IMPlementation of An online Relatives' Toolkit for psychosis or bipolar (IMPART study): iterative multiple case study to identify key factors impacting on staff uptake and use.

BACKGROUND: Despite the potential of digital health interventions to improve the delivery of psychoeducation to people with mental health problems and their relatives, and substantial investment in their development, there is little evidence of successful implementation into clinical practice. We report the first implementation study of a digital health intervention: Relatives Education And Coping Toolkit (REACT), into routine mental healthcare. Our main aim was to identify critical factors affecting staff uptake and use of this online self-management tool for relatives of people with psychosis or bipolar. METHODS: A mixed-methods, theory-driven (Normalisation Process Theory), iterative multiple case study approach using qualitative analysis of interviews with staff and quantitative reporting of uptake. Carer researchers were part of the research team. RESULTS: In all, 281 staff and 159 relatives from Early Intervention teams across six catchment areas (cases) in England registered on REACT; 129 staff took part in qualitative interviews. Staff were positive about REACT helping services improve support and meet clinical targets. Implementation was hindered by: high staff caseloads and difficulties prioritising carers; perception of REACT implementation as research; technical difficulties using REACT; poor interoperability with trust computer systems and care pathways; lack of access to mobile technology and training; restricted forum populations; staff fears of risk, online trolling, and replacement by technology; and uncertainty around REACT's long-term availability. CONCLUSIONS: Digital health interventions, such as REACT, should be iteratively developed, evaluated, adapted and implemented, in partnership with the services they aim to support, and as part of a long term national strategy to co-develop integrated technology-enabled mental healthcare. Implementation strategies must instil a sense of ownership for staff and ensure they have adequate IT training, appropriate governance protocols for online working, and adequate mobile technologies. Wider contextual factors including adequate funding for mental health services and prioritisation of carer support, also need to be addressed for successful implementation of carer focussed digital interventions. TRIAL REGISTRATION: Study registration: ISCTRN 16267685.

Mental health practitioner experiences of engaging with service users in community mental health settings: A systematic review and thematic synthesis of qualitative evidence.

WHAT IS KNOWN ON THE SUBJECT?: Engagement is regarded as important and beneficial for service users and mental health services A universal definition of engagement is not yet fully agreed upon. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Based upon their experience, mental health staff use varied engagement approaches to fit with the changeable and unique needs of people who use services (service users). Mental health staff demonstrate qualities such as persistence and adaptability to successfully engage with service users. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Irrespective of professional background, the role of community mental health staff is not restricted to any single approach. Practical help and social support are as seen as important as clinical treatment to establish successful engagement. Little is known about the engagement experiences of mental health staff working in early intervention settings as most studies in this review focused on the perspectives of staff based in assertive outreach or community mental health teams. There is a need to further understand staff experiences of engagement with service users in early intervention settings. Role descriptions and expectations of community mental health workers should account for the wide-ranging flexible approach required in order to deliver appropriate interventions. This may involve a focus on engagement in training programmes. ABSTRACT: Introduction Effective mental health care is dependent on engaging service users, but some individuals do not actively attend appointments, and may stop engaging with mental health services. Quantitative studies reveal some salient factors that seem to predict engagement, but these studies miss the nuances of good clinical practice in this area. A number of qualitative studies of health professionals' experiences and understanding of effective engagement have been published. Aim This review aimed to systematically identify, evaluate and synthesize results from these studies with a view to informing effective practice in this area. Methods Electronic databases MEDLINE, EMBASE, CINAHL, PsychINFO and AMED were searched (PROSPERO systematic review protocol registry (www.crd.york.ac.uk/prospero/; ID CRD42017083976). Of 799 records, ten papers met the inclusion criteria. All papers were subjected to quality appraisal based on the CASP checklist and data systematically extracted. A thematic synthesis of included studies examining mental health practitioners' experiences of engagement in community mental health settings was conducted. Results Mental health practitioners see engaging service users as depending upon complex, multi-dimensional phenomena which should include individualized person-centred approaches as well as practical, social and clinical support. Mental health practitioners demonstrate qualities such as determination and adaptability to establish and maintain engagement with service users. Implications for practice As a core aspect of nurse education, registered mental health nurses and other professionals would benefit from systematic guidance regarding engagement strategies. Most studies in this review focused on assertive outreach or community mental health teams, more clarification is needed of practitioner's engagement experiences in early intervention settings.

A Web-Based Intervention for Relatives of People Experiencing Psychosis or Bipolar Disorder: Design Study Using a User-Centered Approach.

BACKGROUND: Relatives of people experiencing bipolar mood episodes or psychosis face a multitude of challenges (eg, social isolation, limited coping strategies, and issues with maintaining relationships). Despite this, there is limited informational and emotional support for people who find themselves in supporting or caring roles. Digital technologies provide us with an opportunity to offer accessible tools, which can be used flexibly to provide evidence-based information and support, allowing relatives to build their understanding of mental health problems and learn from others who have similar experiences. However, to design tools that are useful to relatives, we first need to understand their needs. OBJECTIVE: The aim of this study was to use a user-centered design approach to develop an accessible Web-based intervention, based on the Relatives Education And Coping Toolkit (REACT) booklet, to support the informational and emotional needs of relatives of people experiencing psychosis or bipolar disorder. METHODS: We engaged relatives of people with experiences of bipolar disorder or psychosis in workshops to identify their needs and design requirements for developing a Web-based version of a paper-based toolkit. We used a 2-phase qualitative approach to explore relatives' views on content, design, and functionalities, which are considered to be engaging and useful in a Web-based intervention. In phase 1, we consulted 24 relatives in 2 workshops to better understand their existing support infrastructure, their barriers for accessing support, unmet needs, and relatives' views on online support. On the basis of the results of these workshops, we developed a set of design considerations to be explored in a smaller workshop. Workshop 3 then involved working with 2 digitally literate relatives to design a usable and acceptable interface for our Web-based toolkit. Finally, in phase 2, we conducted a heuristic evaluation to assess the usability of the toolkit. RESULTS: Our findings indicated that relatives require technologies that (1) they can place their trust in, particularly when discussing a highly sensitive topic, (2) enable learning from the lived experiences of others while retaining confidentiality, and (3) they can work through at their own pace in a personalized manner. CONCLUSIONS: Our study highlights the need for providing a trustworthy, supportive tool where relatives can engage with people who have similar experiences to their own. Our heuristic evaluation showed promise in terms of perceived usability of the REACT Web-based intervention. Through this work, we emphasize the need to involve stakeholders with various characteristics, including users with limited computer literacy or experience in online support.