Mental Health Care Organizations Research Articles

Envisioning a safety paradigm in inpatient mental health settings: Moving beyond zero-risk approaches

A zero-risk paradigm currently dominates the organization and delivery of mental health care within inpatient settings, giving rise to a proliferation of risk management strategies that are ineffective and produce harms. Drawing on Foucault's confinement and grounded in a comprehensive analysis of the extant literature, we identify three central processes that constitute this paradigm, including: risk is situated within the patient; eliminating risk is a foundational aim; and mental health professionals lead decision-making. Responding to the zero-risk paradigm, this paper proposes a novel safety paradigm comprised of four intersecting components, undertaken collectively by mental health professionals to guide practice: i) holding risk, ii) building capacity, iii) prioritizing relationships, and iv) re-envisioning environments. Foundationally underlying these commitments is direct action toward reducing coercive practices and structures, such as chemical and physical restraints, seclusion, and door locking. Mental health professionals are encouraged to challenge the zero-risk paradigm and its resultant risk management approaches, and embrace a safety paradigm to meaningfully re-orient care toward enhancing patients' safety and well-being during and following hospitalization.

Can Measurement-Based Care Reduce Burnout in Mental Health Clinicians?

Burnout is a syndrome characterized by mental and emotional fatigue or exhaustion, depersonalization, and a lessened sense of personal accomplishment and efficacy. Burnout leads to negative consequences for mental health clinicians and for mental health care organizations. Measurement-based care (MBC) is a clinical process in which clinicians and clients use patient-generated data, also called treatment feedback, to collaboratively monitor mental health care and to inform goal-setting and treatment planning. We propose that MBC may improve the experience of care for both clients and clinicians, and ultimately protect against each of the three components of burnout. When combined with other organizational changes, adoption of MBC may support organizational level efforts to reduce burnout in mental health services.

Mental Health Care in Poland

Abstract Background: Like in other industrialized countries, the development of Polish psychiatry has followed a typical trajectory, initially marked by the establishment of large mental health hospitals using an isolation-based care model. Subsequently, there has been a decline in these institutions, characterized by a reduction in the number of hospital beds, and an ongoing evolution toward decentralized community psychiatry, specifically mental health-care centers. The hospitalizations are for emergency/acute care only. The authors describe how clinical services and personnel training in Poland that have been adjusted in response to societal changes and global trends in mental health care. Methods: The authors collected and critically reviewed information based on literature relevant to the organization of mental health care in Poland. In addition, official government publications such as reports from the Central Statistical Office and Ministry of Health were perused to gather data on the population structure, gross domestic product, and the organizational structure of the mental health care and relevant health-care indices. Results: Mental health care in Poland is evolving and gradually improving, providing more opportunities for collaboration and networking among nongovernmental organizations, patients’ associations, and psychiatrists working toward common goals. Training curricula have been updated and/or modified, with new specialty and subspecialty trainings being offered to meet the demands of health-care professionals and patients alike. Conclusion: Demographic changes, the presence of Ukrainian war refugees, and global trends in psychiatry profoundly influence the delivery of mental health-care services in Poland.

Changing and unfinished narratives of the mental health impact of HIV in the UK

The mental health impacts of HIV have evolved significantly over the last four decades, in parallel with changes in the virus's overall health consequences. This study charts transformation in narratives about mental health problems associated with HIV over the course of the epidemic, as outlined by people with HIV (40%), professional carers (45%) and activists (25%) in the UK. In particular, our study examines evolving mental health impacts and changing service provision during three key periods: The early days of the epidemic; after the introduction of effective antiretroviral therapy (ART) in 1996; and in more recent times as HIV came to be regarded as a chronic manageable condition. Fifty-three participants were recruited: Male (68%), female (32%), White (90%), African/Afro Caribbean (6%) and South Asian (4%). Results indicate that despite important changes in the severity and nature of the mental health impacts of HIV, there were persistent challenges, related to the long-term mental health consequences of HIV among earlier generations of people with HIV. There were additional challenges associated with: ageing with HIV; the development of sexual dysfunction; and the possibility of neurocognitive impairment. The organization of mental health care for people with HIV moved from specialist teams to general practice, presenting challenges of mainstreaming care. The commissioning and delivery of mental health services need to be sensitive to the ever-changing social contexts and the potential for ‘left behind’ people living with HIV, despite the overall ‘naturalisation’ of HIV.

