The Meaning of Shared Decision-Making in Mental Care – A Hermeneutical Study

Background: Shared decision-making is understood to be a process where the patients and the mental healthcare professionals are engaged in a dialogue of information in order to understand each other’s preferences and values regarding care and to agree on a plan of action. This understanding is mainly derived from a medical context. It is important that the scientific knowledge of shared decision-making is linked to the practice where it is to be carried out. The understanding of shared decision-making and its meaning in mental care needs to be developed, based on a caring science perspective. Aims: The overall aim of this study was to develop a deeper understanding of the meaning of shared decision-making in mental care. The specific aims of the three sub-studies were: I) To describe patient participation in shared decision-making in the context of indoor mental care. II) To explore how mental healthcare professionals describe shared decision-making in a therapeutic milieu as expressed through clinical supervision. III) To interpret the meaning of shared decision-making in mental care as perceived by patients and mental healthcare professionals. Methods: This thesis has a hermeneutical approach with an explorative design. Data were collected by means of three empirical sub-studies (Papers I, II and III), which contain in-depth interviews with 16 patients and multistage focus group interviews with eight mental healthcare professionals. Data analysis methods include qualitative content analysis (Papers I and II) and thematic interpretive analysis (Paper III). A deeper understanding of the meaning of shared decision-making was developed based on the empirical inductive findings, through deductive interpretation and finally an abductive interpretation. Findings: The first sub-study revealed the main theme thriving in relation to participating actively in a complementary ensemble of care, and the two themes having mental space to discover my way forward and being in a position to express my case. In the second sub-study, the theme was practising shared decision-making when balancing between power and responsibility to form safe care, comprising the three categories internalizing the mental healthcare professionals’ attributes, facilitating patient participation and creating a culture of trust. The third sub-study revealed the overall theme being in a space of sharing decision-making for dignified mental care, comprising the three themes engaging in a mental room of values and knowledge, relating in a process of awareness and comprehension and responding anchored in acknowledgement. The three sub-studies represented parts of a larger whole of the investigated phenomenon and a synthesis of them was developed. Through a deductive interpretation two understandings emerged; Shared decision- making - a healing process and an integral part of mental care as well as Shared decision-making - a process of understanding. The final abductive stage illuminated the comprehensive understanding: The meaning of shared decision-making in mental care is being partners with an existential responsibility. Conclusion: The meaning of shared decision-making in mental care is being partners with an existential responsibility. The relationship between a person in need of care and the carer constitutes the existential responsibility, which acknowledges the being in human beings and is essential for mental growth. The mental healthcare professionals should be the patients’ partner and supporter throughout care. This understanding conveys that shared decision-making requires great attention to emotional and relational qualities, scoping the existential dimensions in mental care.

. PhD: Thesis UiS No iii Acknowledgements I would like to express my gratitude to several people contributing in various ways in this research project. Firstly, and in particular, I wholeheartedly thank the participants. Thank you for sharing your thoughts and experiences with me. You all helped me understand more.
Thanks to Stavanger University Hospital for funding this project. Both the Stavanger Community Mental Health Centre and the Department of Research have contributed for this study to be conducted. Thank you! A special thanks to my supervisor Kristine Rørtveit, and my cosupervisors Elisabeth Severinsson and Britt Saetre Hansen. You have guided me with your wisdom, insight and professionality throughout this project. I have learned a lot from you and I am very grateful for your support.
I would like to thank the reference group for their valuable comments and feedback. Your contributions have widened my understanding. A huge thank you to the research groups I have attended, especially everyone in the research groups "Life Phenomena and Caring" at the University of Stavanger and "Nursing and Healthcare Research Group" at Stavanger University Hospital. Thank you all for the valuable input and support.
Thank you to the current and former PhD candidates at the University of Stavanger following me through this journey. I have appreciated all our stimulating discussions, your generosity and support. Your engagement has meant a lot to me.
I would like to thank the research school PROFRES for their valuable contribution. Thank you to the engaged teachers for sharing your knowledge and for backing me up. In particular, many thanks to my fellow PhD candidates in PROFRES for many interesting conversations, iv for sharing your knowledge and experience with me and for your great encouragement and support.
I am very grateful for my wonderful colleagues and my leader at VID Specialised University. Thank you for your generosity and for being so understanding.
Thanks to Louise Rankin who has assisted me by proof reading the English in this thesis.
My wonderful friends and family: Thank you for your curiosity and for backing me up. By reminding me of perspectives of life, you have helped me prioritize the important elements in life.
Finally, but most of all, I thank my dear husband Musie, and my dear children Andreas, Benjamin and Sara. Musie, your patience, support and interest in my work means everything to me. Andreas, Benjamin and Sara, your honesty and humour inspire me and provide a wonderful daily life. I love you!  List of Tables

Introduction
In this thesis the phenomenon of shared decision-making (SDM) in mental care was explored, employing qualitative methods in order to develop a deeper understanding of this phenomenon. As a nurse, my research domain is caring science anchored in the human science perspective, looking beyond the instrumental factors related to the researched phenomenon by focusing on ethics, relations and humanity based on an entity of body, soul, and spirit (Eriksson, 2002). Caring science seeks an understanding of human beings in relation to existential conditions such as emotional and relational desires, as well as trying to illuminate the true and the good in care (Martinsen & Eriksson, 2009). By the use of a hermeneutic approach, the perspectives of patients' and mental healthcare professionals' (MHCPs') experiences in mental care were explored. Knowledge of their reality was illuminated, leading us to a deeper understanding of the meaning of SDM (Gadamer, 2013).
Decision-making in mental care is a dynamic social interaction which involves both the patients and the healthcare professionals to a greater or lesser extent (Charles, Gafni, & Whelan, 1999). SDM is a type of user participation, including the patients together with the carers in decisionmaking (Thompson, 2007). How mental care is understood will affect the patients' and the MHCPs' roles in decision-making (Gulbrandsen et al., 2016;Hummelvoll, 2006;Thompson, 2007).
The first definition of the phenomenon SDM was published in the report Making Health Care Decisions in 1982, by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. This definition focused on informed consent and explained SDM as a process based on partnership and mutual respect between the patients and the healthcare professionals (Makoul & Clayman, 2006). SDM had a relatively small focus until the interest escalated in the late 1990s. The definitions of SDM have been varied and vague throughout the years, diverging in how they describe the patients' and healthcare professionals' responsibilities and roles (Charles, Whelan, Gafni, Willan, & Farrell, 2003). This gave rise to Makolul & Clayman's (2006) literature review to determine the variety of conceptual definitions. The authors identified essential elements of SDM required to be present for patients and healthcare professionals to participate in the SDM process: The patients and healthcare professionals define and/or explain the problem together. They present various options, they discuss the pros and cons of the options raised, including the patient's ability to follow up. They regularly check for further clarifications needed, decisions are made or deferred, and they arrange continuation to evaluate the result of decisions that have been made (Makoul & Clayman, 2006). This understanding of SDM is derived from the context of physician-patient encounters, mainly focusing on sharing information and decision-making, together with the patients' right to be self-determinant (Gulbrandsen et al., 2016).
Understanding derived from the perspective of caring science describes SDM to be based on an interdependent relationship between the healthcare professionals and the patients as they influence each other and cooperate in making decisions about the patients' well-being (McCance, Slater, & McCormack, 2009). SDM is argued to bear an existential dimension, which includes both physical needs and capacities, social belonging, psychological self-understanding and spiritual meaning (Gulbrandsen et al., 2016). The intention of SDM is to increase patients´ knowledge and control over treatment decisions that affect their wellbeing (Storm & Edwards, 2013). Bringing the expertise from both MHCPs and patients together is supposed to give rise to better decisions (Farrelly et al., 2016;Slade, 2017). However, the meaning of SDM in mental care remains unclear.
There is international consensus about the importance of SDM. It has been greeted by policymakers worldwide and is accepted as a guiding principle in mental care (Elwyn, Frosch, & Kobrin, 2016;Slade, 2017). WHO (2006) states that improved quality of care depends on the active participation of patients. The patients have a responsibility and play an important role in identifying their own needs, preferences and ways of dealing with their own health with proper support from healthcare professionals. While the healthcare professionals possess professional expertise, the patients possess personal expertise, experiences and knowledge of social circumstances, values and preferences. Combining these types of expertise, together with research evidence, is supposed to be an optimal basis for making the best possible decisions (Slade, 2017). The ethical justification asserts patients participating in SDM as a basic human right. Ethical justifications highlight that patients and healthcare professionals contribute with diverse but equally important forms of expertise (Coulter & Collins, 2011).
Various interventions for practising SDM have been investigated (Légaré et al., 2018), yet SDM and its implementation into mental care practice is still at an early phase (Morant, Kaminskiy, & Ramon, 2016;Stovell, Morrison, Panayiotou, & Hutton, 2016). Tailoring the implementation of SDM to contextual conditions is important in order to increase the chances of successful implementation (Damschroder et al., 2009). SDM in mental care requires MHCPs to be able to recognize that different clinical situations need differing approaches, as well as accepting it as a core element of good practice (Elwyn & Fisher, 2014). There is a need for enhancing knowledge on how to translate the evidence on SDM into mental care practice and to develop an implementation strategy for SDM in mental care (Scholl & Barr, 2017;Schön, Grim, Wallin, Rosenberg, & Svedberg, 2018). Implementation challenges should be the main concern in the effort to push SDM practice forward in mental care (Slade, 2017).
It is necessary to distinguish on what kind of knowledge the understanding of SDM is based and in which context the knowledge derives so that the scientific knowledge of SDM is linked to the practice to be carried out (Martinsen & Eriksson, 2009). The existing knowledge of SDM is mainly derived from a medical context (Gulbrandsen et al., 2016), which involves a risk that important knowledge derived from a caring science perspective will be ignored. Developing the understanding of this phenomenon, it is important to explore the meaning of SDM from a caring science perspective, including experiences from both the patients' and MHCPs' perspectives.

Aims and research questions
The overall aim of this study was to develop a deeper understanding of the meaning of SDM in mental care.
Three sub-studies (Papers I-III) were carried out, each of them presented in separate papers, all representing parts of the whole of this thesis. The overall aim was translated into the following specific aims: 1) To describe patient participation in SDM in the context of indoor mental care (Paper I). 2) To explore how MHCPs describe SDM in a therapeutic milieu as expressed through clinical supervision (Paper II). 3) To interpret the meaning of SDM in mental care as perceived by patients and MHCPs (Paper III).
The research questions (RQ) were: RQ 1) What are patients´ experiences of participating in SDM? (Paper I) RQ 2) What are prerequisites for MHCPs to practise SDM in a therapeutic milieu? (Paper II) RQ 3) What is the meaning of SDM in mental care? (Paper III)

