The complexity of work expectations of staff in supported housing

ABSTRACT

This article focuses on the work conditions of health care workers in supported housing for people with severe mental health problems. It does so by exploring the workers’ experiences of their daily work situations. The article is based on data from a qualitative mental health project within a larger-sized Norwegian municipality. The findings from the study include two main themes and several subthemes that are discussed in light of institutional logic perspectives. One of the main themes is defined as “Time scheduled tasks and the quality of mental health work” with the three subthemes “The wish and need for more time,” “Lack of flexibility and changing appointments,” and “Managing daily expectations and challenges,” The other main theme is defined as “The implementation of skill training activities” with the two subthemes “The normative expectation of and within skill training” and “Managing skill working relationships,” The findings highlight how health care staff are placed in complex work situations by having to manage different and partly contradictory expectations based on the organization of the health and welfare system and supported housing, the organization and implementation of their daily work together with the residents, and their own professional values.

KEYWORDS:

• Mental health
• staff
• supported housing
• institutional logics
• qualitative research

Introduction

Through the rise of the civil rights movement and deinstitutionalization processes, mental health services in the Western world have undergone huge changes over the last decades, implying a transition to more community-based care and housing for people with mental health problems (Fakhoury & Priebe, 2002; Olson, 2006; Pedersen & Kolstad, 2009). As part of this transition, supported housing with empowerment and community integration as underlying principles has emerged as an internationally acknowledged model of combined housing and support (Carling & Curtis, 1997; Hogan & Carling, 1992). However, people with severe mental health problems represent a group with a huge variation in terms of their need for support, which implies challenges in matching users’ needs and wishes to adequate housing and services (Jarbrink, Hallam, & Knapp, 2001; O’Malley & Croucher, 2005). There are no national diagnosis-based population surveys in Norway regarding severe mental health problems, though around 16–22% of the adult population will experience a mental disorder over the course of a 12-month period (Norwegian Institute of Public Health, 2016). In replacing institutional care with community-based housing and services in Norway, different combined models of housing and support have played a central role in providing necessary and comprehensive assistance to people with complex and long-standing mental health needs (Dyb & Myrvold, 2009). These deinstitutionalization and decentralization processes have been further developed by requirements of user participation rights as basic values at all levels (Norwegian Directorate of Health, 2015). The democratization process is intended to strengthen service users’ role in, and responsibility for, their own recovery and to reduce the power differences between professionals and service users. The development of the mental health system may, thus, be justified as being linked to a “principle of healing” tradition within the history of mental health (Yanos, Knight, Vayshenker, Gonzales, & DeLuca, 2017, p. 289). The mentioned processes are, at the same time, part of a more general restructuring of the public health and welfare system. Inspired by New Public Management (NPM) and the later New Public Governance (NPG) trends, the restructuring processes are understood to increase the system’s efficiency and quality. As part of this modernization of the public sector in Norway, many municipalities have reorganized their service production based on a purchaser-provider model (Busch, Johnsen, Klausen, & Vanebo, 2011; Nesheim, 2004). The model represents a sharing of responsibility between the municipal administration (as the purchaser with authority to define the quantity, content, and quality of services) and the various institutional services representing the executive level, with responsibility for the production and development of the services (Busch et al., 2011; Nesheim, 2004). Thus, a communication structure is created between the user applying for support and receiving services, the entity that decides and orders services (such as follow-up medication, assistance with personal care, and other ADL activities), and the entity that receives and executes the orders by providing professional help and support to users and residents. The modernization processes, with their decision and communication structures, have affected the professional role of health and social workers, as well as their practices, in different ways, including the possibilities of being confronted by different and possibly contradictory expectations and values (Dent, O’Neill, & Bagley, 1999; Heggen & Engebretsen, 2012; Røyseland & Vabo, 2016; Sehested, 2002). The professionals are understood as having the right, power, and duty to use their knowledge to produce good and ethical practices that serve people in need of support. The opportunities to make use of this competence are, however, seen as delimited through the new governance structures emphasizing “measurable outputs, targets and cost effectiveness in the provision of public services” (Banks, 2011, p. 5). International studies showing great diversity in outcomes for people with mental health problems living in combined housing and support facilities have contributed to the increased attention paid to the role of the professional staff (Andersson, 2016; Borg & Kristiansen, 2004; Brunt & Rask, 2018; Chernomas, Clarke, & Marchinko, 2008; Denhov & Topor, 2011; McCabe & Priebe, 2004; Topor, 2001). The research focus on the role of the professional staff has given attention primarily to the relationship between the service providers and service users, understood as the cornerstone for strengthening the users’ everyday coping capacity and wellbeing (Andersson, 2016; Borg & Kristiansen, 2004). Research within this relational perspective seems to emphasize primarily the staff’s competence and skills as the influencing factor for developing the quality of individual mental health work (Andersson, 2016). The relationship between the professional staff and the residents in mental health housing and support facilities might, however, be influenced by a broader context in which institutional expectations and demands affect both the staff’s and the residents’ institutional positions. However, little attention is paid to the contextual expectations and demands that may influence the professional staff’s role and practice in combined housing and support facilities for people with severe mental health illness. This article seeks to address this lack of knowledge by exploring how the professional staff of health and social workers seem influenced by different and possibly contradictory expectations, and how these expectations are managed in their daily practices.