For better or worse: Governing healthcare organisations in times of financial distress.

Due to processes of financialisation, financial parties increasingly penetrate the healthcare domain and determine under which conditions care is delivered. Their influence becomes especially visible when healthcare organisations face financial distress. By zooming-in on two of such cases, we come to know more about the considerations, motives and actions of financial parties in healthcare. In this research, we were able to examine the social dynamics between healthcare executives, banks and health insurers involved in a Dutch hospital and mental healthcare organisation on the verge of bankruptcy. Informed by interviews, document analysis and translation theory, we reconstructed the motives and strategies of executives, banks and health insurers and show how they play a crucial role in decision-making processes surrounding the survival or downfall of healthcare organisations. While parties are bound by legislation and company procedures, the outcome of financial distress can still be influenced. Much depends on how executives are perceived by financial stakeholders and how they deal with threats of destabilisation of the network. We further draw attention to the consequences of financialisation processes on the practices of healthcare organisations in financial distress.

Home Care Services and Early Detection & (Risk)Signaling: An Indispensable Link in Integrated Primary Care

Summary: Funded by the city of Antwerp, this project wants to optimize the preventive role and position of Home Care Services (HCS) in primary care by (1) improving the early detection en (risk)signaling of the home care professionals, (2) and elaborating the bridging function between HCS and the different primary care disciplines and sectors through shared vision and goals, suitable tools, communication systems and clear procedures in information sharing.
 Short description: HCS provide essential (non-medical) support that a person or a family in need of care requires in order to continue to live independently at home. Typical for Home Care Services is that employees spend many hours in close contact to the person or family in need of care. As a confidant to the client they quickly pick up on behavior changes, evolution in illness or condition. They are often the “eyes and ears” to a multidisciplinary team of care providers surrounding a client or patient. Or at least: they could be. All too often this indispensable role of HCS is insufficiently recognized by welfare organizations and medical care providers.
 The confidant position and early detection role of HCS professionals can bridge gaps between other professional care givers and a (psychologically or mentally vulnerable) client/patient, via signalization and referral to best placed (mental) health care or welfare actors.
 Several conditions need to be fulfilled for HCS to being able to effectively play this part in an integrated care system, like shared vision and goals, suitable tools, clear procedures in information sharing, recognition of HCS professionals as equal partners in primary care. All these conditions are being addressed in this project.
 Target group: All independent living persons in need of care and their care givers. In the first phase the project focusses on people with a psychological or mental vulnerability. 
 Project design
 * Involved actors:
 All HCS active in the City of Antwerp, in intense collaboration with a network of mental health care organizations, the social health services of the City of Antwerp. A sounding board is established to ensure the involvement of all relevant parties (project intervision, monitoring, adjustment).
 
 * Co –design approach: the target groups are therefore being involved via focus groups and quality surveys, throughout the project.
 * Possible restrictions:
 
 Legal restrictions on information sharing (e.g. GDPR, professional secrecy)
 Diversity in ways of financing of organizations.
 A broad and diverse set of (online) communication tools and ways of information sharing between health care sectors
 
 Next steps:
 
 Roll out of training programs to add to the competences of HCS professionals.
 Adjustment of internal and external communication protocols.
 Development and testing of uniform and shared (digital) communication tools.
 Application of uniformized methods concerning early detection, signalization and guidance in all vulnerable client situations.
 
 Learning for the international audience:
 
 Insights regarding the project's approach
 Importance of the role and contribution of a home care service (with lower-skilled staff) compared to the (highly-skilled) GP or home care nurse.
 
 
 

Family involvement in care: essential next step?!