Context
The context of this thesis is mental care in three wards in a community mental health centre in Norway. The community mental health centres in Norway have the responsibility for serving a geographically defined area, each with an estimated responsibility for 30,000 to 75,000 inhabitants. The core tasks of the community mental health centres are to offer acute and emergency services, both in-and out-patient services, short-term treatment as well as long-term. The referred patients should be checked, diagnosed and offered differentiated treatment. People with severe mental disorders should be offered rehabilitation (Malt, 2019).
There is an ongoing process of reducing places for in-patients at the community mental health centres, as in psychiatric institutions in general, but alternative services are not developed in line with this reduction. Patients are often discharged before they feel restored enough to cope with life outside the hospital and before alternative services are offered (Norwegian Health Directorate, 2015). This situation affects both patients and MHCPs in mental care. The patients are often in very poor mental health when being hospitalized in the community mental health centres, and the time available to work towards restored mental health is often too short. This challenges the relational and holistic focus in care, which involves encountering the patients with their physical, mental, social and spiritual needs (Eriksson, 2002).
Increasing demands of effectiveness and lack of research-based knowledge of mental care have contributed to unclear professional content and a lack of shared professional practice (Borge & Hummelvoll, 2019). The traditional biomedical care system has been dominant in mental care wards in Norway (Martinsen & Eriksson, 2009) which, in contrast to SDM, has placed MHCPs in a position of power and authority with the patients playing a passive role in their care. The MHCPs have instructed their patients about what to do and the patients have usually followed their advice (Lyttle & Ryan, 2010). National authorities have required a focus on user participation, which has been derived with the purpose of increasing the patients' coping ability and influence over their own lives. This means that MHCPs now have to consider the patient as an equal partner, and it challenges the care to be more flexible and person-oriented (Norwegian Ministry of Health & Care Services, 2015. The purpose of mental care is to empower patients to take control and to be self-determinant (Davidson, Tondora, Pavlo, & Stanhope, 2017). Peplau (1991) describes the hospital ward as a social context where the patients will be helped to mature towards improved health. Indoor mental care is based on relational treatment, the main focus being to use relationships to alleviate relational harm. Indoor mental care is intended to be based on a therapeutic milieu, which is more than an environment in the ordinary sense of the word. It is supposed to be a healing culture, rich in therapeutic interpersonal relationships and co-operative attentiveness to patients. Its physical features should soothe patients and provide optimum safety. The purpose of the therapeutic milieu is twofold: to foster patients' optimal healing by being protective, calming and restful, and to provide a practice conducive to their health (Skårderud & Sommerfeldt, 2013). Important factors in a therapeutic milieu are treatment programming, interpersonal relationships, patient empowerment, patient safety and hope for the future (Long, Knight, Bradley, & Thomas, 2012). The optimal therapeutic milieu supports patient-centered care, safety and continuous healing (Mahoney, Palyo, Napier, & Giordano, 2009).
MHCPs are the frontline workers on the ward. MHCPs working in the mental health wards possess various professions, mostly bachelor degrees in nursing or as a social educator, some with a specialized education in mental care (Malt, 2019). Because of the lack of MHCPs, unskilled assistants also work in this clinical context. Psychologists and psychiatrists are linked to the ward as individual therapists. Assistants, psychologists and psychiatrists, as well as the managers are not focused on in this thesis.
The patients hospitalized at community mental health centres, represented in this thesis, struggle with various mental health problems, suffering from different mental illnesses, which makes them in need of being an in-patient for a period of time, short or long term.

Research design
This study was based on an explorative design (Holm, 2009;Polit & Beck, 2010) in order to illuminate stakeholders' experiences, and the meaning of SDM. The design is visualised in Figure I. The interpretative paradigm with a hermeneutic approach was adopted (Gadamer, 2013) to develop a deeper understanding of the meaning of SDM in mental care. Three stages of interpretations were developed; inductive, deductive and abductive (Graneheim, Lindgren, & Lundman, 2017;Råholm, 2014).
The first stage of this study was conducted inductively (Polit & Beck, 2010) arranging for new insights to occur (Hsieh & Shannon, 2005). The empirical part consisted of dialogues with the MHCP participants (N=8) in multistage focus groups (Papers II and III) and with the patient participants (N=16) in individual dialogues (Papers I and III), illuminating a variety of aspects of the researched phenomena (Malterud, Siersma, & Guassora, 2016). Three sub-studies (Papers I-III) were carried out and constituted independent papers that formed the foundation on which the hermeneutic circle was constructed (Gadamer, 2013). Qualitative content analysis (Papers I and II) and thematic interpretive analysis (Paper III) were conducted on the empirical data (Braun & Clarke, 2006;Graneheim et al., 2017;Graneheim & Lundman, 2004). The findings from the empirical sub-studies (Papers I-III) were synthesised in order to grasp a sense of the whole.
The second stage was conducted deductively (Polit & Beck, 2010) in order to develop a deeper understanding of the meaning of SDM (Hsieh & Shannon, 2005). Interpretations from the previous inductive stage were formed in the light of existing knowledge. A systematic review of the research evidence of SDM in mental care was conducted (Smith, Devane, Begley, & Clarke, 2011) and constituted the theoretical background, providing a basis for the deductive interpretation together with theories linked to the focused topic.
In the abductive stage a fusion of horizons created a comprehensive understanding (Gadamer, 2013;Råholm, 2014). Dialogues with the empirical patient perspective, the empirical MHCP perspective, existing knowledge and existential philosophy (Frankl, 2014;Levinas, 2003;Sartre, 2007) as well as and me as researcher, illuminated new insights, contributing to a deeper understanding of the meaning of SDM in mental care.

Structure of the thesis
This thesis is built on three original research papers (Papers I-III) and comprises two parts.
Part I is devided into seven sections. First, in the introduction (Section 1), the research area and the study context are described. The aims, research questions and the research design are presented together with the structure of the thesis. The theoretical background (Section 2) is a presentation of a systematic review of review articles focusing on SDM in mental care. The methodological framework (Section 3) of the thesis presents the hermeneutical approach and methods, as well as methodological and ethical considerations. An overview of the findings (Section 4) derived from the three sub-studies is followed by an interpretation and discussion towards a comprehensive understanding (Section 5). Finally, a conclusion (Section 6) is developed, followed by the implications (Section 7) for clinical practice and suggestions for further research.
Part II contains the three original research papers and the appendices.

Theoretical background
Theory is understood as basic perceptions of the nature of a research area (Fredriksson, 2014). This section presents a systematic review of research evidence of SDM in mental care (Smith et al., 2011). It forms the basis for the theoretical background of this thesis. The synthesis of the scientific knowledge is aimed at obtaining the existing understanding of findings in this research field. The review question was "what is the scientific knowledge of SDM in the context of mental care?".
An electronic search was carried out, assisted by a librarian. The objective was to identify review articles about SDM in mental care in the English language, published between 2015 and 2019 including SDM in the title in the data bases Embase, PsycINFO, Medline, Cinahl (via Ebsco) and Web of Science. An overview of the search strategy is attached (Appendix 1). A total of 321 reviews were identified and screened for relevance. The first stage of screening involved exclusion of duplicates. Articles lacking relevance for the review question were excluded as well. Exclusion criteria were articles focusing on children, youths and medical treatment. A total of 16 reviews were examined during the second screening phase, which involved reading article abstracts to ensure the relevance to the scope of this review. Eight reviews were selected for inclusion in this review (Table 1), reflecting evidence of SDM from 426 different original articles. In order to sum up the evidence, the findings synthesised in this section present the recent status of research of SDM: SDM-an approach in mental care, and Changing attitudes towards the theory and practice of shared decisionmaking.

Shared decision-making -an approach in mental care
SDM is an approach for planning and carrying out care which focuses on the process of decision-making in the setting of the relationship between patients, MHCPs, and sometimes also the patients' next of kin (Davidson et al., 2017). SDM values the patients' experiential knowledge together with the professional and scientific knowledge, and by integrating these perspectives it is expected to lead to better decisions in mental care (James & Quirk, 2017;Ramon, Brooks, Rae, & O'Sullivan, 2017).
Decisions in mental care are not only about rehabilitation and treatment.
The patients' process of restoring their mental health is a dynamic, relational journey which takes place over time and varies according to circumstances (Castillo & Ramon, 2017). Therefore the focus in SDM should be on the process, rather than the final decision (James & Quirk, 2017).
Mental care is about helping patients deal with mental ill-health in the context of their lives and involves the patients' personal decisions and life decisions. The patients are the main characters of the care process and the key decision-makers. The MHCPs can provide the patients with their professional knowledge, but the patients have to participate by sharing their knowledge and experiences of what they think is required to attain the life they desire. The patients' role in SDM is therefore essential and cannot be ignored or assumed. However, the patients' mental challenges often require a level of support, experience and expertise which is hard to find in a traditional mental care system (Davidson et al., 2017). Assisting the patients in these decisions pushes the MHCPs beyond the scope of traditional mental care and requires relationships between patients and MHCPs which stimulate the patients' ability for self-determination. MHCPs have to find out how to apply their own professional skills and knowledge for the patients' to use in search of his or her own goals (Davidson et al., 2017). Core aspects for SDM are respect and open dialogue, in addition to MHCPs being committed to empathetic partnering (Castillo & Ramon, 2017;Davidson et al., 2017).
SDM is an important approach to uphold patient-centered mental care. MHCPs should place emphasis on being their patients' partners by supporting, encouraging and guiding them to voice their own care needs and help their life to move forward in their own process of restoring their mental health (Davidson et al., 2017). The SDM approach improves patients' well-being more than just focusing on a particular intervention .
The purpose of mental care has moved beyond the maintenance of clinical stability and the emphasis is now on empowering patients to take control and live self-determined lives regardless of severe mental illhealth. Traditional mental care is in itself not sufficient to achieve this purpose. The patients need to take an active role, learning about taking responsibility and dealing with all the challenges a life with mental illhealth entails (Davidson et al., 2017). SDM is a useful approach in this regard (James & Quirk, 2017;Kaminskiy, Senner, & Hamann, 2017). James & Quirk (2017) report that SDM strengthens the therapeutic relationship between patients and MHCPs, with qualities such as trust and mutual understanding, genuineness and empathy. It adjusts power imbalances and upholds communication and partnership. SDM activates patients to take control in their lives. It enables them to express their experiences and desires and allows them to influence their care and find their own way of restoring their mental health. This is supposed to give rise to improved self-esteem, self-confidence and self-efficacy and is assessed to be therapeutic in itself. SDM is viewed as a way for patients to take back control, which protects them against coercion (James & Quirk, 2017;Kaminskiy et al., 2017). In addition, Alguera-Lara, Dowsey, Ride, Kinder, and Castle (2017) report that patients participating in SDM have reduced symptoms, increased care satisfaction and improved adherence to care, as well as enhanced knowledge and increased engagement. SDM also strengthens other mental care interventions (Castillo & Ramon, 2017;James & Quirk, 2017;Ramon et al., 2017). Patients with schizophrenia were observed to attain decreased rates of hospitalisation when participating in SDM (Alguera-Lara et al., 2017). James & Quirk (2017) describe SDM in mental care to be cost effective.

Changing attitudes towards the theory and practice of shared decision-making
There is an existing gap between the theoretical model of SDM and the practical implementation of SDM in mental care Zisman-Ilani, Barnett, Harik, Pavlo, & O'Connell, 2017). To better understand this gap between SDM knowledge and practice it is useful to understand patients' and MHCPs' attitudes towards it.
Studies demonstrate that patients and MHCPs prefer and support SDM . The SDM approach is considered "best practice" in mental care and is essential to the "modernisation" of mental care services (James & Quirk, 2017). However, some MHCPs still have ambivalent attitudes towards SDM and view it as distant from the traditional psychiatric approach. Some also have concerns that SDM will threaten their professional responsibility. There is a medical dominance in mental care, probably as a consequence of occupational control over many other conflicting interest groups, and attitudes concerning SDM may be determined by the MHCPs' speciality (Kaminskiy, Senner, & Hamann, 2017).
Patients' preferences for SDM may vary according to education levels, employment status, ethnicity and diagnosis . However, patients in mental care want, and are able, to be involved in decisions about their care, though the degree of involvement varies.
Currently, they often do not experience access to the participation they prefer (Alguera-Lara et al., 2017;James & Quirk, 2017). In practice, they experience a lack of information from their MHCPs and the type of information offered by their MHCPs is lacking in choice. MHCPs sometimes hold back information and do not acknowledge that sharing the responsibility and risk with the patients in their care is a part of SDM . Davidson et al. (2017) report the consideration of patients being incompetent to make their own decisions and take responsibility, to be based on the stigma linked to patients with mental ill-health more than to the nature of the condition itself. Castillo & Ramon (2017) report that MHCPs consider respect to be fully integrated in their practice, while patients do not find that apparent. Their understanding of dialogue differs.
The patients acknowledge a need for increased assistance during phases of mental health crisis. However, they highlight the importance of a therapeutic relationship with the MHCPs; being listened to, building trust and having autonomy returned to them over time (Castillo & Ramon, 2017). MHCPs emphasise the need to modify the decision-making style to the individual patients and the specific situation (Kaminskiy et al., 2017). SDM is associated with basic human dignity (Castillo & Ramon, 2017).
Building relationships between the stakeholders, as well as individual commitment is required for promoting SDM . Implementation of SDM requires all stakeholders to know what SDM is and to be able to distinguish it from their current practices . This demands that MHCPs change the traditional scope of mental care and emphasizes supporting their patients in their entire lives (Davidson et al., 2017). A de-implementation of existing practices is necessary when implementing SDM .
Focus on promoting SDM should be guided by facilitators for SDM, which will be described in the following section.