The institutional framework – housing and support facilities as contexts for mental health work

Different forms of combined housing and support may influence the staff’s role and work activities. Supported housing represents a model that emerged in the late 1980s with an emphasis on independent living in long-term housing with normal contracts, housing integrated into the community, the separation of housing and support, flexible access to support, and choice and shared decision-making related to housing and services (e.g., Hogan & Carling, 1992; Tabol, Drebing, & Rosenheck, 2010). Over the years, the housing model has been modified and partly used as a generic term. This has given rise to a discussion about the need for making a more visible distinction between the term “supported housing,” with its underlying principles, and the term “supportive housing.” The latter model refers to a broad range of housing with elements of time-limited support and skill working activities (Kirsh, Gewurtz, & Bakewell, 2011; Parkinson, Nelson, & Horgan, 1999; Tabol et al., 2010). Housing models with the function of preparing for the next step in skills development are criticized for not contributing to recovery processes (Ridgway & Zipple, 1990; Rog, 2004) and for normalizing residential instability (Rog, 2004). Non-intentional stability among the residents in transitional housing, combined with the complexity of their needs, may lead to the emergence of practices that stimulate a longer stay. An intended care pathway to independent community living for people with severe mental health problems may then be part of a “trans-institutionalization” process instead of a de-institutionalization process (Borg et al., 2005; Killaspy, 2016; Priebe, Frottier, Gaddini, Kilian, Lauber et al., 2008; Wong, Filoromo, & Tennille, 2007). The housing and support facilities included in this study have features from both housing models, like the self-contained apartment, time-limited support, and skill working activities. However, this article uses the term supported housing.

