Increasing access to psychological therapy on acute mental health wards: Staff and patient experiences of a stepped psychological intervention

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However, access is limited, particularly in inpatient mental health settings. The Talk, Understand and Listen in InPatient Settings (TULIPS) study is a large multi-centre cluster-randomised controlled trial which aimed to evaluate a stepped psychological intervention model to increase access to therapies for inpatients. This paper presents findings from the embedded process evaluation focusing on the contextual factors influencing intervention delivery. Methods Thirty-two staff and 31 patients from wards receiving the intervention participated in semi-structured interviews. Data was analysed using reflexive thematic analysis. Staff and patient data were analysed separately but perspectives were compared and interwoven resulting in five themes. Results Patients reported sessions with psychologists facilitated greater self-understanding and coping. Staff and patients reflected that formulations improved staff understanding of patient presentations. This understanding was associated with improved staff-patient relationships, more person focused practice and reduced conflict and burnout. Psychologists’ frequent physical presence on the wards and support of nursing teams enabled staff buy-in. However, significant barriers in resource, skill and confidence inhibited the delivery of nurse-led interventions within the stepped care model, as did perceptions that intervention delivery was outside the remit of nursing staff’s role. Conclusions This study provides evidence that a stepped psychological intervention on acute mental health wards could improve patient coping and ward experience for patients and staff. Future studies should target nursing staff confidence and skill in the delivery of psychological interventions. Trial registration: ClinicalTrials.gov Identifier: NCT03950388. Registered 15th May 2019. https://clinicaltrials.gov/ct2/show/NCT03950388 Clinical Psychology Mental Health Nursing Mental Health Services Interviews Qualitative Research Figures Figure 1 Background Individuals with serious mental health problems should have access to evidence-based psychological therapies across the care pathway [ 1 , 2 ] . Despite clinical guidelines, there is limited access to psychological therapies for these individuals within the United Kingdom, particularly within acute inpatient settings [ 3 , 4 ] . The delivery of psychological therapy on acute wards presents a unique set of challenges including short stays, complex patient needs, ineffective team working and limited suitable space for conducting therapy [ 5 , 6 ] . There is also no evidence-based approach for the delivery of therapy on acute mental health wards and limited research into how to overcome the aforementioned challenges. The TULIPS (Talk Understand and Listen on Inpatient Settings) project aimed to develop and evaluate a stepped psychological intervention model to increase access to psychological therapy on acute mental health wards and consequently reduce serious incidents, improve patient well-being and functioning, and reduce staff burnout [ 7 ] . Thirty-four wards across England, Wales, and Northern Ireland participated in a cluster randomised control trial (RCT) to evaluate the effectiveness of the intervention. A process evaluation, embedded within the trial, aimed to provide additional insights into staff and patient perspectives on the impact of the intervention and contextual factors that impeded or enhanced intervention delivery [ 8 ] . The process evaluation comprised three stands: semi-structured interviews with intervention users and providers, ethnographic observations on intervention wards, and fidelity assessments of intervention delivery. This study presents findings from qualitative interviews with staff and patients’ which aimed to explore their views of the intervention, associated outcomes and highlight barriers and enablers to implementation and engagement. Methods Setting Participants were recruited from acute mental health wards randomised to the intervention arm of theTULIPS trial. Acute mental health wards provide mental health treatment to individuals experiencing episodes of acute mental distress and posing risks to themselves or others. The average length of stay in the UK was 40 days in 2021/22 [ 9 ] , although the range is likely wide. The Intervention The TULIPS intervention involved a stepped model of care with three levels [ 7 ] . Step one was a psychological formulation developed by the psychologist together with the ward team. In step two, nursing staff were trained and supervised by psychologists to deliver brief guided interventions for patients