Facilitating and obstructing a trusting, shared decision-making relationship
Alguera-Lara et al. (2017) found openness, patience, trust and respect to be essential in SDM to support relational attitudes. A prerequisite to practising SDM is a trusting relationship between patients and the MHCPs, which is built on empathy, mutual understanding, compromise and partnership. A non-judgemental and supportive environment, holding up the patient to be an active and deciding agent, is essential for SDM to be beneficial. A respectful culture acknowledging the patients' expertise, communicating belief in the individual patients' potential, as well as recognising power issues in the helping relationships are elements which enhance patients' participation in SDM. This requires MHCPs to possess relational competencies to foster an open, genuine dialogue with their patients (Castillo & Ramon, 2017;Davidson et al., 2017;Kaminskiy et al., 2017).
MHCPs encouraging their patients to participate actively is supposed to reveal an attitude of being open to new understanding. Possessing an active role in SDM, the patients must be provided with information about the options for treatment and the advantages and disadvantages thereof. Behaviours to support SDM are MHCPs educating their patients about available choices, information sharing and giving feedback. Active participation and engagement in the encounters is needed, in addition to collecting information and preparing for the encounters as well as applying the decision (Alguera-Lara et al., 2017; Davidson et al., 2017;Ramon et al., 2017).
Some patients may fear negative consequences if they assert themselves, they may feel powerless, they may not feel safe enough in their relationships with MHCPs and they may lack trust in their MHCPs, in addition to having different expectations about the roles of MHCPs and patients. For that reason, patients need to know that they have a right to participate in their own care and they need to experience the MHCPs as open to new understanding (Alguera-Lara et al., 2017; Davidson et al., 2017).
Being open to new understanding, MHCPs view collaboration with the patients' families and other caregivers as promoting SDM. Another facilitator for SDM may be interprofessional collaboration by providing more occasions for patients to talk about their concerns regarding care and addressing time barriers (Kaminskiy et al., 2017).
A barrier for several patients to participate in SDM is the inability to process information efficiently and to express themselves clearly when in poor mental health. Patients may see their historical passivity, past trauma, their own competence and fragile hope as challenging for participating in SDM, as they are afraid of being incompetent (Castillo & Ramon, 2017;Kaminskiy et al., 2017). The standard mental care approach is that the MHCPs make the decisions. The patients may feel they have to please their MHCPs by just following their decisions, as they often experience being informed rather than involved in choices (Castillo & Ramon, 2017;Davidson et al., 2017). Kaminsky et al. (2017) report that the patients' opinions are seen as less important or less valued than the MHCPs'. Many patients inform that they are struggling to be seen or heard as competent and equal in encounters with their MHCPs.
A barrier for MHCPs practising SDM is that they are not open to new understandings. Their own attitudes and lack of willingness, motivation and empathy keeps them from being able to involve their patients in their own care. Some MHCPs determine certain patients and situations as generally inappropriate for SDM (Alguera-Lara et al., 2017;Kaminskiy et al., 2017;Ramon et al., 2017). Some MHCPs state that patients' adherence, cognitive capacity and insight is essential in order to participate in SDM . Patients' lack of insight into their illness is a key barrier to SDM, as MHCPs consider their obligation is to prevent the patients from the risk of harm to self or to others (Castillo & Ramon, 2017;Kaminskiy et al., 2017). A concern is that an incorporation of the patients' preference may not always reflect the best clinical choice. Being open to new understanding requires a shift in roles from a traditional, paternalistic decision-making style towards SDM, which is necessary to practise SDM (Castillo & Ramon, 2017;. Coercive and legislative frameworks included in the mental care context may be an aspect which can erode trust between patients and MHCPs, thus making the SDM relationships difficult to initiate and sustain. Prevalent norms about control and surveillance in mental care are a direct barrier for SDM, but are seldom confessed by MHCPs. Informal norms within mental care and pressures from the clinical context are likely to impede an openness to new understanding and SDM (Castillo & Ramon, 2017;Ramon et al., 2017).
Practising SDM requires MHCPs to see a difference between current practice and SDM and an understanding of SDM as a continuing process which cannot be fully completed (Castillo & Ramon, 2017;Ramon et al., 2017). Facilitating a practice of openness to new understanding needs broader contextual support, including support from the organisation and upper level administration . Kaminskiy et al. (2017) report that SDM interventions, like decision aids which support patients' involvement in SDM, are necessary for practising SDM.

The evidence of shared decision-making interventions
At present, a proven method of practising SDM in routine care is lacking. A range of interventions have been developed in order to facilitate the practice of SDM (Légaré et al., 2018). Some of the interventions targeting patients are patient activation, decision tools, rapid question lists and training for patients. Examples of interventions targeting MHCPs are aides-mémoires, educational material, educational meetings and educational outreach. Interventions combining patient and MHCP interventions have also been established. Légaré et al. (2018) report the evidence to be very low and therefore cannot designate which interventions for practising SDM are the most effective. However, comparing to no intervention at all, interventions for MHCPs were considered to slightly improve quality of life regarding mental health.
Training to support SDM should be advocated continually and should not only be a one-off decision . Both patients and MHCPs need SDM training. The training of MHCPs might only demonstrate scarce improvements in the long-term, but combining the training of MHCPs with the training of patients has been found to improve results (Castillo & Ramon, 2017;Ramon et al., 2017). However, patients and MHCPs need to have separate SDM interventions (Kaminskiy et al., 2017;Zisman-Ilani et al., 2017).
Documented interventions to implement SDM should not be assumed to work generally. It is necessary to adapt them, together with procedures, to the patients' individual needs . By the education and support of patients they can become empowered and gain selfconfidence regarding their own decision-making (Castillo & Ramon, 2017

Summary
Decisions in the context of mental care involve the patients' personal decisions and life decisions, in addition to concerns about rehabilitation and treatment (Castillo & Ramon, 2017). Assisting the patients in these decisions requires trusting relationships between patients and MHCPs which stimulate the patients' ability for self-determination. Respect and open dialogue are core aspects for SDM, as well as MHCPs being dedicated to empathetic partnering by supporting, encouraging and guiding their patients to move forward in their own process of restoring their mental health (Castillo & Ramon, 2017;Davidson et al., 2017).
SDM is assessed to be healing for patients in mental care and is viewed as a way for patients to take back control, which protects against coercion (Alguera-Lara et al., 2017;James & Quirk, 2017). SDM is considered "best practice" in mental care and is significant for the "modernisation" of services (James & Quirk, 2017 Promoting SDM requires all stakeholders to understand what SDM is and to distinguish it from existing practices (Davidson et al., 2017;Ramon et al., 2017). De-implementation of current practices is required, as well as establishing individual commitment and relationships between the stakeholders in the implementation of SDM . A proven intervention for practising SDM in mental care is currently lacking. Interventions for MHCPs were considered to slightly improve SDM in mental care (Légaré et al., 2018). Combining interventions for MHCPs with training for patients is also found to improve results (Castillo & Ramon, 2017;Ramon et al., 2017). Providing interventions for MHCPs, at a team level, is supposed to prepare them for supporting each other in challenging situations and improving SDM. Clinical supervision sessions are found to facilitate the implementation of SDM. However, how to operationalize these interventions needs further investigation .

Methodological framework
The following section describes the methodological framework applied in this thesis. The hermeneutical approach is defined as well as methods, with a description of participants, data collection methods and methods for analyses. Methodological considerations are discussed and ethical considerations are outlined.

Hermeneutic approach
A deeper understanding of the meaning of SDM in mental care was sought after in this thesis, applying a hermeneutic approach. The hermeneutic research paradigm for this thesis is based on Gadamer (2013) who describes understanding of the world and provides an explanation of human understanding as limited, shaped by our being, such as our values, interests, language, traditions and time in history. In order to experience the world, we must interpret what is around us and through our interpretations we achieve an understanding, which is more complex than an explanation. Achieving an understanding is a starting point for new experiences of being open to new perspectives and being open to encounter the unknown (Gadamer, 2013).
Understanding is described as a multifaceted experience explained as the hermeneutic circle; a dialectic movement between proximity and distance, part and whole, self and others, present and past. Attaining the overall aim of this study, I considered various aspects of SDM as a part, continuously having new aspects in sight and gaining more insight by seeing more clearly. A fusion of horizons, Gadamers description of understanding, was developed as the dialogue, the written text and me as a researcher, entered the hermeneutic circle, dialectically moving between the empirical findings and theory, as well as between the various parts and the whole (Gadamer, 2013). The new expanded understanding, derived from my pre-understanding, was influenced by patients and MHCPs (Holm, 2009), as well as the co-researchers. A hermeneutical movement back and forth between the findings of the sub-studies (Papers I-III), pre-understanding, the theoretical background employed, other relevant theories, as well as philosophy led to a comprehensive understanding of the researched phenomenon.

The researcher's pre-understanding and role
Who we are and the experiences we have had earlier in life will colour the understanding we achieve in new situations. Gadamer (2013) conveys that our pre-understandings derive from the tradition in which we take part, and an intentional organizing is activated when we consider something. Tradition does not stand over in contradiction of our thinking. It is the horizon within that conducts our understanding. Preunderstandings can prevent us from grasping the meaning of a phenomenon in the way that it is impossible to see further and to understand in a new way if the researcher does not know his or her preunderstanding or is aware of his or her prejudices (Gadamer, 2013).
My pre-understanding consists of the human science perspective, ethical understanding, caring and medical knowledge, prejudices, and values in addition to several years of experiences of being a registered mental health nurse. I value every human being as a unique creature, everyone carrying some hidden treasures waiting to be unfolded. I believe all human beings have both resources and vulnerabilities that need to be balanced in order for them to feel valued. I find mental care challenging because so many situations occur without having a clear answer for best practice. Maybe that is why I trained to be a clinical supervisor, helping other MHCPs to reflect on their everyday practices. I think clinical supervision is essential for MHCPs' practice of quality in care. My intention with this thesis was to explore the practice in order to get a deeper understanding of how it can be formed to facilitate the patients' and MHCPs' cooperation for the patients' benefit.
The research team in this study consisted of me as manager of the project, my main supervisor, Associate Professor Kristine Rørtveit and my two co-supervisors Professor Elisabeth Severinsson and Professor Britt Saetre Hansen. Three of us are registered psychiatric nurses (LSB, KR and ES) and one is a registered intensive care nurse (BSH), all possessing many years of clinical experience.
My role in this project was to administer as well as conduct all parts of this study along with the supervisors, who were actively engaged. Firstly, we (LSB, KR and ES) designed the supervision program (Appendix 8), which served as a basis for the multistage focus group interviews. I was responsible for applying to the Regional Ethics Committee for approval to carry out this study and for recruiting the participants. I conducted the individual interviews, transcribed all the recorded interviews and performed the systematization and categorization part of the analysis before the supervisors were engaged in the interpretation and validation of the findings.
I was involved as a researcher and as a participating observer in the clinical supervision sessions in the multistage focus group interviews with the MHCPs and transcribed the recorded data after each session. I was involved in listening to the participants' dialogues and reflections, and I asked questions in order to get deeper into the core of their reflections. The main academic supervisor in this study (KR) had the role of clinical supervisor, guiding the participants through the clinical supervision sessions in the multistage focus group interviews. The role of the co-supervisors, who were not closely involved in the data collection in the clinical supervision group, was to challenge the involved's pre-understanding, as well as validating the analysis process from their "outsider" perspectives (Graneheim et al., 2017).