Theoretical framework

To grasp how different expectations confront the staff and their daily supportive work, we adopt an approach that concerns how institutional practices are influenced by institutional logics (e.g., Friedland & Alford, 1991; Greenwood, Díaz, Li, & Lorente, 2010; Thornton, 2004). Institutional logic perspective provides opportunities to understand how different and possibly contradictory expectations within institutional settings can create challenges and ethical dilemmas among employees. Institutional logic may be defined as “the belief system and associated practices that predominate in an organizational field” (Scott, Ruef, Mendel, & Caronna, 2000, p. 170). This focuses attention on the connection between organizational forms, normative frames, and agency, and how these three dimensions work to produce complex interactional patterns (Greenwood et al., 2010; Scott et al., 2000; Thornton & Occasio, 2008). Institutional logic functions to guide agency and social actions by representing forms of social prescriptions or interpretive schemes that enable actors to make sense of their situation by providing “assumptions and values, usually implicit, about how to interpret organizational reality, what constitutes appropriate behavior and how to succeed” (Thornton, 2004, p. 70). This means that the institutional actors may be understood as “carriers” of cognitive framework and value systems that influence, guide, and give meaning to activities and actions. The interpretive schemes may be both reinforced and challenged by normative frameworks like, e.g., demands for user involvement practices, professional ethics, role instructions, and different institutional procedures (Thornton, Ocasio, & Lounsbury, 2012). The actors and their agency are, however, both enabled and constrained by the plurality of institutional logics (Thornton et al., 2012). The way actors negotiate and resolve the different and possibly contradictory logics may imply that actors are not just “carriers” of institutional logics but are also creators who contribute to transformations of institutional practices (Spitzmueller, 2016; Thornton et al., 2012; Thornton & Occasio, 2008). Professional actors are in a position in which their actions must balance the different institutional logics, such as between professional values, user participation, and the values underlying the institutional management system (Banks, 2011). The logics might coexist, but they also represent contradictory rationalities and values (e.g., Reay & Hinings, 2009; Scott et al., 2000). The actors may then be caught in institutional dilemmas.

Methods

The article is based on empirical data from a mental health project (2014–2016) in a larger-sized Norwegian municipality with eight housing units for people with severe mental health problems. The project was approved by the Norwegian Center for Research Data (NSD) with project number 43,117. The data materials are transcribed and anonymized in accordance with the guidelines for research ethics.

The study context: the combined housing and support units

The eight housing units included are staffed during the daytime; some are staffed 24 hours a day. Each housing unit has a common kitchen and a living room, which both residents and staff can use. As part of the purchaser-provider model, the residents get their different forms of daily support from the staff, while assessment of needs and decisions about the type and amount of services lies with the local health and welfare authorities. All residents have a tenant contract and can stay as long as they are in need of the services and support that the housing units offer. Although no specific time duration for the stay in the housing apartments is set, the expectation is that the residents will develop skills and competencies that enable them to move to a more independent life in ordinary housing in the community. The professional staff is part of this expectation through institutional guidelines regarding the responsibilities and tasks they have as health care workers. This responsibility attempts to ensure that the residents get the services to which they are entitled, as well as to secure predictability and continuity through follow-up work and communication with the residents.

The research method and sampling process

This article presents data from focus group interviews with a sample of health and social workers who make up the professional staff in the eight supported housings. The leaders within the housing units were part of the project group and facilitated the recruitment of the staff, but did not participate in the focus groups themselves. The leaders provided a list with all professional health and social workers with the job title ‘health care workers’ and asked them if they wanted to participate as informants in the study. Out of a total of 73 health care workers, 37 gave their consent. When asked, they were informed that participation was voluntary, that only the researchers had access to the interview data, and that all reports would be anonymous. This information was repeated at the beginning of each focus group interview. The interviews took place in the first phase of the project with the aim of obtaining information about how the health care workers defined their work activities and work situations. An interview guide was prepared in advance with several themes to be discussed, like “How are residents involved in facilitating independence and mastering?” and “Are there any factors in the supported housing that you experience as obstacles in facilitating for coping?” In total, five (5) focus groups were conducted, with four to eight participants in each group. To avoid a situation in which the articulation of group norms would potentially silence individual voices of dissent, we included participants from various house units in each focus group. Most informants were full-time workers and had a bachelor’s degree in health or social work. Some of the participants had additional education in mental health care. Their working experience within mental health services differed, though most of them had worked for over two years. A few had worked for over 14 years.

