We identified six themes with a total of 26 categories representing barriers to implement family involvement: 1) Lack of shared knowledge, perceptions, and practice 2) Lack of routines 3) Lack of resources and logistics 4) Patient-related factors 5) Relative-related factors 6) Provider-related factors. The first three themes represent barriers at the organisational level, while the latter three represent barriers at the clinical level (Fig. 1).
Furthermore, we identified six themes with a total of 14 categories representing facilitators for implementing family involvement: 1) Whole-ward approach 2) Appointed and dedicated roles 3) Standardisation and routines 4) External implementation support 5) Understanding, skills, and self-efficacy among mental health professionals 6) Awareness and positive attitudes among mental health professionals. The first four themes represent facilitators at the organisational level, while the latter two represent facilitators at the clinical level (Fig. 1).
In the beginning of the project, when experience with implementation of family involvement was sparse, the focus was mostly on the barriers and more general or common experiences with implementation of family involvement. During the implementation period the experience with- and focus on facilitators gradually increased, as well as the more specific experiences with systematic implementation through participating in the IFIP trial. In previous research, barriers to the implementation of family involvement have been rather extensively explored, while knowledge about facilitators remains sparse . Thus, in the present article, we focus on the facilitators. An overview of both barriers and facilitators is presented in Fig. 1, while Additional file 3 (barriers) and 4 (facilitators) provide additional illustrative quotes pertaining to the various themes, categories, and subcategories.
Facilitators at the organisational level
Prior to implementation, an important barrier was the lack of shared knowledge, perceptions, and practice. Family involvement practices appeared random, and seemed largely dependent on the individual professional’s interest and competence , hence at risk of falling apart.
In the IFIP trial, the clinical and organisational levels were approached simultaneously. An explicit aim was that all patients and relatives should be offered at least a basic level of family involvement and support. To enable this, all clinical staff were offered training and supervision, and most participated in the training. This may be described as the key elements of a “whole-ward approach”. The approach was experienced as consequential to develop a more family-friendly culture in most of the wards, as portrayed by this participant:
We take relatives into consideration in all settings, in all occasions, really. In the treatment team, reflective team, mini team. It`s hardly ever forgotten. There is something about our way of thinking that has changed. It is very evident with us. (FG12).
Many of the participants emphasised the importance of developing common understanding and priorities among the staff through the whole-ward approach, and enabling the staff to engage with the relatives in new ways:
It is an asset that so many of us have this training, because then we kind of have the same way of thinking about it. For example, that relatives to a greater extent are allowed to share their own experiences, that we are not just focused on obtaining information, or on the patient. (FG13).
Furthermore, the whole word approach was necessary for all clinicians and managers to acknowledge family involvement as a key ingredient in good care and treatment, and FPE as a recommended treatment option:
P: It was so important that all the professional groups were included in the FPE course (…) That helps it spread wider. For example, since I have received the training, I have a different view of the patients’ treatment options. (The researcher further asks whether the participant thinks that the other therapists are feeling the same way):
P: Yes, I think they feel the same. (FG12).
Furthermore, the basic level of family involvement and more comprehensive approach (FPE) appeared to be mutually reinforcing. For instance, the threshold to invite the patient and relatives to more comprehensive family involvement seemed to be lowered by establishing a basic level of family involvement as default approach. This approach also seemed to further a process with stepwise consent, where consent for family involvement was discussed several times and obtained gradually in an ongoing process, starting out with the most basic type of family involvement. This was considered better than an “all or nothing” approach. At the other hand, being trained in the more advanced model of family involvement (FPE) was perceived as useful when practicing basic levels of family involvement. Particularly valuable was the experience that the staff could utilise selected model elements, also when providing basic family involvement:
For instance, in conversations with patients and relatives I have used the FPE information material. To kind of make it easier to present it. So this has contributed to… I was about to say… to the regular conversations with patients and relatives in a positive way. (FG11).
A few participants mentioned that training all staff was time-consuming and was compounded by a high turnover of staff. Participants queried whether training would have been better with a small team of therapists working only with family involvement. However, in general the participants seemed to agree that the advantages of the whole-ward approach outweighed the disadvantages, particularly in a long-term perspective.
From a leader perspective, shared competence also contributed to strengthening the working environment and treatment practices because staff started to work in the same way:
Having a similar professional foundation affects the working environment (…) It ensures the quality of treatment because we think and work more synchronously. (FG9).
Participants reported that the whole-ward approach led to all therapists initiating family involvement with all their patients from an early stage in the illness trajectory:
Especially with new patients, the initial focus on family involvement is much more present, and… yes, we try to really look into both the referral and the patient’s chart, how things are. In addition, we have started to work on a checklist, to become even more conscious of that structure, so it is the same for all therapists, not coincidental, dependent on who is passionate about family involvement or not. It should be a somewhat standardised routine to invite relatives to conversations early in the trajectory, and provide appropriate information about why we think this is important. (FG2).
