Implementing an intervention designed to enhance service user involvement in mental health care planning: a qualitative process evaluation (original) (raw)
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International Journal of Mental Health Systems
Background: As a response to evidence that mental health service users and carers expect greater involvement in decisions about antipsychotic medication choice and prescribing, shared decision-making (SDM) has increasingly come to be viewed as an essential element of person-centred care and practice. However, this aspiration has yet to be realised in practice, as service users and carers continue to feel alienated from healthcare services. Existing understanding of the factors affecting the use of tools to support SDM is limited to inter-individual influences and wider factors affecting potential implementation are underexplored. Aim: To explore the potential use of a tool designed to enhance collaborative antipsychotic prescribing from the perspectives of secondary care mental health service users, carers and professionals. Methods: We conducted a qualitative study (semi-structured interviews and focus groups) using a convenience sample of 33 participants (10 mental health service users, 10 carers and 13 professionals) involved in antipsychotic prescribing in one Trust in the North of England. Participants were asked about the potential implementation of a tool to support SDM within secondary mental health services. Framework analysis incorporating the use of constant comparative method was used to analyse the data. Results: The study identified a divergence in the views of service users and professionals, including a previously undocumented tendency for stakeholder groups to blame each other for potential implementation failure. This dissonance was shaped by meso and macro level influences relating to paternalism, legislative frameworks, accountability and lack of resources. Participants did not identify any macro level (policy or structural) facilitators to the use of the tool highlighting the negative impact of mental health contexts. Our study indicated that inter-individual factors are likely to be most important to implementation, given their potential to transcend meso and macro level barriers. Conclusions: Consideration of the meso and macro level influences identified areas for potential intervention, including challenging professionals' and service users' perceptions of each other, rebalancing the notion of accountability within services and introducing new means for service user feedback on the quality of SDM. Multi-level strategies for facilitating the implementation of tools to support SDM are also presented.
Key issues in the process of implementing shared decision making (DM) in mental health practice
Mental Health Review Journal
Although SDM is seen as a favourable approach in mental health settings, its routine use in everyday practice is low. Implementation is judged to be the test of the intention to use SDM because of its value base and its potential to improve mental health practice, across medical, psychological and social interventions carried out by multidisciplinary providers, including peer support workers. Successful implementation is achieved by enhancing the incorporation of understanding SDM as based on different types of knowledge (scientific and experiential)and leading to decisions more acceptable to service users than only to clinicians, thus enabling a more genuine working partnership between the key stakeholders in mental health services. Purpose: This review article will look at internationally existing publications in the English language on mental health SDM implementation of a variety of interventions, including different methodologies and research methods, age groups and countries. We will aim to provide an overview of: process, degree, and outcomes of implementation; barriers and facilitators; perspectives on implementation by different stakeholders; analysis of the process of implementation in mental health services through the lenses of the Normalisation Process Theory (NPT) Design: Following a targeted literature search the data was analysed in order to provide an overview of methodologies and methods applied in the articles, as well as of the variables listed above. Three different types of information were included: a content analysis of key issues, reflective understanding coming out of participating in implementation of an SDM project in the form of two narratives written by two key participants in an SDM pilot project, and an NPT analysis of the process of implementation. Findings: Only a minority of mental health SDM research focuses on implementation in everyday practice. It is possible and often desirable to achieve SDM in mental health services; it requires a low level of technology, it can save time once routinized, and it is based on enhancing therapeutic alliance, as well as service users' motivation. Implementation requires an explicit policy decision, a clear procedure, and regular adherence to the aims and methods of implementation by all participants. These necessary and sufficient conditions are rarely met, due to the different levels of commitment to SDM and its process by the different key stakeholders, as well as due to competing providers' objectives and the time allocated to achieving them. Implications: The review indicates both the need to take into account the complexity of SDM, as well as future strategies for enhancing its implementation in everyday mental health practice. Perhaps because applying SDM reflects a major cultural change in mental health practice, current value attached to SDM among clinicians and service managers would need to be more positive, prominent, and enduring to enable a greater degree of implementation.
Programme Grants for Applied Research
Background Service users and carers using mental health services want more involvement in their care and the aim of this research programme was to enhance service user and carer involvement in care planning in mental health services. Objectives Co-develop and co-deliver a training intervention for health professionals in community mental health teams, which aimed to enhance service user and carer involvement in care planning. Develop a patient-reported outcome measure of service user involvement in care planning, design an audit tool and assess individual preferences for key aspects of care planning involvement. Evaluate the clinical effectiveness and the cost-effectiveness of the training. Understand the barriers to and facilitators of implementing service user- and carer-involved care planning. Disseminate resources to stakeholders. Methods A systematic review, focus groups and interviews with service users/carers/health professionals informed the training and determined the prior...
