of thinking
The recovery innovations led to shifts in mindset, that is, a change in thinking from what one thought in the past to a new way of thinking that was more recovery-oriented. Examples of this included housing proprietors in Québec changing their preconceived ideas around which tenants might engage with peer support workers. Similarly, but from a tenant’s perspective who participated in WRAP, just offering WRAP in the building and seeing some benefit made other tenants think differently. For family members participating in the support group, a key change in mindset was to stop blaming oneself and feeling guilty. A service provider who participated in recovery training described the following mindset change:
Well, I think I’m intentionally more aware of it, I notice it in what we’re doing but also what’s happening in our community, what our residents are doing, and I’m sure that some of this happened before but I never had the sort of mindset to catch that, capture that and focus on it and then being able to build on that. (Service provider, staff training innovation)
Similarly, another service provider from a different site who participated in a recovery training said:
I would say the biggest impact for me is just like mindset, like the way that you think of the situation or the way that you approach the situation and like I find myself kind of like challenging like old beliefs or old like things that when I started working here were just like a trickledown effect from people previous to me, but now I think of things a lot differently, like I don’t just do things because that’s the way it was taught to me or that’s the way people did it for 20-30 years. (Service provider, staff training innovation)
The recovery innovations were reported to have increased peoples’ knowledge of recovery but also reinforced appreciation of recovery and its principles, including the inclusion of experiential knowledge in organisational processes. In a direct way, the implementation of recovery innovations brought a new perspective or set of ideas into services for people to think about. For example, in all three sites that implemented staff recovery training, participants described one impact as being the inclusion of service users in hiring processes for new staff, as well as other kinds of decision-making committees. The introduction of new ideas not only changed individuals’ ways of thinking, but also led to an exchange of ideas formally and informally in the organisation which pointed to a subtle shift towards embedding key principles of recovery into everyday conversations and processes. Just creating space for reflection on what was learned was itself an impact, as described by the following manager:
…having an opportunity to sort of critically evaluate what we’re doing and whether we’re actually doing it very well or aligned with what we now know recovery means. (Manager, staff training innovation).
Innovations also had the impact of motivating some individuals to aspire to take on new roles representing a new way of thinking about themselves and also a change in how others thought about them. This often referred to service users expressing an interest in taking on a new role, for example becoming a peer worker themselves, becoming involved in staff training or joining committees. It was clear that as a result of the implementation of recovery innovations, new spaces and opportunities for reflection and for learning were created and, in many cases, had a profound impact on collective and individual thinking about recovery and the services provided to people living with a mental health challenge.
Finally, an important change was that stakeholders, particularly managers and staff on the implementation team, gained increased appreciation and knowledge of implementation science, in particular the importance of planning and engagement.
For me personally it has provided me an awareness for the process that is involved in implementing a new innovation within a community setting. The steps involved, the complexity, all the forethought needed prior to an innovation and the process of even implementing and getting buy-in from stakeholders, it kind of opened my eyes to that personally. (Service provider, peer worker innovation)
Ways of operating and doing business
The implementation of recovery innovations impacted how organisations and staff within them operated. In a direct way, one of the impacts was simply having an additional service, programme or option to offer service users in contexts where programming can sometimes be lacking. Recently trained WRAP facilitators framed it as giving them “an extra tool that we didn’t have before” (Service provider, WRAP innovation). More profound than just having something else to offer service users, was that organisations were meeting the needs of service users better as a result of the recovery innovation, in particular by making service users feel more supported, and going beyond what traditional services could offer by drawing on the power of lived-experience rather than professional expertise. This was the case for innovations that were directed specifically to tenants, rather than staff training. For example, in the case of peer worker innovations, a manager put it as follows:
From what’s been reported to me, it’s very beneficial. I think service users feel accompanied by people who are their equals, they speak the same language, who also come at things from a different angle or another way with them, grounded in the day-to-day, in accompaniment, they will take the time to touch on different aspects with them. (Manager, peer worker innovation)
A tenant reflected especially on how transparent the peer worker was about her own experience with psychiatric hospitals and that this really surprised them.
