Implementation strategies for telemental health: a systematic review (preprint)

Background The COVID-19 pandemic resulted in a rapid shift from traditional face-to-face care provision towards delivering mental health care remotely through telecommunications, often referred to as telemental health care. However, the manner and extent of telemental health implementation have varied considerably across settings and areas, and substantial barriers are encountered. There is, therefore, now a need to identify what works best for service users and staff and establish the key mechanisms for efficient integration into routine care. Objective We aimed to identify investigations of pre-planned strategies intended to achieve or improve effective and sustained implementation of telemental health approaches, and to evaluate how different strategies influence implementation outcomes. Methods A systematic review was conducted, with five databases searched for relevant literature using any methodological approach, published between January 2010 and July 2021. Studies were eligible for inclusion if they took place in secondary or tertiary mental health services and focused on pre-planned strategies for achieving or improving delivery of mental health care through remote communication between mental health professionals or between mental health professionals and service users, family members, unpaid carers, or peer supporters. All included studies were assessed for risk of bias. Data were synthesised using the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies and the taxonomy of implementation outcomes. Results A total of 14 studies were identified which met the inclusion criteria. A variety of implementation strategies were identified, the most commonly reported being ‘Train and educate stakeholders’. All studies reported using a combination of several implementation strategies. Conclusions Using a combination of implementation strategies appears to be a helpful method of supporting the implementation of telemental health. Further research is needed to test the impact of specific implementation strategies on implementation outcomes.

Healthcare workers' mental health and wellbeing during the COVID-19 pandemic: Longitudinal analysis of interview and social media data (preprint)

The COVID-19 pandemic has shed light on the fractures of healthcare systems around the world, particularly in relation to the healthcare workforce. Frontline staff, in particular, have been exposed to unprecedented strain and delivering care during the pandemic has impacted their safety, mental health and wellbeing. The aim of this paper was to explore the experiences of HCWs delivering care in the UK during the COVID-19 pandemic to understand their wellbeing needs, experiences and strategies used to maintain wellbeing (at individual and organizational levels). We analysed 94 telephone interviews with HCWs and 2000 tweets about HCWs mental health taking place during the first year of the COVID-19 pandemic. Results were grouped under six themes: redeployment; wellbeing support and coping strategies; mental health effects; organisational support; social network and public support. These findings demonstrate a need for open conversations, where staffs wellbeing needs and strategies can be shared and encouraged, rather than implementing solely top-down psychological interventions. At the macro level, findings also highlighted the impact on HCWs wellbeing of public and government support, as well as the need for ensuring protection through PPE, testing, and/or vaccines for frontline workers.

What works for whom with telemental health? A rapid realist review (preprint)

Background: Telemental health (delivering mental health care via video calls, telephone calls or text messages) is increasingly widespread. Telemental health appears to be useful and effective in providing care to some service users in some settings, especially during an emergency restricting face-to-face contact such as the COVID-19 pandemic. However, important limitations have been reported, and telemental health implementation risks reinforcing pre-existing inequalities in service provision. If it is to be widely incorporated in routine care, a clear understanding is needed of when and for whom it is an acceptable and effective approach, and when face-to-face care is needed. Objective: The aim of this rapid realist review was to develop theory about which telemental health approaches work, or do not work, for whom, in which contexts and through what mechanisms. Methods: Rapid realist reviewing involves synthesising relevant evidence and stakeholder expertise to allow timely development of context-mechanism-outcome (CMO) configurations in areas where evidence is urgently needed to inform policy and practice. The CMOs encapsulate theories about what works for whom, and by what mechanisms. Sources included eligible papers from (a) two previous systematic reviews conducted by our team on telemental health, (b) an updated search using the strategy from these reviews, (c) a call for relevant evidence, including "grey literature", to the public and key experts, and (d) website searches of relevant voluntary and statutory organisations. CMOs formulated from these sources were iteratively refined, including through (a) discussion with an expert reference group including researchers with relevant lived experience and front-line clinicians and (b) consultation with experts focused on three priority groups: 1) children and young people, 2) users of inpatient and crisis care services, and 3) digitally excluded groups. Results: A total of 108 scientific and grey literature sources were included. From our initial CMOs, we derived 30 overarching CMOs within four domains: 1) connecting effectively; 2) flexibility and personalisation; 3) safety, privacy and confidentiality; and 4) therapeutic quality and relationship. Reports and stakeholder input emphasised the importance of personal choice, privacy and safety, and therapeutic relationships in telemental health care. The review also identified particular service users likely to be disadvantaged by telemental health implementation, and a need to ensure that face-to-face care of equivalent timeliness remains available. Mechanisms underlying successful and unsuccessful application of telemental health are discussed. Conclusions: Service user choice, privacy and safety, the ability to connect effectively and fostering strong therapeutic relationships, need to be prioritised in delivering telemental health care. Guidelines and strategies co-produced with service users and frontline staff are needed to optimise telemental health implementation in real-world settings. MS and KRKS are joint first authors.