First, we outline the current state of family involvement in mental health care. Based on testimonials from families and family organizations, the strengths, needs and deficits regarding family involvement in mental health care are listed. Furthermore, some innovative good practices are explained, demonstrating the ongoing evolution in healthcare.
 Research has demonstrated that treatement, involving, supporting and informing family members and children has an important positive impact for family, patient and care provider.
 However, too often Familieplaform receive signals from family members and family organizations that family invovement in mental health care is limited. Moreover, great differences exist between organisations, teams and health care provivers: while some organisations/teams/care providers akcnowlegde the importance of family (involvement) and make great efforts to maximale involve the context, many others don’t. By creating frameworks - such as the multidisciplinary guideline for involving relatives in mental health care - we want to invite mental healthcare organizations to systematically make the ‘family reflex’ and to see family as equal partners in care.
 The ‘Family Reflex’ translates the guideline on involving relatives in mental health care by offering online trainings, a Quickscan, coaching programs, etc. During this workshop, we will discuss the recommendations of the guideline, the merrit of the Family Reflex and our experiences in helping organisations and care providers to integrate these recommendations into their own practice. 
 We discuss with participants on different topics : professional secrecy, support for family members/ children, participation in care.
 Concrete:
 explaination 45min
 interaction 3x15 min (each topic/ can be less)
 
 
 

Exploring the added value of virtual reality biofeedback game DEEP in forensic psychiatric inpatient care-A qualitative study.

Low motivation and suboptimal cognitive skills are common among forensic psychiatric patients. By focusing on doing and experiencing, innovative technologies could offer an alternative to existing treatment for this patient group. One promising technology is DEEP, a VR biofeedback game that teaches diaphragmatic breathing, which has shown its potential in reducing stress in other populations. This exploratory study aimed at identifying if, how and for whom DEEP can be of added value in forensic mental healthcare. This study used a qualitative approach. Six focus groups with 24 healthcare providers and 13 semi-structured interviews with forensic psychiatric inpatients were conducted in two Dutch forensic mental healthcare organizations. All healthcare providers and patients experienced DEEP before participating. The data were coded inductively, using the method of constant comparison. The data revealed six themes with accompanying (sub)codes, including (1) the possible advantages and (2) disadvantages of DEEP, (3) patient characteristics that could make DEEP more or (4) less suitable and beneficial, (5) ways DEEP could be used in current treatment, and (6) conditions that need to be met to successfully implement DEEP in forensic mental healthcare. The results showed that DEEP can offer novel ways to support forensic psychiatric patients in coping with negative emotions by practicing diaphragmatic breathing. Its appealing design might be suitable to motivate a broad range of forensic psychiatric patient groups. However, DEEP cannot be personalized, which might decrease engagement and uptake of DEEP long-term. Regarding its place in current care, DEEP could be structurally integrated in existing treatment programs or used ad hoc when the need arises. Finally, this study showed that both healthcare providers and patients would need practical support and information to use DEEP. With its experience-based and gamified design, DEEP could be useful for forensic mental healthcare. It is recommended that patients and healthcare providers are included in the evaluation and implementation from the start. Besides, a multilevel approach should be used for formulating implementation strategies. If implemented well, DEEP can offer new ways to provide forensic psychiatric patients with coping strategies to better control their anger.

VReedom: training for authorized leave of absence through virtual reality - a feasibility study.

This study assessed the feasibility, implementation process and outcomes of the VReedom training; a virtual reality (VR)-based intervention designed to prepare forensic psychiatric patients for their first authorized leave. Clinical forensic mental healthcare organization Inforsa, operating at security level 3, introduced the VReedom training for forensic patients eligible for their first authorized leave, between March 1st and November 13th, 2022. Employing a retrospective observational cohort study design with patient dossier data as the primary source, the study also used participant observation, weekly evaluative questionnaires and focus group discussions as data sources. Five objectives were utilized to evaluate the feasibility: recruitment capacity and resulting sample characteristics, data collection and evaluation procedures, acceptability and suitability of the training and protocol, training management and implementation, and preliminary participant results. Despite the lack of a control group, findings align with literature suggesting VR's potential for enhancing treatment motivation and reducing stress in preparation for first authorized leave. Of 13 patients approached, 10 participated without dropouts, and no incidents occurred during training. Emotion elicitation was successful, supporting VR Exposure therapy's efficacy. Findings align with literature, emphasizing VR's value in forensic psychiatry. Establishing favorable implementation conditions was crucial, with positive reception from treatment providers. Also, the need for personalization and additional locations was identified, and the training seemed most suitable for patients with a tbs-measure. Future research with control groups is recommended to further validate the effectiveness of the VReedom training intervention, and further protocol development is necessary to make it suitable for a broader population. Current findings contribute to the refinement and expansion of evidence-based practices in the field of VR-assisted training and treatment in forensic psychiatry.