The focus group interview

The focus group interview represents a method that has the potential to create a conversation dynamic that brings forward a diversity of experiences, views, and reflections on the themes to be addressed and negotiated through the informants’ comments about each other’s experiences (Kitzinger, 1994; Watts & Ebbutt, 1987). As such, the interviews may be better defined as discussions. The group discussions were completed over a period of two weeks and took place in meeting rooms in different supported housings. Two interviewees conducted the discussion in each group. One of them had a moderator role, while the other took notes and supported the moderator when necessary. When group dynamics worked, the interviewees took on more peripheral roles. The group discussions included topics related to daily and routine work, as well as the health care workers’ responsibilities, opportunities, and challenges in their daily work situation. The interviews and the transcriptions of the interviews were conducted in Norwegian. The transcripts were translated into English as part of the writing of the Findings section.

Data analysis

The analysis was conducted by following the core principle of Brinkmann and Kvale (2015) for qualitative analysis. First, all three authors read transcripts and looked for what the participants talked about and how they talked. In this reading, we searched for words, phrases, and sentences that were used by the informants and that the authors found important as meaning units associated with the aim of the interview. These could be, e.g., “the appointment system,” “motivation work,” and “work on the users’ premise.” These first meaning units were then discussed and related to a second phase of reading of the data material. The idea was to get a new overview of the participants’ discussion related to the research question. The analysis continued by interpretive coding of the meaning units into key themes. This process revealed that participants tended to draw a contradictory distinction between the formal organization of the daily work activities, the residents’ wishes, and their own strategies for managing the situation with the aim of doing “good professional work.” At this stage in the analysis, the authors began looking for a theoretical perspective that could support the knowledge-production process. The perspective of institutional logics (e.g., Friedland & Alford, 1991; Greenwood et al., 2010; Thornton, 2004) was gradually found to be interesting in the further reflections and discussions between the authors. Throughout the analysis, several themes emerged that were further interpreted and categorized into broader categories related to the informants’ talk about the different expectations they met in their everyday work. We found that their talk was related primarily to the challenges and dilemmas they experienced, and how they managed situations by adjusting and adapting their work to the different and contradictory expectations. The several themes that emerged from the data across the focus groups are organized under two main themes. One is defined as “Time scheduled tasks and the quality of mental health work” with the three subthemes “The wish and need for more time,” “Lack of flexibility and changing appointments,” and “Managing daily expectations and challenges.” The other main theme is defined as “The implementation of skill training activity” with the two subthemes “The normative expectation of and within skill training” and “Managing skill working relationships.” The Findings section will provide an in-depth presentation of the two key themes and the subthemes.

Findings

When talking about their institutional tasks as health care workers, the informants term their main task as “facilitation for learning and coping,” thus highlighting their mission of contributing to the residents’ path to independent living. Although they were unambiguous about this main task and the overarching goal for the supportive work, the informants experienced daily challenges and dilemmas which they had to manage. The following section will elaborate on the two main themes and their subthemes that emerged from the analysis.

Time-scheduled tasks and the quality of mental health work

As the informants described, the health care workers are responsible for providing different forms of support to the residents who stay within the housing units, as well as for providing services to users living outside the housing units. This work takes part in accordance with the decisions made by the local health and welfare authorities about the type and number of services. The daily and weekly work by the health care workers is then structured through a time- and activity-based appointment system in each supported housing, telling them whom to meet, when to meet, and which services to implement together with each resident. The residents have their own weekly schedules, which are prepared in collaboration with the staff and related to the services they receive. One main purpose of this timetable is to ensure predictability for both parties. The informants, however, find that the time- and activity-based system has contributed to major challenges in their daily supportive work for the residents.

The wish and need for more time

Working within supported housing entails continuous attention to the residents’ welfare and needs. This means that the health care staff is doing a lot of work that is not covered by the hourly activities decided on by the health and welfare authorities, but that is seen by themselves as part of creating quality in their services,

We are doing all kinds of things that make the individual user feel special … that goes beyond the decisions by the health and welfare authorities.