Implementation, adoption and perceptions of telemental health during the COVID-19 pandemic: a systematic review (preprint)

Background: Early in 2020, mental health services had to rapidly shift from face-to-face models of care to delivering the majority of treatments remotely (by video or phone call or occasionally messaging) due to the COVID-19 pandemic. This resulted in several challenges for staff and patients, but also in benefits such as convenience or increased access for people with impaired mobility or in rural areas. There is a need to understand the extent and impacts of telemental health implementation, and barriers and facilitators to its effective and acceptable use. This is relevant both to future emergency adoption of telemental health, and to debates on its future use in routine mental health care. Objective: To investigate the adoption and impacts of telemental health approaches during the COVID-19 Pandemic, and facilitators and barriers to optimal implementation. Methods: Four databases (PubMed, PsycINFO, CINAHL and Web of Science) were searched for primary research relating to remote working, mental health care, and the COVID-19 pandemic. Preprint servers were also searched. Results of studies were synthesised using framework synthesis. Results: A total of 77 papers met our inclusion criteria. In most studies, the majority of contacts could be transferred to a remote form during the pandemic, and good acceptability to service users and clinicians tended to be reported, at least where the alternative to remote contacts was interrupting care. However, a range of impediments to dealing optimal care by this means were also identified. Conclusions: Implementation of telemental health allowed some continuing support to the majority of service users during the COVID-19 pandemic and has value in an emergency situation. However, not all service users can be reached by this means, and better evidence is now needed on long-term impacts on therapeutic relationships and quality of care, and on impacts on groups at risk of digital exclusion and how to mitigate these.

Professionals' views on the mental health problems and vulnerability of children and young people during the early phase of the COVID-19 pandemic (preprint)

The COVID-19 pandemic caused major disruptions to everyday life for children and young people. The aim of this study was to examine professionals views on the mental health problems and vulnerabilities of children and young people during the early phase of the COVID-19 pandemic. We conducted a secondary analysis of an online survey completed by mental health professionals in the UK between 22 April 2020 and 12 May 2020. The final sample was N = 601 professionals who at least partly worked with children and young people. Quantitative and qualitative survey data showed that professionals were concerned about young people experiencing economic disadvantage and young people from minority ethnic groups, as pre-existing social inequalities resulted in increased risk of infection and reduced access to physical and mental health care. Professionals were concerned about young people with little family support and young people at risk of relapse or deterioration in mental health, reporting the exacerbation of pre-existing mental health difficulties and challenging behaviours. Further research, involving young people as researchers, is needed to explore the continued impact for children and young people, and their families, including in comparison to their experiences before the pandemic.

Service user experiences and views regarding telemental health during the COVID-19 pandemic: a co-produced framework analysis (preprint)

BackgroundThe prominence of telemental health, including providing care by video call and telephone, has greatly increased during the COVID-19 pandemic. However, there are clear variations in uptake and acceptability, and concerns that digital exclusion may exacerbate previous inequalities in accessing good quality care. Greater understanding is needed of how service users experience telemental health, and what determines whether they engage and find it acceptable. MethodsWe conducted a collaborative framework analysis of data from semi-structured interviews with a sample of people already experiencing mental health problems prior to the pandemic. Data relevant to participants experiences and views regarding telemental health during the pandemic was identified and extracted. Data collection and analysis used a participatory, coproduction approach where lived experience researchers, clinical and academic researchers contributed to all stages of data collection, analysis and interpretation of findings. FindingsParticipants experiences and preferences regarding telemental health care were dynamic and varied across time, settings, and individuals. Participants preferences were shaped by the reason for contacting providers, their relationship with the care provider, and both parties access or acceptability to use remote technology. While face-to-face care tended to be the preferred option, participants identified benefits of remote care including making care more accessible for some populations and improved efficiency for functional appointments such as prescription reviews. Participants highlighted important new challenges around safety and privacy in online settings, and gave examples of good remote care strategies, including scheduling regular phone calls and developing guidelines about how to access remote care tools. DiscussionParticipants in our study and previous literature have highlighted advantages of telemental health care, as well as significant limitations which hinder mental health support and exacerbate inequalities in access to services. Some of these limitations are seen as potentially removable, for example through staff training or better digital access for staff or service users. Others indicate a need to maintain traditional face-to-face contact at least for some appointments. There is a clear need for care to be flexible and individualised to service user circumstances and preferences. Further research is needed on ways of minimising digital exclusion and to support staff in making effective and collaborative use of relevant technologies.