Some participants reported that over time the whole-ward approach led to the emergence of positive attitudes among clinicians with regard to engaging families. This was in contrast to involving families as a token gesture obligation:
Initially, it was kind of not so important, and it was just like “is it done or not”, but now it is on the checklists and markedly permeates the attitudes. A significant change has taken place, from family involvement representing an administrative measure towards being implemented in each individual persons practice. (FG12).
Leadership commitment, through practical adjustments and motivational support, played a pivotal role in the realisation of various facilitators identified in this study. Barriers to implementation—such as competing tasks, lack of resources, and varying ownership—were surmounted by leaders who allocated sufficient resources, appointed dedicated positions (see below), and used the IFIP intervention in a standardised way. Leaders that held a long-term perspective and identified a clear change in team practice as family involvement was prioritised and valued, were vital to the implementation. Important examples include making a working plan that allowed all staff to participate in training and supervision, and to run FPE-groups, stating clearly that offering family involvement is mandatory and that FPE-sessions allowed for a reduction in other therapeutic sessions. Some leaders also mentioned another way to limit the resources spent by the CMHCs; to run FPE-groups in collaboration with municipal health- and care services. In Norway, the CMHCs are by and large part of the specialised health care services (together with the hospitals), so this was also mentioned as a way to improve coordinated care and collaboration between specialised health care and primary health care services before discharge or transfer.
Appointed and dedicated roles
To guide the local implementation effort and operate as a link between the unit and the IFIP project group, each unit in the intervention arm was recommended to appoint a local implementation team and a family coordinator. Overall, study participants experienced that having such dedicated positions was a key facilitator. Especially two main tasks conducted by the local teams and the family coordinator were reported to strengthen implementation: Organising the various interventions, for example by preparing, establishing, and disseminating routines for basic family involvement and FPE at the unit, and to keep staff motivated and committed when faced with stressful workdays and competing tasks, for example through involving all the staff in the development of locally adapted routines.
Not all the family coordinators were allocated time for the intended tasks, and there was some variation in which tasks the various family coordinators performed. However, most coordinators played a fundamental role during the start-up phase by promoting awareness of the implementation, “keeping the family involvement warm” and by contributing to the overall competence development in family involvement. The coordinators provided training and supervision to their colleagues, and several participants pointed out the low threshold for obtaining their help and guidance with challenging cases:
I find that our two coordinators are core resources in reminding us of relatives' rights, and how important they are. I think that we need them. My experience is that I can’t cover all bases as a therapist, so it is nice to have them on the team. They remind me of something that is natural to them, but has not always been to me as a therapist, having been used to mainly focusing on the individual patient. (FG17).
Concerning the implementation team, regular team meetings (often bimonthly or monthly) and working together as a team of enthusiastic personnel with the unit manager were factors reported to strengthen the implementation:
It requires very dedicated people (…) that kind of are passionate about working with relatives. This is crucial, and something that I notice in all quality development projects. If an implementation team does not have these very dedicated people, you are off to a poor start. (FG14).
Nevertheless, some of the implementation teams did not function optimally, with a lack of leadership commitment being one of the explanations:
I do feel that as a leader I haven’t done enough to schedule, invite, and prioritise the implementation team meetings. I have not taken that responsibility as I should have done. (FG11).
Some participants mentioned that varying commitment among staff hampered the implementation process. There appeared confusion as to how to share responsibility and implement tasks effectively at the unit. Finally, a few participants mentioned that extensive commitment by the implementation team led to other clinicians withdrawing from engaging in family involvement, thinking that family involvement was not their responsibility.
Standardisation and routines
Participants` accounts highlighted the need for organising both the family involvement practices and the underlying implementation work systematically. At baseline of the IFIP-trial , most of the units’ family involvement practices suffered from a lack of standardisation with poor engagement, information, documentation-, and evaluation routines. Systematising family involvement, for instance through written procedures and information leaflets, documentation templates, and systems for routinely developing crisis plans and inviting all relatives to relevant evening seminars/courses, reportedly promoted implementation.
Standardisation also reportedly promoted normalisation and anchoring of family involvement as an integrated practice among all staff. Particularly during the start-up phase, the establishment of routines, procedures, and checklists was considered very important to ensure that family involvement was actually performed:
When I worked in somatic health care, we were supposed to call the relatives within 24 h. I think it is natural that we do the same thing here, just call within a day or two to hear how they are doing and if they have any questions. To me, I assume, this is where the shoe pinches (…) If it’s in the procedures, you just do it automatically, right. There is no need to wonder, that’s just the way it is (…) Then we have established contact with the relatives and can catch things at an earlier stage (…) It would have been very helpful if we had a procedure assigning the responsibility to make a call to the relatives, to one of staff. (FG1).