The stress of war. Recommendations for the protection of mental health and wellbeing for both Ukrainian refugees as well as Poles supporting them.

The presence of large numbers of Ukrainians looking for refuge in Poland is a new experience for Poles. The ongoing war and the uncertainty of the situation of those displaced may cause anxiety and lead to stressful reactions, exacerbated by endlessly circulating information on hostilities. Therefore, the sense of security may be threatened not only among Ukrainians who have fled to Poland, but also among people who support Ukrainians, who offer them help and shelter. Prolonged support, if not accompanied by proper selfcare can increase the risk of burnout as well as lead to distressful emotional states, such as a feeling of helplessness, hopelessness, reluctance to provide further help, or even demonstrate hostility. The article presents the situation and current psychosocial needs of Ukrainian refugees in Poland and provides a set of recommendations regarding the organization of mental health care in the face of the ongoing war in Ukraine. There are available tools to use by Polish specialists and lay helpers to support Ukrainian refugees. The Mental Health and Psychosocial Support (MHPSS) Intervention Pyramid, developed by the Inter-Agency Standing Committee, is used to classify suggested interventions. Appropriate care should be available to both refugees as well as the host population involved in their care.

Protecting the Autonomy of Patients with Severe Mental Illness Through Psychiatric Advance Directive Peer-Facilitation

Protecting the Autonomy of Patients with Severe Mental Illness Through Psychiatric Advance Directive Peer-Facilitation

Understanding the Role of Patient Portals in Fostering Interprofessional Collaboration Within Mental Health Care Settings: Mixed Methods Study.

Patient portals are web-based systems through which patients can access their personal health information and communicate with their clinicians. The integration of patient portals into mental health care settings has been evolving over the past decade, as cumulated research to date has highlighted the potential role of portals in facilitating positive health outcomes. However, it is currently unknown whether portal use can foster interprofessional collaboration between clinicians and patients or whether the portal is a tool to support an already established collaborative relationship. This mixed methods study aimed to understand how the use of a patient portal within mental health settings can impact the level of interprofessional collaboration between clinicians and patients. This study was conducted in a large mental health care organization in Ontario, Canada. A convergent mixed methods design was used, where the primary data collection methods included questionnaires and semistructured interviews with patients who had experience using a portal for their mental health care. For the quantitative strand, participants completed the Health Care Communication Questionnaire and the Self-Empowerment subscale of the Mental Health Recovery Measure at 3 time points (baseline, 3 months of use, and 6 months of use) to measure changes in scores over time. For the qualitative strand, semistructured interviews were conducted at the 3-month time point to assess the elements of interprofessional collaboration associated with the portal. For the quantitative strand, 113 participants completed the questionnaire. For the Health Care Communication Questionnaire scores, the raw means of the total scores at the 3 time points were as follows: baseline, 43.01 (SD 7.28); three months, 43.19 (SD 6.65); and 6 months, 42.74 (SD 6.84). In the univariate model with time as the only independent variable, the scores did not differ significantly across the 3 time points (P=.70). For the Mental Health Recovery Measure scores, the raw mean total scores at the 3 time points were as follows: baseline, 10.77 (SD 3.63); three months, 11.09 (SD 3.81); and 6 months, 11.10 (SD 3.33). In the univariate model with time as the only independent variable, the scores did not differ significantly across the 3 time points (P=.34). For the qualitative strand, 10 participants were interviewed and identified various elements of how interprofessional collaboration can be supplemented through the use of a patient portal, including improved team functioning, communication, and conflict resolution. Although the quantitative data produced nonsignificant findings in interprofessional collaboration scores over time, the patients' narrative accounts described how the portal can support various interprofessional collaboration concepts, such as communication, leadership, and conflict resolution. This provides useful information for clinicians to support the interprofessional relationship when using a portal within a mental health setting. RR2-10.1136/bmjopen-2018-025508.