Redeployment and training of healthcare professionals to Intensive Care during COVID-19: a systemic review (preprint)

BackgroundA rapid influx of patients to intensive care and infection control measures during the COVID-19 pandemic required the rapid development of innovative redeployment and training strategies. MethodsWe conducted a systematic search of 9 databases including key terms related to intensive care AND training AND redeployment AND healthcare workers. Analysis consisted of a narrative synthesis of quantitative study outputs, and a framework-based thematic analysis of qualitative study outputs and grey literature. These results were then combined applying an interpretative synthesis. ResultsTwenty papers were analysed. These took place primarily in the UK (N=8, 40%) and USA (N=5, 25%). Themes included in the results are Redeployment: Implementation strategies and learnings; Redeployed staff experience and strategies to address their needs; Redeployed staff learning needs; Training formats offered and training evaluations; and Future redeployment and training concerns. Some of the redeployment implementation and training strategies documented in this review are: Skills-based redeployment, buddy support systems, and agreeing on locally-specific principles, rather than strict procedures. ConclusionThe COVID-19 pandemic presented unique challenges to deliver training promptly while following infection control recommendations and develop flexible redeployment strategies. This study synthesises original approaches to tackle these challenges which are relevant to inform the development of targeted and adaptative training and redeployment plans.

Impact of the COVID-19 pandemic on Older Adults Mental Health Services: a mixed methods study (preprint)

Purpose The Covid-19 pandemic is likely to have a significant impact on older adults mental health care. Our study aimed to explore staff perspectives on key challenges and innovations, to help inform the delivery of older adults mental health care in subsequent waves of the pandemic. Methods A mixed methods online questionnaire developed by NIHR Mental Health Policy Research Unit (MHPRU) was used to gather staff perspectives on their challenges at work, problems faced by service users and their carers, and sources of help and support. Descriptive statistics were used for quantitative analysis and descriptive content analysis for qualitative analysis. Results 158 participants, working in either community or inpatient settings, and from a range of professional disciplines, were included. For inpatient staff, a significant challenge was infection control. In the community, staff identified a lack of access to physical and social care as well as reduced contact with friends and families as being challenges for patients. Remote working was seen as a positive innovation along with Covid-19 related guidance from various sources and peer support. Conclusion Our study, with a focus on staff and patient well-being, helps to inform service development for future waves of the pandemic. We discuss measures to improve infection control in inpatient settings, the role of voluntary organisations in supporting socially isolated community patients, the need for better integration of physical and mental health services at an organisational level, and the importance of training staff to support patients and their families with end of life planning.

How has Covid-19 affected mental health nurses and the delivery of mental health nursing care in the UK? Results of a mixed methods study (preprint)

IntroductionWhile evidence has emerged concerning the impact of Covid-19 on the general population and the challenges facing health services, much less is known regarding how the pandemic has directly affected the delivery of mental health nursing care. AimThis paper aims to explore how Covid-19 has affected the ability of mental health nurses to deliver care in community and inpatient mental health services in the UK. MethodWe investigated staff reports regarding the impact of the Covid-19 pandemic on mental healthcare and mental health service users in the UK, using a mixed methods online survey. A total of 897 nurses across a range of inpatient and community settings participated. DiscussionKey themes within the data explore: new ways of working; remote working; risks of infection/infection control challenges; and the impact on service users. Targeted guidelines are required to support mental health nurses providing care and support during a pandemic to people in severe mental distress, often in unsuitable environments. Implications for PracticeService developments need to occur alongside tailored guidance and support for staff welfare supported by clear leadership. These findings identify areas requiring attention and investment to prepare for future crises and the consequences of the pandemic. Accessible SummaryO_ST_ABSWhat is known on the subject?C_ST_ABSDuring the Covid-19 pandemic there has been research considering the impact on medical healthcare professionals and the mental health needs of the general population. However, limited focus has been placed on mental health services or mental health staff providing care in the community and in hospitals. Whilst nurses make up the largest section of the mental health workforce in the UK, the impact that this pandemic has had on their work has been largely ignored. What the paper adds to existing knowledge?This paper provides a unique insight into the experiences and impact that the Covid-19 pandemic has had on mental health nurses across a range of community and inpatient settings to understand what has changed in their work and the care they can and do provide during this crisis. This includes exploring how services have changed, the move to remote working, the impact of the protective equipment crisis on nurses, and the difficult working conditions facing those in inpatient settings where there is minimal guidance provided. What are the implications for practice?By understanding the impact the pandemic has had on mental health nursing care, we can understand the gaps in guidance that exist, the challenges being faced, and the impact the crisis has had on care for mental health service users. By doing so we can plan for the ongoing nature of this pandemic as well as the aftermath that the crisis may leave for our service users and workforce alike. Relevance StatementThis paper provides insight into the impact that the Covid-19 pandemic has had on the service and care that mental health nurses are expected to and can provide. As a workforce that often requires ongoing face to face contact with service users, many in serious distress, in inpatient and community settings, it is important that we understand their experiences and the challenges and risks that face this workforce. This will enable us to ensure that future planning, guidance, support and safeguarding can take place during the ongoing and future crises.