available in groups or on a one-to-one basis. At step three, patients could access up to 16 sessions of psychological therapy with psychologists. At least half a day’s training on mental health and psychological formulation was offered to all ward staff. Additional half days on specific problem areas likely to present wards (e.g. psychosis, self-harm, low mood etc) were offered to registered mental health nurses or other ward staff nominated by ward managers. Design Semi-structured interviews with staff and patients were used to create narratives of experiences. These narratives were constructed jointly by interviewees and the interviewer but remained centred in the experience of participants [ 10 ] . Interviews were led by topic guides focused on participants’ views on the impact of the intervention and barriers and facilitators to delivery and uptake. Topic guides were informed by findings from earlier interviews exploring how to increase access to psychological therapy on acute wards [ 6 ] and were piloted with stakeholders (i.e. an individual with experience as an inpatient, a registered nurse from inpatient services and a clinical psychologist). Recruitment and procedure Inclusion criteria for staff and patients were: (a) present on intervention wards during the study period; (b) informed consent to participate in the study including the audio recording of the interview. An additional inclusion criterion for patients was capacity to provide informed consent and sufficient levels of concentration to partake in an interview, as determined by the care team in conjunction with the researchers. Participants were recruited until data saturation was reached. We used two different recruitment routes. Either intervention providers asked potential participants for their consent to be contacted by a researcher, or researchers approached participants directly when they were present on intervention wards during ethnographic observations. Participants were purposively sampled on the basis of direct exposure to the intervention. Efforts were made to recruit individuals from diverse backgrounds and with a variety of job roles. Risk and capacity assessments for patient participants were completed with a named nurse, responsible clinician, or member of patients’ community mental health team (when interviews took place following discharge). All potential participants were provided with information on the interview process and goals of the research via participant information sheets before informed consent was sought. Interviews were conducted privately and in person (at NHS sites or patient participant’s homes) or remotely (on the telephone or using Microsoft Teams) depending on participant choice and risk information. Participants Informed consent was gained from 65 participants (33 Patients; 32 Staff). Two patient participants withdrew consent prior to interview due to deteriorations in their mental health. One interview with a patient participant was excluded from analysis due to a poor-quality recording. Interviews with 30 patients and 32 staff members were included in analysis. Interview ranged from 19 to 123 minutes in length (M = 53 minutes). Some participants were interviewed on more than one occasion to capture differences in their experience over time. See Tables 1 and 2 for participant demographics and prior experiences in therapeutic approaches. Table 1 (should appear on/after page 5) Patient Demographics Ethnicity Marital Status Primary Diagnosis Additional Diagnoses Received therapy previously? Therapy received (N = 23) Setting received in (N = 23) White British (N = 20, 65%) White Irish (N = 2, 6%) Black African (N = 2, 6%) Mixed White and Black Caribbean (N = 2, 6%) Mixed White and Black African (N = 2, 6%) Black Caribbean and African (N = 1, 3%) Black Other (N = 1, 3%) Single (N = 21, 68%) Married (N = 3, 10%) Divorced (N = 2, 6%) Separated (N = 1, 3%) Widowed (N = 1, 3%) Civil Partnership (N = 1, 3%) Common-Law (N = 2, 6%) Personality Disorder (N = 11, 37%) Schizophrenia, Schizoaffective or psychosis (N = 9, 30%) Bipolar (N = 4, 13%) Anxiety (N = 3, 10%) Depression (N = 1, 3%) Obsessive Compulsive Disorder (N = 1, 3%) Aspergers (N = 1, 3%) No Formal Diagnosis (N = 1, 3%) Anxiety (N = 12, 39%) Depression (N = 12, 39%) Other (N = 6, 19%) Personality Disorder (N = 2, 7%) None (N = 9, 29%) Yes (N = 23, 74%) No (N = 8, 26%) Cognitive Behavioural Therapy (N = 12, 44%) Talking Therapy (N = 13, 41%) Mindfulness (N = 6, 19%) Dialectical Behavioural Therapy (N = 2, 6%) Other (N = 2, 6%) Cognitive Analytical Therapy (N = 1, 3%) Counselling (N = 1, 3%) Formulation (N = 1, 3%) Acceptance Commitment Therapy (N = 1, 3%) Outpatient (N = 11, 49%) Inpatient (N = 4, 17%) Inpatient and Outpatient (N = 7, 30%) Not given (N = 1, 4%) Note. Other