Establishing trustworthiness
To establish confidence in the research it was necessary to have a thoughtful, conscious self-awareness and critical reflection of preunderstanding during all parts of the study (Polit & Beck, 2010). To achieve a horizon means to look beyond what is nearnot with the intention of looking away from it but to grasp it better, within a larger whole and in truer proportion (Gadamer, 2013). If we want to expand the horizon of meaning and our understanding we should look beyond what is nearby and overcome our pure subjectivity with its preunderstanding and existing prejudices (Launsø, Olsen, & Rieper, 2011).

Own awareness and self-understanding
Gadamer (2013) emphasizes that the phenomenon we want to understand, must appear on its own terms as far as possible. My intuition, insight, awareness of prejudice and knowledge facilitated this. The dialogue between the participants and me as a researcher formed a communion. A circular motion was created between my expectations and the meaning that the participants conveyed as I was deeply tuned-in to the experiences and meanings of the participants (Dwyer & Buckle, 2009). In order to uncover the meaning, I had to be aware that I did not understand and I had to take part in the dialogue that took place (Gadamer, 2013). I searched for something that provoked my preunderstanding in order to find what the participants were telling me and it was important for me to critically reflect when something appeared that was not in line with my pre-understanding, as well as discussing the issues with the research team. This gave me a better position to search for new aspects of the researched phenomenon and it was necessary for promoting a deeper understanding of the meaning of SDM (Launsø et al., 2011).
Being aware of one's own subjectivity and pre-understanding is challenging. It was important that the research team, the reference group as well as research groups, were actively involved in the research process in order to optimize the study's trustworthiness.

The research team's, reference group's and research groups' contribution
In addition to me, three supervisors participated as co-researchers, crosschecked and discussed the content throughout the analysis process, focusing on how to understand and discover a deeper meaning of the content of the data (Graneheim et al., 2017).
A reference group was established in order to secure that this study mirrored the practice field and to keep an outsider-view on the project. In addition to me as the project leader and the main supervisor in the project, the reference group was comprised of a service user representative, a representative from the hospital managerial group and the MHCPs, as well as a psychologist representing the interdisciplinary team. The reference group met at least once every 6 months, and its members were consulted whenever needed. Their role was to evaluate the various activities and elements in the research process from their point of view, including the interview guide, recruitment of participants and the findings derived from the data analysis.

The hermeneutical interpretation process
Three empirical sub-studies and a review of review articles were conducted in order to achieve the overall aim and to answer the research questions of this thesis. The sub-studies (Papers I-III) were interpreted inductively. The starting point was the empirical data material, and by the use of my pre-understanding the data was organized according to similarities and differences, which created patterns, presented as themes and categories (Braun & Clarke, 2006;Graneheim et al., 2017;Graneheim & Lundman, 2004). Each sub-study (Papers I-III) was interpreted and published sequentially, allowing each part to be understood separately. I was constantly aware that each sub-study was an independent unit representing distinctive findings, as well as simultaneously being part of the whole. The three sub-studies were positioned in the hermeneutic circle (as described in 3.1), now dependent on each other, as together they created a synthesis of the inductive findings from the empirical sub-studies (Papers I-III) in order to grasp a sense of the whole.
The hermeneutic circle continued by making a dialogue between the already inductively interpreted empirical findings and theory (the review presented in the theoretical background in Section 2), and other applicable theories. A deductive interpretation was conducted, trying to understand the inductive findings in the light of theory (Graneheim et al., 2017) in order to grasp a new sense of the whole (Gadamer, 2013) and developing new dimensions of SDM in mental care (Graneheim et al., 2017;Hsieh & Shannon, 2005).
An abductive interpretation was based on the already inductively and deductively interpreted knowledge, moving beyond the already known understanding. A deeper understanding of the meaning of SDM was developed through dialogues with the various empirical aspects of SDM and the existing knowledge, by means of the researchers' preunderstanding as an impetus (Graneheim et al., 2017;Råholm, 2014). Through the inductive and deductive interpretations, a new consciousness emerged. During the process of intertwining existential philosophy to the various parts, a pattern of meaning emerged. The fusion of horizons created a comprehensive understanding of the meaning of SDM in mental care (cf. Gadamer, 2013).

Methods
This study consists of three sub-studies. The methods conducted in these sub-studies will be outlined in this section. Table 2 provides a brief overview of the sub-studies (Papers I-III).

Participants
In the three empirical sub-studies the participants were patients (Papers I and III) and MHCPs (Papers II and III). In order to illuminate various perspectives of the researched phenomenon it was important to explore the patients' experiences (Paper I), the MHCPs' experiences (Paper II) as well as interpreting their experiences combined with each other (Paper III). Paper III involved the same participants as in Papers I and II.
In January 2016 I contacted clinical nurse managers at a community mental health centre in Norway and informed them face-to-face about the study, after which the clinical nurse managers invited MHCPs from three different wards to participate in a clinical supervision group, informed to serve as a multistage focus group in this study. We recruited nine MHCP participants after which one withdrew following the introduction session due to prioritization of time regarding workload on the ward. Eight MHCPs participated throughout the ten clinical supervision sessions, however not everyone was able to participate in each session. Four to twelve participants in a focus group are a sufficient number to generate adequate data (Jayasekara, 2012).
Snowball sampling, which means that previous participants recruit new participants (Polit & Beck, 2010), was performed as the MHCP participants were asked to recruit two patients each who were willing to participate from the ward where they worked. Snowball sampling would enable the MHCPs to identify patients with mental health in-patient experience for the individual research interviews with specific experiences that matched our study aims (Polit & Beck, 2010). In line with a patient participation approach, the participation of these patients would be of great value for the study. A sample size of 16 was considered to ensure data with high information richness (Malterud et al., 2016;Polit & Beck, 2010).

Patient participants in Papers I and III
16 patients, aged from 30 to 77 years, were included in this study. There were nine females and seven males with experience from one to 38 hospitalizations. The patient participants described the reason for their hospitalization as anxiety, depression, life crisis, obsessive-compulsive disorder, personality disorder, posttraumatic stress disorder, psychoses and suicidal attempt.
The inclusion criteria for the patients' participation were experience of being an in-patient at a mental health ward for at least one month, aged >20 years and the ability to speak Norwegian in order to be a source of rich data. There were no exclusion criteria.
The 16 patient participants were unknown to the researchers.

MHCP participants in Papers II and III
The eight MHCPs in this study, were aged from 38 to 60 years and included one male and seven females. Six of them were registered mental health nurses, one was a nurse and one was a social educator. They had from one to 27 years of experience in mental care in-patient settings.
The inclusion criteria were at least one year of work experience in inpatient settings and a Bachelor degree in nursing or related social sciences. MHCPs with at least one year's experience of mental health inpatient work were expected to yield rich data (Malterud et al., 2016;Polit & Beck, 2010). The exclusion criteria were part time MHCPs who worked for less than 28 hours per week, those who exclusively worked night shifts and clinical nurse managers. This ensured that the participants were engaged in clinical practice and could engage with experiences with SDM from their daily work.
The eight included MHCP participants were unknown to the researchers.

Data collection methods
There were two steps in the data collection, including two different data collection methods in the three sub-studies; multistage focus groups and individual interviews. All of the focus group sessions and individual interviews were audio recorded and transcribed. These methods and the data collection processes are described in the following.

Multistage focus group interviews (Papers II and III)
Multistage focus group interviews are a method for collecting data based on the same group exploring a certain phenomenon through dialogues focused on predefined themes over several sessions (Hummelvoll, 2008; D. L. Morgan, 1997). As I was searching for a deeper understanding of the MHCPs' various experiences, concerns and beliefs, in addition to a more comprehensive understanding of the meaning of SDM, multistage focus group interviews with MHCPs were considered to be a suitable method for creating rich data (Hummelvoll, 2008).
When searching for a deeper understanding of the meaning of SDM the researchers have to be involved in the data collection (Polit & Beck, 2010) in order to be deeply tuned-in to the experiences and meaning systems of the researched to provide rich data (Colucci, 2007;Dwyer & Buckle, 2009). Flyvbjerg (2006) claims that the most advanced form of understanding can be achieved when the researchers are highly involved and put themselves right into in the context under study. When the researchers have proximity to situations in real life and create a substantial involvement with those researched, a rich data set around a series of aspects of the theme researched will be provided (M. S. Morgan, 2015). Based on this, clinical supervision sessions were chosen for data collection, serving as multistage focus groups. Clinical supervision is defined as a support tool for professionals where they can share clinical, emotional, developmental and organizational experiences with each other in a confidential and secure setting in order to improve knowledge and skills. This process will be the basis for an increased attentiveness of other perceptions comprising accountability and reflective practice (Lyth, 2000). The ten sessions took place every second week and each session had a duration of 1.5 hours. The structure of the clinical supervision sessions was comprised of five phases. The first phase was bridging from the last session, where the question "what have we brought with us from the last session?". In the second phase this session's topic was introduced (Holm Wiebe et al., 2011). The third phase consisted of an individual creative exercise where the participants got their own sheets and pencils and drew while they reflected individually on this session's topic (Colucci, 2007). The fourth phase was plenum sharing and reflection based on questions related to this session's theme. The participants shared their thoughts and feelings in a dialogical process. The last phase involved an evaluation of the day's session, content and structure based on the question "how have you experienced the clinical supervision today?" and "what will you bring with you from the today's clinical supervision session?".
The ten focus group interview sessions took place at the community mental health centre where the MHCPs were employed, from February to June 2016, in a room where there were no interruptions. The purpose of the focus group interview sessions was to facilitate wondering indepth dialogues that addressed the research question. The pre-designed supervision programme, based on value-based topics related to patient participation, was the starting point for all the sessions (Appendix 2). The main supervisor (KR) in this study, who is a registered mental health nurse and clinical supervisor, performed the role of moderator and clinical supervisor, being involved in the dialogues by commenting and leading the reflections by asking follow-up questions. I was present in the group as a researcher, asking for more in-depth information when needed. Possessing a more distant role in the group made it easier for me to be aware of the group dynamics and to attain an overall picture of the participants' reflections.
A number of three to five sessions is suggested to be suitable for multistage focus groups (Liamputtong, 2011). In this study the number of sessions was directed by the clinical supervision program, involving ten themes covered over ten sessions. The participants became familiar with each other and the supervisors throughout the sessions, which made them more confident and comfortable. In addition, they had an internal agreement not to share the information given in the group with others, which was also important in order to create confidence in the group. When the participants are confident, they will feel freer to share their thoughts and feelings about the topics being reflected on, which is important for providing rich data material. A space for sharing breadth and depth of experiences was created. This improved the reflective process, which was also important for attaining rich data (Hummelvoll, 2008).