Mental healthcare and service user impact of the COVID-19 pandemic: results of a UK survey of staff working with people with intellectual disability and developmental disorders (preprint)

Background Very little is known about the impact of previous epidemics on the care of people with intellectual and developmental disabilities, particularly in terms of mental health services. The COVID-19 pandemic has the potential to exacerbate existing health inequalities as well as expose gaps in service provision for this vulnerable population group. Methods We investigated the responses of 648 staff working in mental healthcare with people with intellectual disabilities and/or developmental disabilities. Participants contributed to a UK-wide online survey undertaken by the National Institute for Health Research Mental Health Policy Research Unit between 22nd April and 12th May 2020. Recruitment was via professional networks, social media and third sector organisations. Quantitative data describing staff experience over three domains (challenges at work, service user and carer problems, sources of help at work) were summarised and differences between groups explored using Chi square tests. Content analysis was used to organise qualitative data focusing on service changes in response to the pandemic. Results The majority of survey respondents worked in the NHS and in community mental health services. One third had managerial responsibility. Major concerns expressed by mental healthcare staff were: difficulties for service users due to lack of access to usual support networks and health and social care services during the pandemic; and difficulties maintaining adequate levels of support secondary to increased service user need. Staff reported having to quickly adopt new digital ways of working was challenging; nevertheless, free text responses identified remote working as the innovation that staff would most like to retain after the pandemic subsides. Conclusions Understanding the experiences of staff working across different settings in mental healthcare for people with intellectual and developmental disabilities during the COVID-19 pandemic is essential in guiding contingency planning and fostering service developments to ensure the health of this vulnerable group is protected in any future disease outbreaks.

Healthcare Workers' Mental Health and Wellbeing During the COVID-19 Pandemic in the UK: Contrasting Guidelines with Experiences in Practice (preprint)

BackgroundSubstantial evidence has highlighted the importance of considering healthcare workers (HCW) mental health during the COVID-19 pandemic, and several organisations have issued guidelines with recommendations. However, the definition of wellbeing and the evidence-base behind such guidelines remains unclear. ObjectivesAssessing the applicability of wellbeing guidelines in practice; identifying unaddressed HCWs needs; and providing recommendations for supporting frontline staff during the current and future pandemics. Methods and DesignThis paper discusses the findings of a qualitative study based on interviews with frontline healthcare staff in the UK and examines them in relation to a rapid review of wellbeing guidelines developed in response to the COVID-19 pandemic. Results14 guidelines were included in the rapid review and 33 interviews with HCWs were conducted in the qualitative study. As a whole, the guidelines placed greater emphasis on wellbeing at an individual level, while HCWs placed greater emphasis on structural conditions at work, such as understaffing and the invaluable support of the community. This in turn had implications for the focus of wellbeing intervention strategies; staff reported an increased availability of formal mental health support, however, understaffing or clashing schedules prevented them from participating in these activities. ConclusionHCWs expressed wellbeing needs which align with social-ecological conceptualisations of wellbeing related to quality of life. This approach to wellbeing has been highlighted in literature about HCWs support in previous health emergencies, yet it has not been monitored during this pandemic. Wellbeing guidelines should explore staffs needs and contextual characteristics affecting the implementation of recommendations.

Impact on mental health care and on mental health service users of the COVID-19 pandemic: a mixed methods survey of UK mental health care staff (preprint)

PurposeThe COVID-19 pandemic has potential to disrupt and burden the mental health care system, and to magnify inequalities experienced by mental health service users. MethodsWe investigated staff reports regarding the impact of the COVID-19 pandemic in its early weeks on mental health care and mental health service users in the UK using a mixed methods online survey. Recruitment channels included professional associations and networks, charities and social media. Quantitative findings were reported with descriptive statistics, and content analysis conducted for qualitative data. Results2,180 staff from a range of sectors, professions and specialties participated. Immediate infection control concerns were highly salient for inpatient staff, new ways of working for community staff. Multiple rapid adaptations and innovations in response to the crisis were described, especially remote working. This was cautiously welcomed but found successful in only some clinical situations. Staff had specific concerns about many groups of service users, including people whose conditions are exacerbated by pandemic anxieties and social disruptions; people experiencing loneliness, domestic abuse and family conflict; those unable to understand and follow social distancing requirements; and those who cannot engage with remote care. ConclusionThis overview of staff concerns and experiences in the early COVID-19 pandemic suggests directions for further research and service development: we suggest that how to combine infection control and a therapeutic environment in hospital, and how to achieve effective and targeted tele-health implementation in the community, should be priorities. The limitations of our convenience sample must be noted.