Themes/Subthemes | Normalisation Process Theory Mechanisms | |||
---|---|---|---|---|
Coherence | Cognitive Participation | Collective Action | Reflexive Monitoring | |
Patient | ||||
Patient engagement | - The patients’ understanding of the benefits of early intervention was an important for individuals to engage with the model. - The active outreach and engagement work were valued by clinicians and were seen as important for patient coherence. | - Outreach, the engagement call, and emphasising the importance of early intervention enrols patients in FREED work. | - Engagement calls were easy to integrate but depends on the relation/interaction with patient and/or referrer. - Rota system used in some teams to distribute engagement calls. | - Individual clinicians were engaged in appraisal work regarding the impact of FREED on motivation and engagement. |
Patient complexity and comorbidities | - Difficulties determining suitability for FREED. - Individual and collective work (i.e., thorough evaluation and team discussions) to determine and develop confidence in suitability. | |||
Clinician | ||||
Hope and enthusiasm: Making sense of early intervention and FREED | - There was a high degree of individual and collective understanding of FREED and its value in FREED teams. - The potential benefits of FREED to patients were core to how clinicians made sense of FREED. - There was a high degree of personal alignment and internalisation of the objectives of FREED amongst clinicians. - Assessing the evidence-base was a key mechanism in how clinicians attribute value to FREED. - Comparison of FREED against standard illness prioritisation procedures built coherence towards the model. | - Key enthusiastic individuals drive FREED forward using a range of activities to create and maintain ‘buy-in’. | - Clinician and senior staff supporting the adoption of FREED was central to implementation and the distribution of resources. | - Appraisal of the evidence-base and the observed impact on patients and the team was used to evaluate the worth of FREED. |
Conflicting feelings: Eligibility and concerns about non-FREED patients | - Individual and collective concerns regarding the impact on waiting lists and non-FREED patients were key barriers. - Wider team did not always value all aspects of FREED (i.e., perceived as ‘privileged’ and ‘light’ work). - Most clinicians perceived FREED as beneficial for all ages. Equally, the age eligibility criterion was understood as pragmatic and enabled tailoring to developmental stage. - The value of FREED was perceived to extend beyond FREED patients. | - Some services adapted the eligibility criteria to align with their service and beliefs. - Difficulties determining duration of an untreated eating disorder due to confidence/skills, and clarity of information from patient. | - Ongoing clinician appraisal of the broader impact of the model (i.e., impact on non-FREEDs, wider service). - Clinicians re-configured the eligibility criteria and formally (data) and informally (personal experience) appraised the change. | |
Self-efficacy: Experience, stress, and resilience | - Greater experience in EDs increases the internalisation of FREED as important and needed. | - Individual skills and belief about skills and capacity to implement FREED impacted the implementation. - Continued investment and engagement with FREED builds skills and confidence around the model over time. - Individuals with pre-existing caseloads and many years in EDs are required to do more work to integrate FREED into their existing practice. - Active support to manage stress/anxiety provides individuals with the resources to engage in FREED work. | - Ongoing appraisal regarding oneself and other’s ability to understand and use the model. | |
The Service Model | ||||
Flexibility and structure | - Structure enables clear understanding of the specific tasks and steps needed to implement FREED. - An understanding of how FREED compares to standard practice was needed to adapt it to the local context. - The flexibility around the model was valued. | - There was individual and collective work taking place to adapt FREED to ‘fit’ the local context (e.g., sharing the Champion responsibilities, ‘whole team’ approach to implementing FREED) – largely undertaken by senior staff and FREED Champion. | ||
Champion as invaluable | - Champion as designated individual that drives FREED forward, creates, and maintains engagement, and enrols others in FREED work. | - Champion distributes and manages the work and resources needed to implement FREED. - Champion supports ongoing training and skill development to enable clinicians to implement FREED (also relevant to the Practice and ongoing training subtheme). - Insufficient capacity for Champion to complete all tasks. Sharing and delegating Champion tasks and responsibilities is often needed. | ||
Meeting people where they are at: Care package and resources | - Tailoring treatment perceived as beneficial and valued. - Some difficulties understanding how and when to integrate care package adaptations into standard treatment. - Some unawareness of care package components (typically at outset and in wider team). | - Tailoring treatment and having resources available online engages clinicians and patients into FREED work. | - Work was required to adapt standard treatment to accommodate FREED adaptations. - FREED-related materials (e.g., tracker template), prompts, reminders, and using different communication methods made FREED easier to integrate into work. - The interaction between the patient’s life stage and adaptations can make the adaptations easy (e.g., relevance) and difficult (e.g., family involvement for students) to use. | |