2015
Collaboration between service users and mental health professionals is at the heart of values based practice and shared decision making. However, there has been limited analysis of the implications of these approaches within a healthcare context that involves depriving service users of their freedom. This article proposes a framework that aims to promote shared decision making which acknowledges, all participants must be Informed, Involved and Influential in the decision-making process. However, these are fluid; they refer to a sliding scale of influence that moves between these different positions depending on context, capacity and desire to influence.
Journal of Public Mental Health
Purpose The purpose of this study was to describe mental health professionals’ experiences of changes in attitudes towards, and knowledge about, users of mental health-care recovery and decisional participation in clinical practice after an educational intervention. Design/methodology/approach Users of mental health care want to participate in decisions regarding their own mental health care. Shared decision-making as a method is coherent with recovery orientation in mental health services and results in better-informed patients and fewer conflicts regarding decisions. A qualitative intervention study was designed to evaluate changes in attitudes and knowledge about mental health recovery in Sweden. Nine participants were interviewed, and the data were analysed by content analysis. Findings Three categories were generated from the analysis: Increased theoretical knowledge, changing attitudes about practical approaches and the significance of social factors in recovery. Originality/v...
Health expectations : an international journal of public participation in health care and health policy, 2017
It has been established that mental health-care planning does not adequately respond to the needs of those accessing services. Understanding the reasons for this and identifying whose needs care plans serve requires an exploration of the perspectives of service users, carers and professionals within the wider organizational context. To explore the current operationalization of care planning and perceptions of its function within mental health services from the perspectives of multiple stakeholders. Participants included 21 mental health professionals, 29 service users and 4 carers from seven Mental Health Trusts in England. All participants had experience of care planning processes within secondary mental health-care services. Fifty-four semi-structured interviews were conducted with participants and analysed utilizing a qualitative framework approach. Care plans and care planning were characterized by a failure to meet the complexity of mental health needs, and care planning proces...
Journal of psychiatric and mental health nursing, 2016
WHAT IS KNOWN ON THE SUBJECT?: UK mental health policy dictates user involvement in mental health care planning. Service users report feeling marginalized in the care planning process. Ongoing dissatisfaction with care planning involvement suggests a failure to translate policy into practice over time. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Service user involvement should no longer be regarded as a nebulous concept. Ten key criteria underpin service user satisfaction with care planning involvement. Five criteria characterizing the process of care planning involvement are prioritized by service users. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Service users can conceptualize and describe meaningful user involvement. Service user requests, summarized through a 10C framework of care planning involvement, provide a clear structure for practice improvement. Background Service users wish to be involved in care planning but typically feel marginalized in this process. Qualitative explo...
“Work with me”: service users’ perspectives on shared decision making in mental health
Mental Health Review Journal
Purpose-While shared decision making (SDM) in general health has proven effectiveness, it has received far less attention within mental health practice with a disconnection between policy and ideals. The purpose of this paper to review existing developments, contemporary challenges, and evidence regarding SDM in mental health with a particular focus on the perspectives of service users. Design/methodology/approach-This is a review of international papers analysed using narrative synthesis of relevant data bases. Findings-The review shows significant barriers to the utilisation of SDM including ethical and legal frameworks, accountability and risk. The medical model of psychiatry and diagnostic stigma also contributes to a lack of professional acknowledgement of service user expertise. Service users experience an imbalance of power and feel they lack choices, being "done to" rather than "worked with". Practical implications-The paper also presents perspectives about how barriers can be overcome, and service users enabled to take back power and acknowledge their own expertise. Originality/value-This review is the first with a particular focus on the perspectives of service users and SDM.
BMC Psychiatry, 2015
Background: Formal recognition and involvement of carers in mental health services has been the focus of recent policy and practice initiatives as well as being supported by carers themselves. However, carers still report feeling marginalised and distanced from services. A prominent theme is that that they are not listened to and their concerns are not taken seriously. Compared to service user views, the reasons underpinning carers' dissatisfaction with care-planning procedures have been relatively neglected in the research literature, despite the substantial and significant contribution that they make to mental health services. The aim of the study was to explore carers' experiences of the care planning process for people with severe mental illness. Methods: Qualitative interviews and focus groups were undertaken with carers. Data were combined and analysed using framework analysis. Results: Whilst identifying a shared desire for involvement and confirming a potential role for carers within services, our data highlighted that many carers perceive a lack of involvement in care planning and a lack of recognition and appreciation of their role from health professionals. Barriers to involvement included structural barriers, such as the timing and location of meetings, cultural barriers relating to power imbalances within the system and specific barriers relating to confidentiality. Conclusions: This qualitative study led by a researcher who was a carer herself has developed the understanding of the potential role of carers within the care planning process within mental health services, along with the facilitators and barriers to achieving optimal involvement.