Individual in-depth interviews (Papers I and III)
Individual face-to-face interviews facilitated a close dialogue between me and the patient participants which offered them the opportunity to share their experiences and opinions (D. L. Morgan, 1997) and provided insight into their personal feelings, thoughts and world views (Guest, Namey, & McKenna, 2017). This was considered to create rich data for this study (Malterud et al., 2016). A pre-designed semi-structured interview guide (Appendix 3) validated by the reference group guided the interviews. A pilot interview was carried out with one patient in order to test the interview guide, who after the interview asked to be included as participant in the study because she wanted her voice to be heard and she hoped her contribution could provide for change in clinical practice.
The in-depth individual interviews (Polit & Beck, 2010) with the 16 patients took place at the community mental health centre where the patients had their present connection. All the interviews were conducted by me between March and August 2016.
Based on the open-ended preset questions from the interview guide, I involved the patients in a dialogue about their experiences of participating in SDM while being hospitalized. This dialogue took place in accordance with Gadamer (2013). As I searched for a deeper understanding of the meaning of SDM through dialogue, I engaged in the conversation with the patients in order to grasp what they conveyed. The flexible and fluid nature of individual interviews made it possible for me to follow up understandings, interpretations and subjective experiences, which is of special importance in the data collection from vulnerable groups, as mental inpatients are defined (Liamputtong, 2007).

Data analysis methods
Two different analysis methods were performed in the sub-studies; qualitative content analysis (Graneheim et al., 2017;Graneheim & Lundman, 2004) and thematic interpretive analysis (Braun & Clarke, 2006). Both the qualitative content analysis and the thematic interpretive analysis were conducted inductively, strongly driven by the data themselves without a specific theoretical interest (Braun & Clarke, 2006;Graneheim et al., 2017).

Qualitative content analysis (Papers I and II)
A qualitative content analysis was conducted for organizing the data in the two first sub-studies (Papers I and II) by following the steps of Graneheim and Lundman (2004).
Qualitative content analysis is a method of describing the meaning of qualitative data material systematically. It focuses on context and the phenomena, and emphasizes the identification of similarities and differences within and between codes and categories. This method allows for analysis on different levels of abstraction and interpretation by dealing with manifested as well as latent content in a text. What the text says, the manifest content, is often presented in categories, while the expressions of the latent content is presented in themes (Graneheim et al., 2017;Graneheim & Lundman, 2004).
This analysis method is systematic in that all data related to the research question were taken into account, certain steps were followed throughout the analysis process and the coding was checked for consistency. The coding was modified to fit the data material in order to secure trustworthiness. Through classifying distinct information into a category, it was considered under a more general concept. The qualitative content analysis contributed to developing a deeper understanding of the researched phenomena (Schreier, 2012).

Thematic interpretive analysis (Paper III)
The analysis of the third sub-study was performed using thematic interpretive analysis, guided by Braun & Clark's (2006) phases of analysis.
A thematic analysis is suitable for almost all kinds of qualitative data and does not require linking to a certain theoretical framework. Being transparent, Braun and Clarke (2006) point to the importance of clarifying the researcher's theoretical position. Applying a hermeneutic study, I make explicit that I conducted a thematic interpretive analysis.
Thematic interpretive analysis is a method of recognizing and interpreting various aspects of the researched phenomena within the data, labelling themes and reporting these. It is a method for reflecting on the experiences, meanings and reality of participants, as well as illuminating the surface of reality. This analysis involves a recursive process of six phases, with a movement back and forth throughout the phases. The research question drove the analysis of the data and involved searching across the entire data set to discover patterns of meaning related to it. The analysis needed interpretation, which required me to be grounded in, and simultaneously go beyond the surface of the data (Braun & Clarke, 2006). Thematic interpretive analysis helped me to reflect on the understandings which were taken for granted and to unravel the surface of these realities in order to gain a deeper understanding of the meaning of SDM (Ho, Chiang, & Leung, 2017).

Methodological considerations
A hermeneutic approach was assessed to be the most appropriate method of answering this study's research questions. However, this study represents one angle of understanding of the meaning of SDM in mental care. Though the findings in this study are adequate, other understandings are possible (Gadamer, 2013).
Quality in qualitative research is described to be both descriptively precise and clear, and interpretively creative and rich (Polit & Beck, 2010). Various initiatives were taken throughout the study in order to ensure trustworthiness. Important aspects regarding the research are reported according to the COREQ checklist (Tong, Sainsbury, & Craig, 2007) in order to ensure high quality (Appendix 4). However, methodological strengths and limitations exist and must be taken into consideration when assessing quality. This section will critically reflect on methodological issues which are of significance for the quality of this study.
There should be a red thread between the study's research questions, the context, the participants and the methods for data collection and analysis securing that the results as a whole reflect what each part in the study intends to convey. All parts should be reflexive, letting the readers assess the information provided. Trustworthiness in research is crucial and concerns credibility, transferability, dependability, confirmability and authenticity. These terms are chosen to discuss the trustworthiness of this study in the following sections (Polit & Beck, 2010).

Credibility
Credibility refers to the consistency of the data and the interpretations thereof. The study must be performed in a way that improves the believability of the results, which should clearly mirror the data, and be carried out in a way that validates external credibility (Polit & Beck, 2010).
A purposive sampling was conducted in order to find participants possessing a wide range of in-depth experiences (Malterud et al., 2016), able to mirror the various facets of SDM in mental care. The included MHCP participants represented three different wards with different ward cultures, practices and considerations, and their reflections gave rise to a deeper understanding of issues related to SDM in the context of mental care. However, the participants represented only one community mental health centre in Norway. It is possible that the results would have been different had participants been recruited from various hospitals, other parts of Norway or from other countries.
Purposive sampling was conducted in the recruitment of patient participants as well. The MHCPs participants were asked to identify key participants with mental health in-patient experience who would be appropriate for this study. The use of snowball sampling enabled us to find patients with specific experience matching our study targets, who wanted to attend individual research interviews (Polit & Beck, 2010). However, the MHCP participants used their power to select which patients to invite to participate. They may have avoided inviting some patients to participate in order to protect them against harm rather than safeguarding their opportunity to participate in research (Carlsson, Blomqvist, & Jormfeldt, 2017). The results could have been different if other patients had received an invitation to participate.
Everything the participants said during the interviews was transcribed and included in the analysis process. Quotations were used in order to give the reader the opportunity to assess the credibility of the interpretations. I read the text a number of times in order to grasp its meaning and the interpretations were reflected upon and compared by my supervisors. Preliminary results were given to the reference group, as well as presented in various research groups in order for them to assess the quality and give feedback. In this way the results were validated internally and externally.

Transferability
Transferability refers to whether or not the results of the study can be transferred to other similar contexts or are applicable to other groups (Polit & Beck, 2010). I have made considerable effort to provide enough descriptive data in order to facilitate the readers' assessment of the applicability of this study's results to other settings. Yet, it is out of my control how the reader interprets the results and judges the applicability to their own practice.

Dependability
Dependability refers to the constancy of the data over time and in various situations (Polit & Beck, 2010). Ensuring both that all topics in the interview guides were covered, and that the data collection with the MHCP participants was carried out over ten sessions, gave constancy of the data. Yet, the fact that the data collection took the form of dialogues and that the follow-up questions were ad-hoc, meant that the data will be difficult to duplicate. However, I have administered as well as conducted all parts throughout this study, in collaboration with my supervisors. This stability made it possible to safeguard constancy in all parts of the study. The consistency between the parts and the whole throughout the interpretations was found to facilitate dependability in this study (Gadamer, 2013).

Authenticity
Authenticity refers to the researchers' faithfulness in showing various realities. In this study I have made determined effort to capture the nuances in the data material, describing the participants' various experiences and reality, which facilitate the readers' improved understanding of the lives being represented (Polit & Beck, 2010).
Securing authenticity, I was involved in the multistage focus group interviews with clinical supervision sessions as a researcher. I chose not to have the role of clinical supervisor so that I could more easily take the meta-perspective of what was spoken in the focus group interviews with clinical supervision sessions. The main academic supervisor and coresearcher in this study (KR) had the role of clinical supervisor, guiding the participants through the clinical supervision sessions in the multistage focus group interviews. Together with the clinical supervisor (KR) we critically reflected upon our roles and the content of the group reflections before and after each focus group interview with clinical supervision session. This was important in order to maintain the conciseness and focus of our roles, whether in any way we affected the participants, the quality of the multistage focus group interviews with clinical supervision sessions, and the research. It was important that we had the necessary skills required (Aase & Fossåskaret, 2014) to lead the clinical supervision group. We are both educated clinical supervisors and have broad experience as clinical supervisors. It was therefore not a contrived experiment, but a natural clinical supervision situation where the studied phenomenon became activated in real life.
Possessing different roles in the multistage focus group interviews with clinical supervision sessions, the participants had to be and were all wellinformed about our roles and our intentions when conducting the clinical supervision sessions. It was important to be aware of the role expectations the participants had of us, as well as of their own role and the setting in which they were positioned. The participants were supposed to respond as clinical supervisees and reflect upon the chosen theme in another way than if they were seen as research participants sharing information about the focused theme (Aase & Fossåskaret, 2014;Fangen, 2010). The participants were well-informed about the clinical supervisors' and my role in the multistage focus group interviews with clinical supervision sessions, as well as their own role. This data collection led us close to the practice field, securing authenticity in the research.
This study is limited to include patients and MHCPs. If the patients' next of kin, psychiatrists, psychologists or unskilled employees had participated, other important nuances could have been included.

Confirmability
Confirmability refers to the findings' derived from the text without being controlled by the researchers' pre-understanding, allowing congruence of the meaning between two or more autonomous people (Polit & Beck, 2010). Being aware of own pre-understanding and being self-reflective and reflexive during all parts of the study has been crucial. Doing so, it was necessary to cooperate with the co-researchers, the reference group and research groups which were not closely involved. Balancing between proximity and distance was necessary to safeguard a deep insight into practice, simultaneously as the research was not based on subjective constructions. Doing so, the participants' voices were hopefully grasped and reflected in the findings and expectantly the interpretations have been conducted in accordance with the participants' original meaning.
Possessing different roles in the multistage focus group interviews/clinical supervision sessions challenged the data collection not to be controlled by the researchers' pre-understanding. We constantly had to be conscious of how our own involvement in the data collection may have had an impact on the research process (Aase & Fossåskaret, 2014;Fangen, 2010).

Ethical considerations
Research ethics refer to standards and values that are complex and support the regulation and constitution of scientific activity. Ethical guidelines serve as a tool to help researchers take relevant factors into account and weigh important issues against each other in order to protect both human and scientific interests in the research work (World Medical Association, 2008). This study has been carried out in accordance with guidelines for research ethics (World Medical Association, 2008) and has been approved by the Regional Ethics Committee of Western Norway (2015/1721) (Appendix 5). In the following section, the ethical considerations concerning this study will be outlined.
Considering that mental health in-patients consented to participate in this study, their ability to accurately understand the benefits and risks of participation and their ability to make informed decisions required great care (Polit & Beck, 2010). This project safeguarded the participants by defining in the inclusion criteria for patients´ participation that they must be limited to using only Norwegian language and that they must have an age of over 20 years. In addition, the MHCPs from the patients' ward, who knew them well, informed and invited patients whom they assessed as able to understand the benefits and risks of participation and to have the ability to give informed consent to participate.
Both the patients and the MHCPs who consented to participate in this study were contacted by the researcher, who gave thorough information about the study. The researcher also provided practical information about participation and the study in general. The information was given verbally and in writing. The written information they received is attached in Appendix 6 and 7. Feedback from both the patients and the MHCPs made it clear that they had understood the information. There was no compensation or payment offered for participating in this research project in order to prevent them from feeling any obligation or pressure to participate (World Medical Association, 2008).
If the participants voluntarily agreed to participate, they were asked to sign a consent form. They were informed that at any time and without giving any reason they could withdraw their consent to participate in the study without any negative consequences (World Medical Association, 2008).
Mentally ill in-patients are defined as particularly vulnerable participants (Liamputtong, 2007;Polit & Beck, 2010). Excluding vulnerable patients because they are mentally ill will hinder SDM and this research could not have been completed without including these patients in the study. Vulnerable participants can be sensitive in different ways and some issues can serve as triggers to their vulnerability. As a professional and experienced MHCP, I could address these risks and meet the patient participants in a professional and safe manner. The participants were asked to share their experiences that felt comfortable and right to them. At the end of the individual interviews all the patient participants were asked how they experienced the interview. Their feedback was positive.
They said that it was a pleasure for them to share their experiences and they were glad they had been given the opportunity to participate as informants in this research project. The information about the further work with the taped interview was repeated in order to give the patient participants the opportunity to withdraw if they were not comfortable with it (World Medical Association, 2008). No participants withdrew after the interview.
Patient participants were given the opportunity to take part in a followup conversation with their therapists if necessary, in order to safeguard access to professional help with thoughts or difficult memories that may have been trigged after the interview. In this way we ensured that the vulnerable patient participants were not left with any harm linked to the interview (Liamputtong, 2007).
The MHCP participants were engaged in the data collection as clinical supervisees. This made them involved in the research in another way than if they were engaged only as informants answering a set of questions. Their role as clinical supervisees made them exposed in the way that they also engaged themselves emotionally by sharing personal experiences in the group. In order to safeguard the MHCP participants, a guarantee was given by the researcher that their responses would remain anonymous. They also had an internal agreement not to share the information given in the group with any other person. In addition, the MHCP participants were informed that they could withdraw their consent at any time without any negative consequences. The researcher did not ask for sensitive information during the focus group interviews (World Medical Association, 2008). These ethical principles protected and respected the MHCP participants' right to self-determination and autonomy, as well as their integrity and dignity (Polit & Beck, 2010).
All data, both recorded interviews and written documents, were treated confidentially, kept securely locked away and only used for research purposes. A guarantee was given to all participants that their responses would remain anonymous (World Medical Association, 2008).