I found it really fantastic to have someone so transparent in my life, and I was very transparent with her too, and I feel that it helps, it helps more than a psychologist or psychiatrist. (Service user, peer worker innovation).
For a service provider, offering WRAP to service users had the perceived impact of showing service users “we do care and then we are supportive, and we are there for them.” (Service provider, WRAP innovation).
Feeling supported was also a clear impact of the family support group innovation. The lived experience of one of the facilitators was also noted positively:
I really liked how it was really open, I liked it when they [facilitators] shared personal things in their life, like it showed us that they are not above us, like we are all together in the same boat, and I found that a really nice way, a nice collective approach I guess you could say. (service user, family support group innovation).
The recovery innovations had an impact on how individual staff members operated in their roles, in that they changed some of their practices. For both Manitoba 2 and New Brunswick 2 that implemented a staff training programme, one change in practice was to be less punitive when it came to dealing with “rule-breaking” in their housing service.
[before] There were like clear boundaries around, you know, somebody screams at the staff, they’re out for 3 days, you know? And that’s really shifted and changed, where we are speaking to the person, having conversations about what’s going on and you know? So, talking about the behaviour rather than you know drawing a line in the sand and saying this is what you can do, and this is what you can’t, so a little bit of self-determination starting to be more normal than, than not, and I think that’s been like evident like since the beginning of the training. (Manager, staff training innovation)
Even in sites where staff were not the immediate focus of the innovation, staff reported changes in practice as a result of the recovery innovations. In Québec a service provider described:
I have seen how their [peer workers’] interactions have also helped me work better and know the better approach to work with them [service users] because of what the peer advocate has been able to achieve with them. (Service provider, peer worker innovation).
By changing old ways of doing things, implementation of recovery innovations also had the impact of “shaking things up” in the organisation. This implied changes that disrupted norms and power dynamics and that could, at times come at a cost for some. The most extreme example of this was in one site that implemented staff training. The training challenged the organisation to look at its ways of doing things and as a result some staff members took-on advocating for change to key organisational documents including the organization’s mission statement, in an effort to use “a more inclusive and positive language.”. This led to a termination of employment of one staff member and a suspension of two others as the Executive Director felt that they “were trying to eliminate the core mission of the organization. Following “a formal grievance” against the director, the latter resigned. One of the staff persons who was temporarily suspended and described the previous six months as “a nightmare”, reflected:
And so, I mean if this recovery piece—you know, project—never came about we probably wouldn’t have gotten to this sort of, this big bang [laughs] and explosion and that’s where I mean the challenges—you know, the benefits of all this really outweigh [the challenges] and if I look back on things, I probably would not have it done it any other way. (service provider, staff training innovation).
At the organisational level both participation in a research project and the implementation of recovery innovations effectively confirmed organisations’ commitment to recovery and pushed recovery forward. Many of the organisations already had standing internal and external mandates to implement recovery into services, and therefore implementation of the innovations aligned with their goals. In the process of implementing the recovery innovation, the commitment of the organisation, staff and senior management was reinforced. It also created a precedent and laid foundations in the organisation. For example, laying the foundations in human resources departments for hiring a peer worker, establishing a pay scale, and making temporary contracts permanent. The success of the innovations gave those involved confidence that they had succeeded and could succeed again. In fact, another impact observed in all sites was that stakeholders were inspired to expand or scale-up their innovations. All described wanting the innovation to grow in the organisation and plans for achieving the growth. The family support group for example, went online due to COVID-19 and was expanded to participants across the county and plans were being made to offer it province-wide. A service provider’s enthusiasm is evident in the following statement:
So me, I’m super motivated about this project. Whatever amount of energy it might take in terms of the organisation, in terms of time, in terms of meetings, it is worth it if the result is getting things into action, and that’s what we are doing. So, from my side I say, we’ve got the support of managers, we’ve got the support of the director. What more can you want? We had everything in place to be able to make it work and I think it will continue, it will continue to grow, it will continue to take-up its place and that’s fantastic. (service provider, family support group innovation).
Thus, from the perspectives of stakeholders, the implementation of recovery innovations, whether it be a peer support worker, WRAP, a family support group or staff recovery training, had profound and multifaceted impacts on ways of operating and doing business.