The informants found that the main challenge in their work was not having enough time resources for the residents and their daily needs for support. Many informants point to the consequences of the resource situation; one said that “some users want more support than we have possibilities to offer them,” and further expressed that this situation may lead to “lower progress in skill training.” The informants’ concern seems, then, to be related not only to their ability to provide enough support to each resident but also to the consequences with respect to the residents’ path to more independent living. As such, informants also reveal how restricted time resources have consequences for the institutional function of the supported housing.

Lack of flexibility and changing appointments

In the further discussions about lack of time, it became clear that it is not always the amount of time itself that is questioned but, rather, the ability to use the time they have for each resident in a more flexible way. The organization of the staff’s work is experienced as a functional system at the planning level. However, when the agreed-upon meetings with the residents are to be carried out, problems arise. The informants find that most residents show a highly variable motivation for planned activities. One of the informants described it this way:

They must be met in different ways, it’s so individual … maybe there is strong motivation and mastery one day … but the days are so different.

When motivation for planned activities varies from day to day, as well as within the same day, the health care workers must be continually prepared to change their plans for the day or the week. One informant commented about an experienced contradiction between professional values of importance in interaction with the residents and the appointment system by pointing to the consequences of their meetings,

… it’s important to be able to work on the users’ premises, however, what I have learned in this game is that no one is ready when the appointment time is there.

The informants underline that their primary professional responsibility is to meet the residents’ need for support, including acknowledging their varying motivation by trying to “be ready when the users are ready.” This intention is simultaneously stated as being impossible to realize within the time and activity structure of their daily work and, thus, is experienced as representing a kind of institutional ignorance to the residents’ needs and wishes. Many of the informants experience the pre-structured daily work as an obstacle that limits their opportunities to provide individual and situated customized help and support. One of the informants would like to have the opportunity to work in a more varied way, such as

being able to work more systematically with close meetings with a resident over a week or two.

However, as their work is embedded in a tight appointment system, the health care workers may find that they must reject residents who come with a desire to talk. One says,

Then you may have to refer them to another day, like Tuesday next week when your healthcare worker comes … then you can talk about this.

Meeting the users “where they are” as well as “to work on the users’ premises” represents appreciated strategies related to professional values of individualization which the health care workers are committed to safeguarding, but which they also find difficult and sometimes impossible to realize.

Managing daily expectations and challenges

In trying to manage this contradictory situation between professional values related to individualized work and the institutional time structure of their daily work, the informants look for ways to make their appointments with the residents more flexible and user-oriented. One way of taking account of the residents’ challenges with the appointment system is talked about as openness to changing agreed-upon meetings. One of the informants commented on such opportunities, saying that

… we could, maybe, make the work lists a little better for some of the residents who need more help to cope and who might want more backing.

However, she is doubtful as to whether more time will help. She sees the mental health work in the housing as trying to “help them to have a good enough life” – work that will imply challenges and unpredictability. The consequence for the health care workers with days characterized by continuous changes is seen here as unavoidable. However, others are looking for ways to overcome the challenges related to the appointment system. One strategy talked about was the use of the “in-between time” more actively and creatively by combining activities, such as using the time it takes to drive to an activity to talk about important themes in the resident’s life situation. One of the informants initiated a discussion about how place and space could be of importance in better meeting the residents’ needs, indicating that the staff had to expand their understanding of where and when to do supportive work. The informant stated that,

I think we are too much interwoven with the everyday structure of the housing to grasp the opportunities for other ways of working (…) I think things can change any time and in the most amazing ways and places. The best plan for further working I’ve ever written was written on a napkin at a café (…) we sat there and suddenly she just said, ‘Yes, you know I have a goal I want to work with.’

This statement motivated other informants to talk about their experiences of how the use of different spaces outside the residents’ flat had been important for developing a better working relationship. In particular, walking in the woods and driving a car were mentioned as creating openings for a better conversation with the residents – a conversation related to their life situations, challenges, and dreams for the future.