Applying the Model of the European Foundation for Quality Management to evaluate quality of care alongside the merger of mental health care institutes in Amsterdam: a five year pre–post study

Abstract Background Health care reforms over the past decades in the Netherlands enforced institutions to enhance quality and to contain costs. To cope with the policy context, a majority of mental health care institutes applied a merger strategy and hence large mental health care organizations were created. This study assesses the impact of a merger and the related quality management approach on the quality of care of three large Dutch mental health care institutes in Amsterdam. The nine criteria of the Model of the European Foundation for Quality Management (EFQM Model) with 32 criteria parts for total quality management were used. Method A case study with a pre–post design was applied, with the EFQM baseline (pre) and follow-up (post) assessments using the standardized EFQM protocol with a 0%–100% scoring system. The baseline status of 2007–2008 was scored and validated by seven independent certified assessors. During a period of 5 years, the merge was conducted, enhancing the quality management and effectuating the findings of the advice of the feedback report. An EFQM post-assessment of the status of 2012–2013 was carried out by five independent certified assessors applying the strict EFQM assessment protocol. The statistics of pre–post differences were evaluated. The study can be seen as a before–after assessment of a naturalistic experiment. Results The comparison of the nine EFQM criteria before and after the merger on the bases of the scores of the assessors shows an overall improvement from 358 to 425 points on the EFQM scale 0–1000. There is one slight deterioration concerning criterion 8: Society Results, five criteria show positive changes. The top three criteria with the highest improvement are 1: Leadership (15% improvement), 5: Processes, Products, and Services (12%), 6: Customer Results (15%). The overall statement of the audit team of 2013 is ‘The merged organisation strives for effectiveness, which leads to better results in most of the areas.’ Learning from the results is one recommendation of the assessors for the future. Conclusion The conduced merge of three Dutch mental health care institutions in Amsterdam showed an improvement of quality based on the criteria of the EFQM Model over a period of 5 years. This naturalistic experiment can stimulate further studies about mergers. The systematic and transparent approach and documentation can facilitate mutual learning.

Values and practice of collaboration in a mental health care system in the Netherlands: a qualitative study

BackgroundTo offer optimal care, the mental health system needs new routes for collaboration, involving both interprofessional and interorganizational aspects. The transition from intramural to extramural mental health care has given rise to new dynamics between public and mental health care, introducing a challenge for interprofessional and interorganizational collaboration. This study aims to determine values and expectations of collaboration and to understand how collaboration in mental health care organizations takes shape in daily practice.MethodsWe conducted a qualitative study using semi-structured interviews and a focus group, in the setting of the Program for Mentally Vulnerable Persons (PMV). Data were analysed following thematic analysis.ResultsWe found three aspect that were considered important in collaboration: commonality, relationships, and psychological ownership. However, our findings indicate a discrepancy between what is considered essential in collaboration and how this materializes in day-to-day practice: collaboration appears to be less manageable than anticipated by interviewees. Our data suggest psychological ownership should be added as value to the interorganizational collaboration theory.ConclusionOur study offers a new definition of collaboration and adding “psychological ownership” to the existing literature on collaboration theory. Furthermore, we gained insight into how collaboration between different organizations works in practice. Our research points to a discrepancy between what all the partners find important in collaboration, and what they actually do in practice. Finally, we expressed ways to improve the collaboration, such as choosing between a chain or a network approach and acting on it and re-highlighting the goal of the Program Mentally Vulnerable persons.

What innovative practices and processes are used to deliver psychosocial care in India? A qualitative case study of three non-profit community mental health organisations

The global mental health field seeks to close the “treatment gap” for mental illness in low-and middle-income countries by scaling evidence-based interventions. The evidence base has often bypassed psychosocial interventions by local organizations who do not fit a biomedical approach to evidence building. In India, non-profit mental health organizations are addressing care gaps through novel approaches that emphasize social recovery and inclusion.This study seeks to better understand the nature and dynamic of this innovation by examining what was working well in the practices and processes of three such community mental health care organizations. A comparative case approach was chosen for its strength as an exploratory means for inductive theory building. Three case organizations in Kerala, West Bengal and Uttarakhand states were selected based on their diverse socio-cultural and health systems settings. Qualitative data was collected in 2018–20, to examine their practices and processes using mixed methods and data sources including interviews, focus groups, participant observation and document analysis.Common strategies observed across the three organizations, included engaging community, prioritising beneficiaries, co-opting resources, devolving care, reorganising communication and recovery and integration. These strategies were further categorized into three domains: constructing a sustainable resource base, managing knowledge and redefining meanings. In contrast with conventional problem-solving approaches, these cases used an approach that built on assets and strengths using inclusive governance which enabled coordination of the community health system.This study argues that these organizations incorporate reflexive practice and two-way flows of knowledge to enable them to address complex social determinants of mental health. This has implications for how psychosocial care in CMH is conceptualized. We argue that the ways the organizations respond to the complexities of mental health difficulties contributes to reframing mental health as a social development issue, centering inclusion of people with psychosocial disabilities. Our findings argue against a polarization between biomedical and psychosocial CMH models and illustrate ways of integrating both approaches and their centrality to effective mental health care.