Some participants emphasised standardisation of patient conversations about family involvement as a means to better engage with the most severely and chronically ill patients. Many of these patients hadn’t previously engaged family in their care, which led to a break down in close relationships, sometimes permanently:
It will be good to concentrate more on offering all patients a conversation about family involvement. Because I believe that ensures that we’ll ask, even when the patient hasn’t involved his family before. That the therapists do not just assume that the patients do not want it. (FG11).
Some highlighted the importance of «flexible standardisation» and tailoring family involvement to the needs of each individual patient and family, such as this clinician describing how some relatives are more experienced in the role than others, thus having different needs:
…to establish contact, that applies to most of the patients, and is effective (…) while several other factors are more individual. It`s not always like "the more, the better". Because, you also have relatives who know a lot, and already have a lot of information. They may need something other than those who are relatives to a patient who has recently been diagnosed with a psychotic disorder. (FG17).
Some participants described feelings of fatigue due to an overload of checklists and procedures. To meet such challenges, one of the units successfully introduced adjustments to fit the intervention to the local working culture and level of competence. They decided to establish a “procedure for family involvement” which all clinicians were encouraged to follow, but without having to tick off that the tasks were done, as in a checklist:
We are absolutely allergic to even more checklists where we have to tick off whether we have done it right. We cannot stand it. But (we want) a list of ideas for how to proceed and what is prudent to do (…) Not mandatory, but more as a support. Designed for adult, responsible therapists who know that they should—and want to do their job. (FG13).
One advantage of such standardisation is that the procedure is available to all clinicians. Several months after the implementation, the manager at this particular unit reported that the procedure had been very useful when faced by staff turnover.
Another way to integrate family involvement was to secure that family involvement was always on the agenda in regular treatment meetings and included in all types of plans, e.g. work plans, treatment plans, capacity building plans, and discharge summaries. Furthermore, developing a clear plan on how to get started with FPE groups immediately after training seemed to be vital to get the most out of the FPE training and subsequent supervision, and also to increase the number of patients that were offered this kind of treatment. One way to achieve this was to have the family coordinator register patients and relatives who needed more comprehensive family involvement, and to match this list with available staff with FPE training. This could also be a way to prioritise FPE treatment fairly, if the units FPE capacity was not sufficient.
Some also mentioned the need to define required qualifications and a formal job description for the family coordinator:
Formalising the work… that the family coordinator holds an assigned position with competence requirements (…) is a way of making the family involvement visible. To me that would signalised that one took it seriously. (FG12).
External implementation support
Access to implementation resources from the IFIP project such as fidelity monitoring, training in FPE, and ongoing external support and supervision was considered crucial. External support was reported to be particularly important in helping the units to get started, generate the imperative of family involvement, build enthusiasm, and promote the implementation:
The most important thing is that we got help to sit down and look at what we have…, those fidelity assessments sort of confirmed what we already knew… And the fact that we did not let go… Even in difficult times. Having an implementation team, trying to get started with the groups and systematising our practice, we had not achieved that if you were not there, on the field with us. Because it has driven us. So I'm very happy about that, because otherwise it would have faded out, I'm pretty sure. And the supervision is “gold”. The training and supervision provided by TIPS Sør-Øst has been very important (…) Fantastic, yes. (FG13).
Some participants expressed concerns regarding the sustainability of ensuing family involvement when the external support was no longer available:
I have had such negative experiences throughout the years (…) a lot is invested in various things, but when the follow-up disappears and management takes over… This is what I worry about the most. That shift. (FG12).
Facilitators at the clinical level
Understanding, skills, and self-efficacy among mental health professionals
At baseline, participants reported that clinical staff were often unfamiliar with family involvement prior to training and experience. Several participants feared that involving relatives would jeopardise their therapeutical alliance with the patient. They lacked understanding of the significance of services involving and supporting the family, and they lacked sufficient knowledge and skills to conduct family involvement. Training in FPE reportedly promoted understanding of the significance of involving and supporting the family, and contributed to increased understanding, skills, and self-efficacy among participants:
The FPE education has made me more structured with regard to family… that is, I have received a method and confidence—and especially quantity training and practice (…) and I have received supervision along the way. Then you become more confident. (FG15).
Clinical practice with regards to introducing family involvement to the patient and establishing contact with the family was noted to improve in response to training and experience. Several participants described how lack of knowledge and uncertainty previously meant they refrained from involving relatives, especially if the patient was reluctant:
One of the first patients where I was supposed to do it… you know, call the relatives… then the patient said: “No, you are not allowed to do that”. So. Yes. That was it (laughing). (FG4).