The talk among the informants shows how an appointment system intended to create predictability for both the residents and the health care staff may become an unpredictable work situation for the workers within a tight day schedule. The normative expectations of a more efficient way of doing their daily work seem to create a professional dilemma for the health care workers, between the institutionally organized time available to each resident, the residents’ needs and motivation for support, and individualization as a professional healthcare value. In trying to more flexibly meet the residents’ needs, one of the strategies at hand is to more creatively use the available time, such as more effectively utilizing the in-between time to and from activities.

The implementation of skill training activities

Skill training activities are described by the informants as part of the housing goal to promote independent living and represent as such a future-oriented facilitation work. They are highlighting that this facilitation work is based on professional values that include giving the residents an active role in their path to more independent living, as well as acknowledging the residents as individuals with different degrees of illness, skills, challenges, and wishes for how they want to live their lives. The amount and type of skill training activity given to each resident is, however, based on the assignment from the health and welfare authorities as part of the purchaser-provider organization model. Because skill training activities are part of the residents’ housing contract, the training represents a compulsory activity.

The normative expectation of and within skill training

In trying to manage the double responsibility of implementing skills training and realizing the residents’ user participation rights, the informants are concerned with how to build a “good working relationship.” The working relationship, seen as the foundation for their professional contribution to development and change in the residents’ life situations, is experienced as being challenging to realize due to recurrent experiences of disagreement with the residents about participation in the skill training. As part of this discussion, the opportunities for residents to influence or decide how they would live their lives emerge as a theme. Questions are raised about whether the skill activities introduced to the residents are part of a predefined cultural understanding of what is important in a good life. As such, some informants expressed fear that views about the “good” or “normalized” life may govern the skill training in ways that ignore the residents’ views. One of them commented that,

Many of us may think that the residents living here have a very poor life situation, so by helping them, we think we help them feel that they will cope with a life outside of this house.

Other informants discussed how skill training guided by the intention of “a more normalized life” represents a “possible devaluation” of the residents’ way of life or wishes for their future lives. As part of discussions about the consequences of not giving space for or value to different ways of living, some informants expressed concern about whether implicit and explicit expectations for living a “normal” life can take the form of coercion for the residents, but concluded that “it is a balancing act to define what is good enough living.”

The dilemma for the health care workers seems to emerge as an underlying contradiction between the institutional-based value of specific skill training activities as part of the residents’ path to more independent living and the professional values associated with the recognition of individuals’ right to choose how they want to live.

Managing skill working relationships

In the discussion about realizing a good working relationship, the informants directed their attention to the use of motivation work as a coping strategy. Motivation work is, however, experienced as a time-consuming strategy with unpredictable outcomes related to the residents’ situated motivation. The experience of recurrent disagreement and arguing situations tends to create frustration, which one of the informants characterized as something that “both the users and us are terribly tired of; we really want to start doing other things.” Others point to how such situations may boost a growing uncertainty about whether the work they perform represents what is “the best for the users.” Longstanding passive and active resistance from the residents may sometimes lead to what the informants define as problematic ways of dealing with situations. This can imply a “takeover” of the skill training activity, such as doing the housework themselves within the residents’ apartments. Such coping strategies can also arise from a desire to get “things done faster than the users.” Managing difficult and frustrating situations through such “by-passing” of the residents’ responsibilities is, however, understood as a perilous strategy due to its possible contribution to a change in the staff’s role from that of a facilitator to that of a helper “who fixes things” for the residents. This helper identity is understood as easy to enter but necessary to fight in protecting their professional role as facilitators. Another strategy in taking over the skill training is to use what the informants term “mild pressure,” with forms of forced participation for the residents. Although sometimes finding it “a little difficult to know where to draw the line” between voluntariness and compulsion, some informants see such pressure as an unavoidable dimension of the health care staff’s responsibility to facilitate change. One of the informants described a situation in which he experienced success in his motivation work by using what he defined as mild pressure. The informant stated,

I encouraged the resident over a long period to go out for a walk and at last the resident joined me, more or less voluntarily. But after some walks in the woods, the resident told me that she got bored just sitting in her own apartment.