Findings
This section presents the main findings (Table 3) from the three substudies related to the aims and research questions (Papers I -III). These findings create a basis for further interpretation and discussion.

Patients' experiences of participating actively in shared decision-making in mental care (Paper I)
The aim of this sub-study (Paper I) was to describe patient participation in SDM in the context of indoor mental care. The research question was what are patients´ experiences of participating in SDM?
The analysis revealed the main theme thriving in relation to participating actively in a complementary ensemble of care. A complementary ensemble of care means that all those involved in the patients' care work together in companionship. The patients experienced being important and included when participating in SDM, regardless of mental ill-health, and the process of participation contributed to growth and restored mental health. The patients felt safe when the MHCPs were their companions and were complementary to their own participation in SDM, which was a support for them when working to improve their mental health. In situations where the patients were not able to make rational choices, they felt safe knowing that the MHCPs would take care of them by treating them according to their best interests and safeguarding their values. When the participants were able to make rational choices, they wanted to participate actively in order to collaborate with their MHCPs to find good solutions and to make appropriate decisions. They experienced that their contribution of participating actively was necessary for making a complementary ensemble of their care.
The first theme having mental space to discover my way forward reflected the patients' wish to find out what worked or not in their process of restoring their mental health. They wanted to learn from life experiences without the MHCPs deciding for them. On their way to discovering a new way forward, they desired to feel encouraged by supportive MHCPs. To discover the way forward the patients needed to make use of flexible frames in order to find a solution suitable for them and their situation.
The theme being in a position to express my case described the patients' desire to express what was important to them. They wanted to influence the decision-making, to be listened and responded to when participating by using their own current resources, which could vary throughout their care. Feeling trustingly included was essential for participating actively, which required that the MHCPs were present and took the initiative to include them in their care. Sensing an empowering ward atmosphere where patients' autonomy and value were appreciated, was an important issue for the patients to participate actively in SDM.

Shared decision-making -Balancing between power and responsibility as mental healthcare professionals in a therapeutic milieu (Paper II)
The aim of this sub-study (Paper II) was to explore how MHCPs describe SDM in a therapeutic milieu as expressed through clinical supervision.

The research question was what are prerequisites for MHCPs to practise SDM in a therapeutic milieu?
The theme practising SDM when balancing between power and responsibility to form safe care described the MHCPs' experiences of being in a dynamic process together with their patients. They should safeguard patients' participation and sense of control at the same time as ensuring good recovery conditions for their patients. In order to share the power they possessed with their patients in a way that improved their patients' mental health, they continuously had to assess their patients' ability to take responsibility for their own choices and balance it with their responsibility for promoting safe care. The balance between power and responsibility should always be in the patients' best interests.
The category internalizing the MHCPs' attributes explained the importance of possessing a high level of professional skills and being attentive to patients. Making use of professional skills was important in order to practise a balance between power and responsibility in SDM. It implied possessing professional knowledge, in addition to interpersonal competence, which involved attitudes, values and ways of being. The interpersonal competence was experienced as challenging to improve because it was considered as mostly based on unconscious features. By being attentive to the patient, the MHCPs experienced that they should encounter their patients with a dialogue in order to understand the patients, thus intervene in accordance with the patients' benefit. The MHCPs conveyed that reflecting together on challenging situations was necessary in order to understand various aspects of a specific situation, the patients and oneself. They experienced that a well-reflected situation would lead to improving professional skills, which in turn would facilitate practising SDM.
The category facilitating patient participation described that the MHCPs considered it their responsibility to take the initiative to facilitate patient participation. Yet, they found it challenging to assess in what ways and to what extent each patient was able to participate in their own care. The MHCPs experienced trustworthiness, honesty, and always showing respect for the patients' feelings as essential for stimulating patient involvement. Being aware of their own emotions, thoughts and processing was found to be necessary in order to uphold a trusting relationship with the patients throughout mental care. The MHCPs experienced that patient participation varied and it was important to acknowledge the patients' process of participation in order to balance between power and responsibility. Facilitating patient participation required MHCPs to possess insight and a high level of expertise to be capable of meeting their patients' personal needs.
The category creating a culture of trust was described as essential in order to uphold a balance between power and responsibility to form safe care. Applying guidelines, procedures and a structure of the ward in a person-centered way was described as challenging because they experienced that the procedures and structure of the ward could hinder SDM. The MHCPs wanted to use procedures and checklists as guidelines, but safeguarding a person-centered practice they needed flexible frames to do it differently if they found it beneficial for the patients. Doing so, they had to be confident in their own assessment, and needed supporting and trusting expectations from their colleagues.

Being in a space of sharing decision-making for dignified mental care (Paper III)
The aim of this sub-study (Paper III) was to interpret the meaning of SDM in mental care as perceived by patients and MHCPs. The research question was what is the meaning of SDM in mental care?
The overall theme being in a space of sharing decision-making for dignified mental care expressed the patients' and the MHCPs' continued search for an expansion of the patients' room for action and dignity. The patients' autonomy needed to be balanced in line with their mental health and capacity for taking responsibility in decision-making in order to form dignified care. The MHCPs' respectful and caring relationship with their patients affected dignified care.
The first theme engaging in a mental room of values and knowledge reflected the moments when the patients and the MHCPs were relating with engagement. The patients moved between involvement and being cared for throughout their care and the MCHP's felt responsible for taking care of their patients at all times. They wanted to cooperate and contribute with their own professionality for the individual patients' benefit. The moments when the patients neither understood nor chose in their own best interests were especially challenging for the MHCPs in order to safeguard dignified care.
The theme relating in a process of awareness and comprehension described how the patients and MHCPs continually should search for awareness and comprehension. The patients longed for information and to be understood at the same time as the MCHPs desired to understand and appreciated their patients' engagement. If the MHCPs succeeded in relating to their patients like partners, showing them that they wanted to understand more, the patients were more likely to show them trust. Being too occupied with finding the "right" practice, following guidelines, and even the MHCPs' own pre-understanding could hinder the process of awareness and comprehension in care. Putting their own opinions and guidelines at stake and being willing to open up to new perspectives were found necessary when relating in a process of awareness and comprehension.
The theme responding anchored in acknowledgement explained the patients' search for confirmation and for being affirmed. The patients felt acknowledged and valued when the MHCPs responded to their message. It sometimes took courage for the MHCPs to respond because they were afraid of not being perceived as professionals when the patients' wishes did not match the guidelines or their colleagues' opinions of best practice. The MHCPs experienced that they sometimes had to act against the patients' will in order to provide safe care in a dignified manner. When the MHCPs responded to their patients in order to support their worth they felt affirmed, and compulsion sometimes seemed to be necessary for providing dignified care. Responses anchored in acknowledgement appeared to form dignified care.

Overall theme
Being in a space of sharing decisionmaking for dignified mental care

Theme 1
Having mental space to discover my way forward

Category 1
Internalizing the mental healthcare professionals' attributes

Theme 1
Engaging in a mental room of values and knowledge

Theme 2
Being in a position to express my case

Category 2
Facilitating patient participation

Theme 2
Relating in a process of awareness and comprehension

Category 3
Creating a culture of trust

Theme 3
Responding anchored in acknowledgement 5 Interpretation and discussion towards a comprehensive understanding The overall aim of this study was to develop a deeper understanding of the meaning of SDM in mental care. This section contains interpretations and discussions towards a comprehensive understanding of the explored phenomenon. The findings from the three inductive empirical substudies describe different perspectives of SDM. In this section they will be synthesised, deductively interpreted and discussed as a whole, and eventually an abductive interpretation of the new whole will be conducted towards a comprehensive understanding (Gadamer, 2013). An overview over the three stages in the interpretational process is presented in Table 4. Table 4 -Overview over the three stages in the interpretational process towards a comprehensive understanding of SDM in mental care Stage I:

Inductive
SDM contributes to patients' thriving and requires the MHCPs balancing between power and responsibility for dignified mental care.

Stage II:
Deductive SDM -a healing process and an integral part of mental care.
SDM -a process of understanding.
Stage III:

Abductive
The meaning of SDM is being partners with an existential responsibility.

Shared decision-making contributes to patients' thriving and requires the MHCPs balancing between power and responsibility for dignified mental care
The inductive stage consists of a synthesis of the findings from the different perspectives in the empirical sub-studies (Papers I-III) in order to grasp a sense of the whole.
Findings from the inductive stage showed that the patients experienced being important and included when participating in SDM, and the process contributed to thriving in relation to participating actively in a complementary ensemble of care. They felt safe when the MHCPs were companions and were complementary to their own participation in SDM. SDM gave them the opportunity to find out what worked or not in the process of restoring their mental health. They could learn from their own life experiences, feel encouraged by supportive MHCPs and make use of flexible frames. SDM also gave the patients the opportunity of being in a position to express their case. They could participate by using their own current resources, whilst feeling trustingly included and having the sense of an empowering ward atmosphere (Paper I).
The patients move between involvement and being cared for throughout their care, and the MCHP's are responsible for taking care of their patients at all times. They should cooperate and contribute with their own professionality for the individual patients' benefit. SDM implies the MHCPs' being in a dynamic process together with their patients. They have to balance between power and responsibility as they safeguard patients' participation and sense of control, at the same time as they ensure good conditions for their patients to restore their mental health. Practising SDM the MHCPs should internalize their attributes by possessing professional knowledge, in addition to interpersonal competence, involving attitudes, values and ways of being, and they should be attentive to their patients (Papers II and III).
Both patients and MHCPs embrace SDM but find it challenging to practise (Papers I and II). MHCPs should take the initiative to facilitate patient participation in SDM. Yet, they find it challenging to assess in what way and to what extent each patient is able to participate in their own care. Facilitating patient participation requires MHCPs to possess insight and a high level of expertise to be capable of meeting their patients' personal needs (Papers II and III).
A trusting relationship between the patients and the MHCPs is necessary in order to practise SDM. A basis for a trusting relationship is the MHCPs being aware of their own emotions and thoughts and processing these. If the MHCPs succeed in relating to their patients like partners, showing them that they want to understand more, the patients are more likely to show them trust. A culture of trust is essential in order to uphold a balance between power and responsibility, thus practising SDM in mental care (Papers II and III).
Practising SDM the MHCPs should acknowledge their patients' process of participation. The patients feel acknowledged and valued when the MHCPs respond to their message. Responses anchored in acknowledgement appear to form dignified care. It sometimes takes courage for the MHCPs to respond because they may be afraid of not being perceived as professionals when the patients' wishes do not match the guidelines or their colleagues' opinions of best practice (Papers I-III).
Applying guidelines, procedures and structure of the ward in a personcentered way may be challenging as the MHCPs experience that the procedures and structure of the ward could hinder SDM. In order to safeguard a person-centered practice, the MHCPs need flexible frames to act differently if they find it beneficial for the patients. Doing so, they must be confident in their own assessment and receive support and trust from their colleagues. Being too occupied with finding the "right" practice, following guidelines, and even the MHCPs' own pre-understanding could hinder the process of awareness and comprehension in care. Putting their own opinions and guidelines at stake and being willing to open up to new perspectives is necessary for practising SDM (Paper III).
A well-reflected situation would improve MHCPs' professional skills, which in turn would facilitate practising SDM (Papers II and III).
Both the patients and the MHCPs experienced SDM as being in a space of sharing decision-making for dignified mental care. The patients' autonomy needed to be balanced in line with their mental health and their capacity for taking responsibility in decision-making in order to form dignified care. The MHCPs' respectful and caring relationship with their patients affected dignified care (Paper III).