During implementation, when participants increased their knowledge and self-confidence on how to approach patients and relatives, core barriers such as lack of consent and the duty of confidentiality were dealt with in constructive ways. Conversations with patients about family involvement performed by skilled personnel provided them with information about how they could benefit from involving their closest relatives:
I think that they (colleagues) have improved in kind of introducing family involvement to the patient. For instance, taking that course taught me how to present it. If the patient says no right away, we do not resign, but continue to raise the issue. (FG3).
With increased competence and experience, clinicians started to explore why the patient was reluctant, if this was the case. They also became more confident on how to tailor family involvement to the patient’s needs, and to deal with the situation to benefit the patient and the relatives, thus increasing the odds that family involvement would actually take place.
Awareness, attitudes, and motivation among mental health professionals
Throughout the project, particularly in the beginning, many participants described how barriers related to mental health professionals (such as negative attitudes, lack of awareness and prioritisation of family involvement), barriers related to patients (such as lack of patient consent, confidentiality issues, and patients suffering from long-term illness without relatives being involved), difficult family dynamics and relatives` frustration towards services (see Fig. 1), hindered family involvement. This clinician emphasises the value of getting in touch with the relatives at early stage to prevent the patient's social network from dissolving:
It is important to establish early contact to prevent burnout and exhaustion. If relatives do not feel like been taken care of early enough in the process, the likelihood of them discontinuing contact with the patient increases (…) (thus some patients) live in group homes in which their closest next of kin is the personnel who work there. (FG14).
Participants reflected on how the involvement in the training and practice led to an increased level of awareness and appreciation of the importance of family involvement as an important element of treatment:
I feel that family involvement is far more present now. It is discussed every Monday.., also the FPE groups, we discuss much more… I feel that the role clarification is much clearer, more staff are engaged and the coordinators have the main responsibility. We are more conscious about family involvement, all the time. Talk about, ask for, clarify… relatives. And that is very good. (FG18).
Several participants noted that traditionally mental health services have neglected family involvement in the treatment of patients with psychotic disorders. Through the IFIP project, it became evident for many of the participants that this neglect, however widespread, is not very well justified:
So… I am a bit puzzled that we have been doing this for so many years without involving the relatives. It's a bit odd. (FG15).
With experience participants came to appreciate the benefit of the patient – relatives – therapists alliance. This also led to a greater awareness of the strain and challenges experienced by relatives and the importance of recognising and responding to career burden:
Just asking relatives a simple question like: "What is your experience as next of kin?” right. Just to get a question like that.., it's something that all relatives feel that they have never been asked. And when you are that vulnerable and exhausted… a large proportion are on sick leave due to the great burden of being a next of kin, imagine how valuable it is when someone asks that simple question! You don`t have to be a professional FPE-supervisor to manage that. (FG2).
Involving and supporting relatives at an early stage of the disease course also had an important function in preventing maladaptive interplay between patients, relatives, and health care personnel. Participants repeatedly identified the benefit of being trained in and practicing family involvement to help them understand their role and contribute to recovery:
P: We had this sick, sick girl. Then she moved to CITY (…) and the (therapists) there were much more committed to family involvement after they got that group (FPE) and saw the value in it (…) There were such ripple effects, I shudder when I say it (…) Basically (she was) very difficult to follow up or treat, but this group was the one thing that brought the family together. They thought that they (she) could not be released from HOSPITAL. But when they used problem solving techniques (core FPE-element to promote more adequate responses when symptomatic behaviors emerge) the moving process had gone well, so they were almost shocked. (Further the researcher asks what would have previously happened—and the participant responds as follows):
P: The parents would have been frustrated, wouldn’t understand and been angry at the treatment/clinic, at least that’s what happened before. Coercion, perhaps (…) inside a closed psychiatric ward. (The researcher then point out that these scenarios are quite different):
P: Yes (…) we need to think completely differently. Thinking of possibilities or… adapting to the individual, looking more broadly at the patients’ needs and the family, alternative solutions and not simply “that's how we do it, medicine and then out and finished” (FG5).
In response to positive clinical experiences, participants reportedly felt more motivated to continue providing family involvement:
A successful FPE course was raised several times. I believe that it kind of inspired the therapists to think that family involvement is important (…), at least after one such complete FPE course which was very successful. And that was one of the most ill patients. (FG19).
We also found that clinicians` positive perceptions of- and experiences with the FPE-model strengthened the implementation of family involvement in general. For example did they convey that the model being evidence-based, containing useful clinical tools and that one could utilise selected model elements also when performing basic levels of family involvement (see whole-ward approach), had a motivational effect:
The overall FPE mindset, not just the FPE groups, is a useful tool when meeting the relatives (…) also “outside” the model. (FG13).