Implementation Strategy | ||||
Practical and ongoing training | - Training and its continuation as key to developing individual and collective understanding of FREED and its benefits. | - Training supports initiation and legitimisation of FREED. | - Sufficient training was undertaken to develop the skills to implement FREED, but more and ongoing training was desired. FREED Champion was key for ongoing training and skill development in teams. | |
Being part of something bigger: The FREED Network | - Network enabled teams to work together to make sense of FREED and its implementation. - Wider investment and interest lead to greater internalisation of the importance of FREED. - Conferences as key medium to share information and “take FREED off the pedestal”. | - Network and data feedback create a broad community of practice that legitimises and maintains engagement. | - Implementation supervision and ongoing evaluation contribute towards accountability and confidence in using the model. - Data collection work shared with/delegated to assistant psychologists, support workers, and administrators. | - Formal and informal appraisal during implementation supervision and data feedback to evaluate whether FREED and its components are working and worthwhile. |
Service | ||||
Capacity and competing demands | - Concerns regarding capacity at the outset and over time can impact value attributed to FREED. | - Champion, mini team, and Network identified as important for maintaining momentum and engagement amongst competing demands. | - Insufficient resources allocated to implement FREED in some but not all teams. - Individually and collectively adapting mental and material resources to address capacity issues. | - Ongoing individual and communal appraisal around capacity and the re-configuration of FREED and treatment as usual as capacity fluctuates. |
Compatibility and integration | - Developing an understanding of how FREED differs from standard practice was done to allow for integration work. - At the outset, FREED was sometimes perceived as “special” and very different from standard practice, which was a barrier, but this changed over time as it became integrated. | - Integration and protected time supported the enrolment, legitimisation, and sustainability of FREED. | - Compatibility with the existing service and clinician values and practice was a facilitator. - Relational and contextual integration through integrating into service processes and procedures, culture, and resources (e.g., protected Champion time and meetings). - Limited integration with wider team can disrupt working relations and FREED. - Carefully balancing and integrating FREED and non-FREED work was important. | - Dedicated FREED huddles and integrating FREED into discussion in general meetings was used to appraise FREED work. - Clinicians appraised and re-configured to overcome integrational barriers. |
An open dialogue: Sharing and involvement | - Involvement and an open dialogue allowed teams to work together to develop a shared understanding of the model, its benefits, and to address concerns. | - Active involvement and creating an open dialogue initiate and enrol clinicians in FREED work. - Mini team enables ongoing engagement and maintenance of the model. | - Subtheme included the interactional work people do around FREED to develop accountability and confidence in the model. - Allocated time in meetings to enable interactional work to take place. - FREED work distributed amongst the entire team or mini team. - FREED can disrupt working relations/create a divide in the service. | - Communal appraisal of the functioning, and problems around FREED was an important facilitator. - Re-configuring the structure of FREED, i.e., mini vs. whole team approach, following appraisal and then appraising the value of this re-configuration. |
Wider System | ||||
Broader system care | - A wider shared understanding (e.g., public, healthcare services) of EDs and FREED is needed for early identification but was not always present. - Understanding of outreach work as a core responsibility in early intervention and a valued part of FREED. | - Identification and enrolment of referrers at the outset is needed to ensure successful implementation. | - Funding/resources needs to be obtained quickly from the broader system (e.g., commissioners) to enable implementation. - Relational work with educational institutions and referrers was taking place to ensure early identification and appropriate referrals. | - Clinicians engaged in appraisal work regarding the referral pathways and processes into the service to ensure the earliest identification. |
Coronavirus diseases 2019 (COVID-19) | - FREED still perceived as important; however, less important relative to pressing COVID-19 demands. | - COVID-19 disrupted interactional and relational work. Clinicians and patients required to re-establish relations and implement FREED in the context of COVID-19. - Clinicians worked to re-operationalise and maintain FREED in altered circumstances (e.g., virtual appointments). | - Clinicians were routinely engaged in informal appraisal of the positive and negative impacts of virtual working. |