Shared decision-making -a healing process and an integral part of mental care
In the deductive stage (Sections 5.2 and 5.3), findings from the inductive interpreted sub-studies will be interpreted and discussed in light of the theoretical background (Section 2) and theories linked to the focused area. The deductive interpretation will assess this study's findings together with existing knowledge of SDM in mental care, mainly based on the headings in the theoretical background; Shared decision-makingan approach in mental care and Changing attitudes towards the theory and practice of shared decision-making. The aim is to develop a deeper understanding of the meaning of SDM in mental care (Graneheim et al., 2017).
The heading in the theoretical background SDM -an approach in mental care is the theoretical basis for this section, together with theory of interpersonal relations in nursing (Peplau, 1991) and self-determination theory (Deci & Ryan, 2008). Davidson et al. (2017) claim that the purpose of mental care is to empower patients to take control and live self-determined lives regardless of severe mental ill-health. Autonomy and self-determination is a human need and expanding these competencies is supposed to give rise to restored mental health (Deci & Ryan, 2008). The current study investigated SDM as a phenomenon in mental care and from the patients' perspective it illuminated that SDM is experienced as thriving in relation to participating actively in a complementary ensemble of care. In such a process a mental space to discover ones' way forward and being in a position to express ones' case is essential (Paper I). This points to SDM being understood as an interpersonal healing process. Peplau (1991) describes a human relationship between a person who needs health services and a MHCP to be caring. SDM is described to be an approach for planning and carrying out care (Davidson et al., 2017). Mental care is concerned with ways for facilitating people to stay healthy, and technical procedures alone cannot help the patients to mature (Peplau, 1991). Mental care is first of all a process, which means that its ongoing and goal-directed character demands certain steps and actions to take place between the patients and the MHCPs. Participation between these parts is necessary, and the interaction between them should be focused towards understanding the patients' difficulties and identifying their needs (Peplau, 1991). This is in line with Castillo and Ramon (2017) who describe the patients' process of restoring their mental health to be a relational and dynamic journey. Due to the patients' mental challenges they often call for a level of support, but no others can ever possess the same comprehensive understanding of their individual and personal needs and desires as they do (Paper I). The patients' active participation in SDM is therefore essential (Davidson et al., 2017) in mental care. Deci and Ryan (2008) describe the type of a patient's motivation as essential for growth. Making decisions based on their own inner values and ideals promotes autonomous motivation, and will encourage a volition for action. In contrast, if a decision is guided or regulated by MHCPs, a controlled motivation will be promoted and the person will feel obligated to think, feel or behave in certain ways. An autonomous motivation is important to improve mental health and maintain change towards beneficial choices of action. A controlled motivation is more likely to promote rigid functioning and decreased well-being (Deci & Ryan, 2008). The MHCPs' role in SDM should be to assist their patients in growing and becoming more skilled in coping with their difficulties (Papers II and III). The quality of SDM and the patients' process of growth and restored mental health depend on how well the MHCPs can facilitate their patients' active participation in SDM (Peplau, 1991).
Patients experience SDM as having the mental space to discover their way forward (Paper I). Mental care is about facilitating patients to deal with mental ill-health in the context of their life (Davidson et al., 2017). Patients cannot be helped to experience health without their own real-life situations (Paper I). The MHCPs should assist their patients in expanding their understanding of their actual mental health challenge (Paper II). Deci and Ryan (2008) point to the importance of facilitating the person's autonomy by providing them with competence in order to understand and be conscious of the consequences and the values an autonomous decision may have. SDM may contribute to new experiences (Paper I) which will promote the patients' maturing processes. When the patients learn how to cope with their mental ill-health through experimenting with various possibilities to find a way through their life, the experience will take them another step towards greater maturity in dealing with their mental challenges (Peplau, 1991).
SDM integrates the patients' experiential knowledge and the professional knowledge for conducting better decisions in mental care (James & Quirk, 2017;Ramon et al., 2017). This provides the patients with a position from which to express their case (Paper I). The patients are central and the key decision-makers in their process of mental growth. Therefore, they need to take an active role in their unique position, learning about taking responsibility and dealing with all the challenges that a life with mental ill-health entails (Davidson et al., 2017). MHCPs should be their patients' partners by supporting, encouraging and guiding them to take their position to express their case (Papers I and II; Davidson et al., 2017). Deci and Ryan (2008) argue that feeling involved will facilitate the patients becoming autonomous and participating actively based on their own values and ideals. A MHCP patient-relationship should be developed to provide concrete experiences of reducing feelings of helplessness in patients and to displace feelings of powerlessness and helplessness with feelings of autonomy and dignity (Paper III). This facilitates growth of the patients' personality, which is supposed to be healing (Peplau, 1991).
The patients thrive when participating actively in a complementary ensemble of care (Paper I). A complementary ensemble of care involves a personal relationship where the patients and the MHCPs get to know each other well enough to identify the patients' problem in a co-operative way and to work together to find out what each is seeking in the relationship. The process of SDM is supposed to be healing when the patients and the MHCPs get to know and respect each other as different but equals who share the decision-making in the patients' life (Peplau, 1991).
Up to now, research has described SDM to be an approach for planning and carrying out care (Davidson et al., 2017) and for making better decisions (James & Quirk, 2017;Ramon et al., 2017). Findings in this study illuminate that the SDM process contributes to growth and restored mental health (Papers I and III) which is understood to be a healing process in mental care. This study's findings viewed in the light of theory develop a deeper understanding of the researched phenomenon: SDM is understood to be a healing process and an integral part of mental care where the patients' autonomy and support towards self-determination is central.

Shared decision-making -a process of understanding
The deductive stage continues in this section. The theoretical basis is the heading in the theoretical background Changing attitudes towards the theory and practice of shared decision-making, mainly together with the theory of Lassenius (2014) and Martinsen and Eriksson (2009). Alguera-Lara et al. (2017) found that shared understanding, empathy, compromise and partnership were fundamental to practising SDM. This requires that the MHCPs are in a process of understanding their patients' personal requests, difficulties and opportunities (Peplau, 1991). This study finds that MHCPs practise SDM when balancing between power and responsibility to form safe care (Paper II), which requires them to possess a high level of expertise and insight in order to meet their patients' personal needs (Papers II and III). Providing a position in which the patients can express their case and participate actively in SDM (Paper I) depends on the MHCPs' ability to listen and be open to new understanding. Every patient is unique and deserves the focus in the encounter with the MHCPs. It is necessary to understand the patients' life world in order to help them in their process of restoring their mental health. It is the MHCPs' task to illuminate what is hidden, to grasp the essence of each patient's life world in order to move towards a shared understanding (Lassenius, 2014).
If the MHCPs show their patients that they want to understand more, SDM is more likely to succeed (Paper II). The theory describes that MHCPs often do not try to understand their patients and refuse to consider the patients' preference because it is not in line with the best clinical choice (Castillo & Ramon, 2017;Ramon et al., 2017). MHCPs sometimes hold back information  and some MHCPs consider their patients incompetent to make their own decisions (Davidson et al., 2017). Some MHCPs are also concerned that SDM will threaten their professional responsibility (Kaminskiy et al., 2017). It is likely that this may be why the patients experience their opinions to be less valued than the MHCPs' and that they are struggling to be seen or heard as competent and equal in the encounters with their MHCPs (Kaminskiy et al., 2017). Martinsen and Eriksson (2009) describe such an understanding to be in line with a medical paradigm, which is based on medical knowledge, derived from statistics and randomised controlled trials. The theory describes a medical dominance in mental care, which seems to be in conflict with SDM (Kaminskiy et al., 2017). The patients feel controlled by their MHCPs as they often experience being informed rather than involved about choices and the MHCPs prefer to make the decisions themselves (Castillo & Ramon, 2017;Davidson et al., 2017). The apparent emphasis on generalizations regarding effective treatment, which is best known by the professionals, usually the physicians, gives rise to procedures and rules that are to be followed by all patients (Martinsen & Eriksson, 2009). MHCPs find it challenging to respond to their patients when the patients' wishes do not match the guidelines (Papers I-III) because they may be afraid of not being perceived as professionals (Paper II). A paternalistic decision-making style based solely on the MHCPs' professional competence and attitudes will hinder SDM (Castillo & Ramon, 2017). Letting the medical paradigm guide the understanding of mental care may be destructive for the individual patients' care (Martinsen & Eriksson, 2009).
Practising SDM requires that the MHCPs know what SDM is and that they are able to distinguish it from their existing practices . The traditional mental care should be questioned continually (Davidson et al., 2017) in order to be open to the understanding of each patient to support them in restoring their mental health (Lassenius, 2014).
To understand more, it is necessary to open up to a new and different way of seeing and understanding (Martinsen & Eriksson, 2009). The patients expressed a wish for mental space to discover their way forward (Paper I). They need to learn to deal with the challenges that their life with mental ill-health entails (Davidson et al., 2017), which involves forming new understanding. The discovery of their way forward is a personal development and therefore the focus in SDM should be on the process, rather than a compromise on a final decision (James & Quirk, 2017). Mental care may fail if the MHCPs believe that they can understand and explain their patients solely based on their own professional competence and they try to transfer this understanding to their patients, expecting their patients to implement it into their own lives. It is not possible to understand anything from just one dimension (Frankl, 2014). Both the patients and the MHCPs need each other to make a new and shared understanding (Lassenius, 2014). The patients need their MHCPs to understand their life-world in order to support them in the process of making new and more mature understandings.
All understanding is guided by pre-understanding. The MHCPs' understanding in the encounter with known or unknown patients, in new or well-known situations will always be a result of the existing preunderstanding (Gadamer, 2013). If the patients are understood out of the pre-understanding of for instance a medical diagnosis, the essence in the patients' situation will be lost and an understanding of the patients' lifeworld will probably fail (Lassenius, 2014). MHCPs putting their own opinions and guidelines on hold and being willing to open up to new perspectives is necessary for practising SDM (Lassenius, 2014;Paper III). The quality of mental care depends on the MHCPs' ability to understand, which means that they have to step out of their own preunderstanding, question it and open up to what is different and unknown (Martinsen & Eriksson, 2009). This will not only provide for a greater understanding, but a transformed understanding. A new understanding of each unique patient may emerge in a new way (Lassenius, 2014).
SDM requires interventions beyond the traditional decision support tools and information exchange (Zisman-Ilani et al., 2017) and such a method is still lacking (Légaré et al., 2018). However, clinical supervision sessions are suggested to facilitate practising SDM . Papers II and III report that a well-reflected situation is supposed to facilitate practising SDM. Through dialogue and reflection, the MHCPs come together in wonder of how to understand each unique patient and situation in which they are involved. Wonder is about staying by an experience and exploring the uncertainty and diversity in it. The basic premise of wonder is to be open, inquiring and receptive to the core of the situation. It is in the moment of being and occurrence of creation that the phenomenon can become illuminated. The MHCPs should allow themselves to be touched, lift themselves above their own personal feelings and opinions through listening to the wonder. By allowing the focused phenomena to reveal itself in wonder, a new understanding will occur and a new meaning will emerge (Hansen, 2014). Ramon et al. (2017) claim that training to support SDM should be advocated continually, which implies that the MHCPs constantly should seek to reach a shared understanding with their patients. There is no understanding that would constitute absolute knowledge. With every new understanding, a new question is raised (Gadamer, 1996). SDM requires attitudes and culture in mental care to reach out for being in a process of understanding. This study's findings viewed in the light of theory develop a deeper understanding of the researched phenomenon: SDM is understood to be a process of understanding.