Some other informants talked about using different forms of reward to motivate, like “to get a user to clean up the terrace table by offering a walk as a reward.” Others think it is important to use negotiations with the residents, illustrated here by one of the informants:

I made an agreement about housework with one resident that functions very well, as we agreed to talk about housework only on certain days.

A few health care workers also point out that, in some situations, their motivational work can emerge as a practice with paternalistic traits.

The discussions among the informants reveal a complex work situation when skill training is to be implemented. When this training is perceived as difficult to perform, and, at times, frustrating for both parties, little attention is paid to the skill training itself and the compulsory participation for the residents. Attention is given primarily to how residents’ changing motivation makes it difficult to realize the planned activity and how their meetings around skill working activities may result in a disagreement that makes it difficult to realize professional values and the mental health provisions regarding user participation. During the informants’ discussion about ways to manage the situation, their actions seem, for the most part, to be related to overcoming the residents’ resistance to participation, where motivational work represents a valued professional method they seek to use. However, this work is sometimes experienced as leading to unintentional forms of forced skill training situations.

Discussion

This article set out to obtain more knowledge about how the professional staff of health care workers in supported housing for people with severe mental health problems seem to be influenced by different and possibly contradictory expectations, and how these expectations are managed in their daily practices. Through the health care workers’ ongoing meetings and interactions with the residents, they may be seen as representing a group of institutional actors with powerful influence and normative control over everyday life in the supported housing (Scott et al., 2000). However, the findings show that the health care staff are not just acting themselves; they are also acting upon in ways that contribute to producing work situations characterized by complex interactional patterns (Greenwood et al., 2010; Scott et al., 2000; Thornton & Occasio, 2008). A rather rigid appointment system and forced participation in skill training for residents with changing and situated motivation (Palmer, 2017), combined with a more individualized and needs-based orientation from the health care staff, imply that various and contradictory logics are at play and that a complicated work situation develops for the professional staff (Banks, 2011; Sehested, 2002). The situation creates challenges and dilemmas for the health care staff, who are responsible not only for providing the services at planned and agreed-upon times but also for addressing concerns regarding the individual needs of residents who face challenges with scheduled and obliged appointments. Efficiency based on time management – and, thus, linear time – seems particularly difficult in collaboration with residents who have serious mental health difficulties, who may relate to “process times,” where the emphasis is on “processes and embodiment in the here and now” (Juhila, Günther, & Raitakari, 2015:8). An attempt to solve the experienced dilemma between professional values and the institutional work organization by more efficiently using the in-between time may result in more attention being paid to the residents. However, the strategy represents an individualization of the institutional challenges, implying no demands for changing the governing function of the institutional logic (Thornton & Occasio, 2008).

The findings show that skill working activities represent situations in which the complexity of the work for the health care staff develops. Representing a core activity on the residents’ path to a future independent life, the health care staff are important actors in the realization of the institutional goal of the supported housing. To realize this task, the professional work must be oriented to the promotion of increased individual coping and, thus, tends to coexist with the underlying logic of the pattern of values, perceptions, and rules that create the supported housing business (Scott et al., 2000). When this planned future orientation work meets residents with a more here-and-now motivation, different logics are set in play, implying the possibility of different wishes that become disagreements. As skill training represents an obligatory activity for the residents, and the health care staff are responsible for implementing the training, they are both placed in some form of a coercive situation, although representing different institutional positions. Attempts to motivate participation in an already stressful situation, may, as also seen in this study, involve the use of pressure from the staff’s side (). This situation may be related to the possibility that skill training has become a more traditional learning arena with a hierarchical relationship between the health care staff and the residents (Rog, 2004), related to de-professionalization processes, when professional competence and assessments are reduced and replaced by more structured performances (Banks, 2011; Healy, 2009). The informants’ concerns about limited opportunities for skill-related practices that include paying more attention to the residents’ needs and wishes in accordance with professional values support trends of de-professionalization as part of New Public Management (Sehested, 2002). Skill training seems, then, to represent a core arena for setting in play the complex tensions between contradictory and coexisting institutional logics (Thornton et al., 2012). The agenda of supported housing corresponds with the agenda of the staff in their striving to realize skill training but seems to stand in opposition to the residents’ possibilities for realizing participation rights and having their situating motivation acknowledged. The staff’s work situation in supported housing must receive more attention to produce an understanding of how the institutional regulation influences their professional work.