Provision of Telemental Health Before and After COVID-19 Onset

To examine the organizational characteristics associated with telemedicine services provided by mental health care organizations before and after onset of the COVID-19 pandemic in the United States. Using 2019-2020 National Mental Health Services Survey data, we assessed changes in provisions of telemedicine services by mental health care facilities before and after onset of the COVID-19 pandemic. We estimated multivariable logistic regression models comparing pre- vs postpandemic changes in prevalence of telemedicine offered by mental health care facilities. We incorporated mental health care organizations' characteristics, including facility type, accepted payment, geography, and language service provisions, as well as state-level policies, such as payment parity laws, shelter-in-place laws, and number of COVID-19 cases. Mental health care facilities had 4 times the odds (odds ratio [OR], 4.3; 95% CI, 4.09-4.61)​​ of telemedicine provision post pandemic in 2020 compared with prepandemic in 2019. In 2020, facilities that accepted Medicaid (OR, 1.3; 95% CI, 1.11-1.49) and Medicare (OR, 1.3; 95% CI, 1.14-1.39) were more likely to provide telemedicine than those that did not. Facilities that offered American Sign Language (OR, 1.3; 95% CI, 1.16-1.43) and non-English language services (OR, 1.3; 95% CI, 1.15-1.44) were more likely to provide telemedicine than facilities that did not. Facilities located in states with payment parity laws (OR, 1.2; 95% CI, 1.11-1.36) were more likely to offer telemedicine than states without. Telemedicine availability in mental health facilities has expanded post COVID-19 pandemic, but telemedicine provision has been uneven across organizational and state-level factors. Expansion of regional investments and payment parity might be necessary to ensure equitable provision of telemedicine.

Innovations in treatment of psychosis in southeast europe

AbstractSoutheast Europe (SEE) is home to 70 million people living across 12 countries. These countries share similar socioeconomic background and tradition of healthcare systems, although many differences exist in the organisation of mental health care. The region has been called ‘the blind spot on the global mental health map’ due to lack of research and innovations in mental health care. In recent years European Commission has invested significant resources to improve mental health care of individuals with severe mental disorders in Southeast Europe. Two major, recently completed, projects are Recover-e and Impulse. This presentation will focus on findings from the Impulse study. We will start with an overview of evidence-based, non-pharmacological interventions for individuals with psychosis, with focus on what is offered and implemented in 12 SEE countries. Next, we will present key findings from the hybrid type II effectiveness-implementation psychosocial randomised-controlled trial. We will show an evidence-based approach how to improve psychosocial aspect of treatment of individuals with psychotic disorders. Mental health services that offer a combined-therapy approach, including psychosocial interventions and pharmacotherapy, can ensure holistic care, preferred by patients and their families. Discussion will include the role of implementation science tool in mental health care and sustainability of implemented interventions.Disclosure of InterestNone Declared

Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial.