The meaning of shared decision-making is being partners with an existential responsibility
The abductive stage of the interpretation was performed from the inductive stage through the deductive stage, guided by my preunderstanding, which was developing throughout the interpretation process. As caring science seeks an understanding of human beings in relation to existential conditions (Martinsen & Eriksson, 2009), existential philosophy (Frankl, 2014;Levinas, 2003;Sartre, 2007) was included as a new part of the whole in order to deepen the understanding of the researched phenomenon. A fusion of horizons occurred by the development of a pattern connecting the previous interpretations into a comprehensive understanding of the meaning of SDM in mental care (Gadamer, 2013;Råholm, 2014).
To date, the interpretation process has developed my pre-understanding of the meaning of SDM to being in a space of sharing decision-making for dignified mental care. I understand this space to be a community where the one in need of care and the carer are connected with a joint focus on the one in need of care's mental health. The one in need of care's urge to be understood and the carer's desire to understand, draw them towards each other into a unity. Including philosophy in this understanding, this unity can be understood to constitute their existential responsibility in SDM (Frankl, 2014;Levinas, 2003;Sartre, 2007).
Responsibility in care may be understood out of the formal principles and professional guidelines to be followed or by the expectations created in a personal encounter (Sjögren, 2012). Sartre (2007) claims that human beings are characterised by an existence that goes before essence, with subjectivity as a starting point. Existential responsibility involves relating with the other and placing oneself at the disposal of the other (Sjögren, 2012). When a person in need of care and a carer meet, they both meet someone other than themselves. Levinas (2003) claims that it is in this meeting the responsibility appears: The face of the other expresses an appeal to the other, which calls the other to be good, which is where the existential responsibility occurs. SDM involves a social interaction between the person in need of care and the carer and brings an existential responsibility. Levinas (2003) describes relating as a meeting with someone that is totally different from ourselves. The other is the one I can never understand, in the sense of understanding by general terms. The face of the other cannot be generalized as a representative of my fellow human beings. The other is always a unique and determined individual person, totally different from me. This view offers a special meaning to the social interaction between the person in need of care and the carer. The existential responsibility arising in the meeting is primarily a response to the appeal with which the individual person meets the other, allowing oneself to be touched by the other. Being conscious of the existential responsibility in SDM, the carer will continually search to understand the one in need of care. The needs of the one in care should always be at the centre, not one's own needs. It is the carer's existential responsibility when engaging with the other person to accept the appeal from the other's face and respond by making a difference in the other's life, for the other's good.
Frankl (2014) claims that a human being's life means taking the existential responsibility to find a true answer to its difficulties and to search for the meaning of life. As human beings we are responsible for what we are, and we all need to take our responsibility in order to be defined as human beings. Sartre (2007) states that we all have a duty to bear the responsibility of own actions and we must take the consequences of own choices and we all choose our own selves. This may be the core of why it is so important to participate actively when being in need of mental care. If others make the decisions without the other being able to participate, they simultaneously hinder them from taking some of their existential responsibility and some of the other's own being will become lost. Participating actively in one's own care means taking the responsibility for living one own's life meaningfully. Being responsible is essential for the ability to change and move forward. Frankl (2014) claims that human beings must take responsibility for what has been done, use the opportunities offered and act upon them in order to realize one's own chances and values, even in a despairing situation. SDM provides for this when the carer stands together with the one in need of care as a partner, supporting him/her in taking the existential responsibility.
Frankl (2014) asserts that the meaning of each persons' life must be discovered in the encounter with others rather than within each individual. We are all dependent on others to attain truth about ourselves.
Others are indispensable to our existence and the awareness we have of ourselves. Together with others, we can discover what we are and what others are. Therefore, it is so important that the carers take their role as partners in SDM, exploring together with the one in need of care the basis on which the decisions are to be made and together finding and choosing a decision. Sartre (2007) states that besides being responsible for ourselves, we are also responsible for choosing others. The carers must take their existential responsibility by choosing the one in need of care, being their partners and helping them attain the truth about themselves. Frankl (2014) argues that everybody has a healthy core and internal resources and the carers should enlighten the one in need of care's healthy parts and provide for them in their search for meaning and mental growth.
Frankl (2014) advises that taking an existential responsibility when caring for others, the carers should not transfer their own values to the one in need of care. They should be tolerant and recognize the other's right to trust and obey their own beliefs without agreeing with them. The one in need of care should be given the opportunity to refer to his/her own convictions. However, if the conviction is deceptive or harmful to themselves or others the carers must intervene, take responsibility for the other's responsibility and try to lead him/her to a more beneficial choice. Sartre (2007) claims that the helpers' existential responsibility is to guide the one in need of care towards comprehending themselves and recovering. Taking an existential responsibility for a person in need of care requires the carer to possess insight and wisdom in order for the one in need of care to experience thriving.
Carers possess both a formal, professional responsibility and an existential responsibility. Their professional responsibility requires them to follow certain regulations, laws, guidelines and rules, which do not always involve a deeper personal attitude and conviction (Sjögren, 2012). A hinder for SDM is that the carers may be more concerned with the procedures and guidelines to be followed, rather than the subjectivity of the one in need of care. Principles concerning the professional responsibility will dominate and the one in need of care's values and wishes may be ignored if they are not in line with the professional principles. Sartre (2007) claims that carers doing what they are supposed to do by law and guidelines safeguards the system more than protecting the dignity of those in need of care. Levinas (2003) states that this makes the ones in need of care become all the same, like an anonymous. "faceless" group of people. Taking the existential responsibility, we need to challenge what we believe in order to know about the one in need of care and unbind ourselves from general guidelines. A face-to-face relationship can modify unwanted interference and rigid generalizations and principles (Levinas, 2003). For SDM to succeed the carers have to relate and cooperate as partners together with the one in need of care. A co-operating relationship between the one in need of care and the carer will promote dignity, growth and maturation of mental health (Sartre, 2007).
Possessing an existential responsibility for the other, the carer is called to be good to the one in need of care. An unanswered question is the relationship between the carer's professional knowledge and the one in need of care's experiential knowledge of their own lives. How does the carer balance their own convictions with the one in need of care's convictions if they differ, in order to be good? According to Levinas (2003) we find ourselves standing in an insoluble dilemma in the gap between the unique individual and the common general.
This abductive stage of interpretation has illuminated the meaning of SDM in mental care to being partners with an existential responsibility. The existential responsibility constitutes the relationship between the one in need of care and the carer, and requires a response to the other, always for the other's good. Possessing the existential responsibility and acknowledging the human being is essential for the ability to change and move forward. The carer should be a partner to the one in need of care, helping them enlighten their healthy parts and providing for them in their search for meaning and mental growth.

Conclusion
A deeper understanding of the meaning of SDM in mental care was illuminated through the perspective of caring science in this thesis. From that view this thesis concludes that the meaning of shared decisionmaking in mental care is being partners with an existential responsibility. The relationship between a person in need of care and the carer constitutes the existential responsibility, which acknowledges the being in human beings and is essential for mental growth. The MHCPs should be the patients' partner and supporter throughout care.
The SDM process contributes to growth and restored mental health. It is is a healing process and an integral part of mental care, where the patients' autonomy and support towards self-determination is essential. SDM is also considered to be a process of understanding. MHCPs should constantly seek to reach a shared understanding with their patients. No understanding is final. With every new understanding, a new question is raised. SDM requires attitudes and cultures in mental care to reach out to being in a process of understanding. SDM contributes to patients' thriving and emphasises the MHCPs balance between power and responsibility for dignified mental care.
This understanding conveys that SDM is much greater than just sharing information and making decisions. SDM requires close attention to emotional and relational qualities, encompassing the existential dimensions in mental care.

Implications
Considering the findings of this study, I suggest the following in order to facilitate practising SDM in mental care and for further research.

Implications for clinical practice
Improving SDM practice requires the MHCPs to acknowledge and respond to the existential dimensions of mental care. Mental care must be understood as a process, with the patient relationship at the core. The MHCPs should follow their patients towards restored mental health by being their partners, acknowledging the patients' subjectivity in care and placing them at the core of the care. In this process it is important not to push the patients to understand what the MHCPs think is the best answer to cure their mental ill-health, but to be humble and listen to their patients as well as responding to their desires. SDM should be implemented as an integral part of mental care. This may require a cultural change in mental health wards and high-level professional skills are crucial.
Development of the MHCPs' professional skills should be given great attention. MHCPs need to be able to respond individually to each patient according to the patient's needs and expressions. Professional skills include MHCPs being able to understand their patients experience and emotions and enhance their patients' autonomous capacity while safeguarding dignified care. It is necessary that the professional skills essential for practising SDM are trained throughout the education of MHCPs. In order to safeguard the development of the MHCPs' professional skills in practice, all MHCPs should be taught and should attend clinical supervision continuously. The clinical supervision must emphasise reflections on attitudes and relational competencies, and provide space for wonder and new understanding.
The hospital managers and the managers of the wards are essential in the implementation process of SDM. It is crucial that they value SDM and understand its importance. They should take responsibility for facilitating teaching and clinical supervision for their MHCPs and that such initiatives are funded, prioritized in the time schedule and highlighted as important for the MHCPs to attend. Facilitating continuity of care is also an important issue. SDM is dependent on MHCPs knowing and following the same patients over time and the managers should organize the ward in such a way that the same MHCPs and their patients can be partners throughout the patients' hospitalization. Furthermore, it is important that the managers set a standard that values the existential responsibility as much as the formal responsibility. The MHCPs should be encouraged to safeguard their existential responsibility by being allowed to set aside formal principles and guidelines if they are not the most beneficial for the patients.
SDM challenges the clinical mental care practice to change attitudes as well as culture. This may be difficult to achieve without forcing it forward by political expectations and regulations in the law to facilitate SDM.

Implications for further research
This study has illuminated the meaning of SDM in a caring science perspective. This is a contribution to the research field, yet further research is needed. I suggest further research to focus on the following: The MHCPs dilemma of possessing both an existential and a formal, professional responsibility for practising SDM should be explored.
The implementation of SDM is needed to be investigated in an action research model, involving patients even more, together with next of kins, managers and interdisciplinary professionals, expanding the various perspectives of the understanding of SDM.
An understanding of leadership involvement in SDM should be developed, as well as the impact of the ward atmosphere on SDM.
Studies regarding clinical supervision's impact on MHCPs' attitudes to SDM should be performed.
I suggest an effect study investigating the clinical benefits of SDM, by doing a pre-and post-intervention survey.
Patient safety is a major concern in mental care and the role of SDM in patient safety in this context should be a focus in future research. Illuminating the importance of being ready to leave the group (Imagine and draw a tree) 8.
Eng: What will it take for you to be actively involved in decision making concerning your treatment?
Eng: What would you as a patient recommend that treatment in the psychiatric ward focuses on for even better patient safety?