Although showing great reflexivity to the complexity of their work situation, including awareness of how their practice of motivation work may challenge and constrain their own professional values, the health care workers seem to have internalized a strong responsibility for the implementation of the supported housing’s aim and strategies for working toward independent living among the residents. This responsibility, when combined with facilitation work that becomes a learning relationship or motivational pressure, implies a danger of developing a relationship of paternalism (Mathisen, Lorem, Obstfelder, & Måseide, 2016).

In accordance with how institutional logics may function as an implicit guide for agency and social actions, the health care workers seem to function as non-intended “carriers” (Thornton, 2004) of frameworks that contribute to the reproduction of a service delivery system of which they are critical to. As such, they tend to be caught in an in-between situation amid expectations characterized by differences in influencing power, which implies that the residents’ situated needs and wishes, as well as their participation rights with a choice to decide on behalf of themselves, may be downgraded (Greener, 2007). Organizational expectations conveyed through the health and welfare authorities, the daily organization of their work, their own professional principles, and the residents’ wishes and actions all represent contradictory normative expectations to the health care workers, with the implication of a complicated professional practice. Here, the health care staff are placed in a difficult situation, as they are expected to balance different and contradictory expectations that are impossible to manage by a professional group alone (Banks, 2011).

Limitations and strengths

The findings of the present article do not allow for generalization, as they stem from an exploration of housing services in just one municipality. The findings are, nevertheless, interesting, as they illuminate some of the complexity in expectations of the health care staff in supported housing for people with severe mental health problems. The sample size is large for a qualitative study, which is considered a strength of this study. However, to enhance the transferability and relevance of the findings, there is a need for further research into the work situation for professional workers in different types of supported housing and different geographic locations. Validity may be questioned when the authors move between different languages as part of the article’s writing. The authors of this article have tried to enhance the validity of the findings by following recommendations presented by Nes, Amba, Jonsson, and Deeg (2010).

Conclusion

The intention behind the modernization of the municipal health and welfare organization was to create more effective and qualitatively better support (Busch et al., 2011; Nesheim, 2004). However, this study makes visible that efficiency and quality are not necessarily positively related. The work situation for the staff, as made visible in this study, seems to be in line with findings from other studies showing difficult conditions for the professional’s orientation toward individualized help and support for users within mental health institutions organized within the frame of New Public Management principles (Hannigan & Allen, 2011; Liff & Andersson, 2011; Orvik, Vågen, Axelsson, & Axelsson, 2015). The supported housing model, with its organization of the work for future independent living for people with severe mental health problems, may create difficult conditions for individualized help and support in accordance with professional values and participation rights. This implies that the health care workers are trapped in a squeeze between professional loyalty to the residents and employee loyalty to the supported housing and the health and welfare authorities.

Authorship/author contribution in line with order 1–3

First author – contributed to the design of the study and in collecting the data. Primary responsibility for the analysis of the data, and the main writer of all article drafts as well as the submitted manuscript.

Second author – project leader, main responsibility for the design of the study, contributed in collecting the data, the analysis, all article drafts, and the submitted manuscript.

Third author – contributed collecting data, the analysis, all article drafts, and the submitted manuscript.

Acknowledgments

The authors would like to acknowledge both the staff in connection to the different supported housing units who volunteered to take part in this study. In addition, we thank all other members of the project group.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

There is no external funding related to this article.