Internet-based cognitive behavioral therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for strategies that improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective. Tailored implementation is considered as a promising approach. The self-guided integrated theory-based Framework for intervention tailoring strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves identifying local barriers; matching selected barriers to implementation strategies; developing an actionable work plan; and applying, monitoring, and adapting where necessary. This study aimed to compare the effectiveness of the ItFits-toolkit with implementation-as-usual (IAU) in implementing iCBT services in 12 routine mental health care organizations in 9 countries in Europe and Australia. A stepped-wedge cluster randomized trial design with repeated measures was applied. The trial period lasted 30 months. The primary outcome was the normalization of iCBT delivery by service providers (therapists, referrers, IT developers, and administrators), which was measured with the Normalization Measure Development as a proxy for implementation success. A 3-level linear mixed-effects modeling was applied to estimate the effects. iCBT service uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. The perceived satisfaction (Client Satisfaction Questionnaire), usability (System Usability Scale), and impact of the ItFits-toolkit by implementers were used to assess the acceptability of the ItFits-toolkit. In total, 456 mental health service providers were included in this study. Compared with IAU, the ItFits-toolkit had a small positive statistically significant effect on normalization levels in service providers (mean 0.09, SD 0.04; P=.02; Cohen d=0.12). The uptake of iCBT by patients was similar to that of IAU. Implementers did not spend more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it. The ItFits-toolkit performed better than the usual implementation activities in implementing iCBT services in routine practice. There is practical utility in the ItFits-toolkit for supporting implementers in developing and applying effective tailored implementation strategies. However, the effect on normalization levels among mental health service providers was small. These findings warrant modesty regarding the effectiveness of self-guided tailored implementation of iCBT services in routine practice. ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883. RR2-10.1186/s13063-020-04686-4.

Effectiveness of an Educational Intervention on Clinical Competency among Mental Health Nurses Working at a Government Mental Health Hospital: A Quasi-experimental Study

Background: Mental health nurses play an important role in caring for patients with mental illnesses. In order to provide comprehensive mental health nursing care, it is important to establish periodic educational interventions about mental health and psychiatric nursing in any mental health institution. The presence of frequent educational programs can lead to improvements in mental health nurses' clinical competency. Aim: To evaluate the effectiveness of an educational intervention on the clinical competency of mental health nurses. Methods: A quasi-experiment study pretest and posttest with one group study design were conducted among 80 nurses in a large mental health hospital in Tabuk city, Saudi Arabia. Data were collected by using the clinical competence evaluation in mental health nurses scale to evaluate the effectiveness of an educational intervention on the clinical competency of mental health nurses by comparing the result of the pretest and posttest scores. Result & Discussion: The total score for the pre-test was (74.83±14.25/Average), and then the score increased dramatically for the post-test (96.18±26.53/Good) also, the Wilcoxon signed-rank test indicated that Post-test (Mean rank=102) significantly higher than pre-test (Mean rank=59) (U=1480, p<0.001). As a result of the current study, the program showed great effectiveness (p<0.001) with an advantage for post-test. Conclusion: The collected data analysis revealed a statistically significant positive effect of educational programs on improving mental health clinical competency, hence, Healthcare organizations and senior decision-makers should develop well designed periodic mental health programs that involve nurses who have a master's and doctorate degrees in mental health nursing to enhance mental health clinical competency.

Introducing Peer-supported Open Dialogue in changing mental health care.

The need to transform mental health care toward person-centered, recovery-based, and network-oriented care is recognized worldwide. Open Dialogue (OD) is seen as a hopeful approach in the context of this transformation and is introduced in countries around the globe. Five Dutch mental health care organizations spread over the Netherlands introduced the Peer-supported Open Dialogue (POD) approach, which adds an explicit role of peer-support workers to the OD approach. It appeared that (P)OD-trained professionals face issues in introducing the (P)OD approach in existing MHC settings. One of the reasons, which is the focus of this study, may be that they encounter difficulties in explaining to non-(P)OD-trained professionals what (P)OD entails. The main objective of this study is to provide guidance to and contribute to making (P)OD better understandable for non-(P)OD-trained professionals. In this study, we used a qualitative design and conducted 23 semi-structured interviews with POD-trained professionals with various backgrounds, to cultivate a rich understanding of which aspects could contribute to a better understanding of POD for non-POD-trained professionals. We used a hybrid approach to analyze the data, meaning that the technique of both inductive and deductive thematic analyses has been applied. From these analyses, six aspects emerged that could give guidance to and contribute to making (P)OD more understandable for non-(P)OD-trained professionals: (1) Experiencing (P)OD by attending treatment network sessions, (2) a coherent and profound narrative about (P)OD, (3) adjusting terminology to better fit the context, such as the two terms "principles" and "responsibility" in this study, (4) the order in which (P)OD elements are introduced in the narrative, (5) bringing the elements "presence," "reflecting," and "expertise by experience" more to the foreground, and (6) conceptualizing the main elements in a "talking paper." A better understanding of (P)OD might be one of the building blocks for improving (P)OD adoption in existing MHC practices, which are on their way toward person-centered, recovery-based, and network-oriented care.