therapies included art and music therapy. Table 2 (should appear on/after page 5) Staff Demographics Ethnicity Job role Band Years Experience in Mental Health Years Experience in Acute Training in psychological interventions Therapies Trained in (N = 21) Delivery Setting (N = 21) White British (N = 25, 78%) Black African (N = 3, 9%) South Asian (N = 2, 6%) Mixed White and Black Caribbean (N = 1, 3%) Clinical Psychologist (N = 6, 19%) Healthcare Assistant (N = 6, 19%) Nurse (N = 5, 16%) Ward Manager (N = 5, 16%) Occupational Therapist (N = 3, 9%) Psychiatrist (N = 3, 9%) Activities Co-ordinator (N = 2, 6%) Deputy Ward Manager (N = 1, 3%) Assistant Psychologist (N = 1, 3%) Band 2 (N = 3, 9%) Band 3 (N = 3, 9%) Band 4 (N = 2, 6%) Band 5 (N = 3, 9%) Band 6 (N = 4, 13%) Band 7 (N = 6, 19%) Band 8a (N = 3, 9%) Band 8b (N = 1, 3%) Band 8c < (N = 2, 6%) Not applicable (N = 3, 9%) Not Given (N = 2, 6%) 10 years (N = 5, 16%) 10 years (N = 12, 38%) Yes (N = 21, 66%) No (N = 11, 34%) Cognitive Behavioural Therapy (N = 11, 52%) Mindfulness (N = 11, 52%) Other (N = 7, 33%) Dialectical Behavioural Therapy (N = 5, 24%) Cognitive Analytical Therapy (N = 5, 24%) Acceptance Commitment Therapy (N = 5, 24%) Compassion Focused (N = 4, 19%) Schema Therapy (N = 3, 14%) Meta Cognitive Therapy (N = 2, 10%) Eye Movement Desensitization and Reprocessing (N = 2, 10%) Talking Therapy (N = 2, 10%) Counselling (N = 1, 3%) Formulation (N = 1, 3%) Inpatient (N = 8, 38%) Outpatient (N = 3, 10%) Inpatient and Outpatient (N = 5, 24%) Not Given (N = 5, 24%) Analysis All interviews were audio recorded, transcribed verbatim and analysed inductively using reflexive thematic analysis [ 11 , 12 ] . The coding was carried out with Nvivo 12 software. The following stages of analysis were completed separately for the staff and patient interviews. Firstly, a small team of three researchers coded the same transcript. A consensus meeting was then held to discuss differences in interpretation, develop a shared meaning and create a code book. Transcripts were then randomly assigned to coders and the codebook applied. All data felt to be incongruent with the codebook was labelled with ‘other’ and discussed during regular coding meetings leading to adaptations of the codebook. These meetings also facilitated discussions of emerging themes, reflections and renaming and reorganising of codes. In addition to the initial consensus checking, 30% of transcripts were coded by at least two researchers. Where there were discrepancies in coding these were overcome through discussion, review of reflexive diaries and the raw data. Once all transcripts from that participant group were coded, theme development meetings were held where codes were organised into domain summaries. During the meetings emergent themes discussed throughout the analysis were expanded on and additional themes were identified through reviewing the final codebook and raw data. This process was iterative and reflexive, informed by researchers’ knowledge of the data, experience conducting interviews and awareness of the wider study [ 12 ] . Initial themes (eight staff themes and six patient themes) were written up by author1 and refined based on feedback from the coding team. Initial themes where then presented to three members of the TULIPS patient and carer group during validation workshops [ 13 ] . All members had a lived experienced of inpatient wards as a patient or carer. Quotes felt to be most representative of each theme were presented without interpretation and members were asked open questions to encourage discussion and gain their perceptions of the raw data. Interpretations were explored and detailed minutes taken. These interpretations were then compared with the research teams and helped to further refine or validate themes. Participants themselves did not provide feedback on transcripts or themes. Once the aforementioned steps were completed for both staff and patient data, associated themes were organised into the domains of the Consolidated Framework for Implementation Science Research (CFIR) [ 14 ] . When themes from staff and patient interviews were associated with the same domain these were extracted, compared and, where appropriate, interwoven to create rich themes accounting for both staff and patient perspectives. We initially aimed to conduct a framework analysis informed by CFIR but after indexing we found our data transcended the domains. Instead, our analysis remained thematic with CFIR being utilised only to organise and combine datasets, but not influencing interpretations. Analysis continued throughout the writing process with feedback from the wider study team contributing to refinements in themes. Reflexivity All authors involved in the collection and analysis of data were female and employed researchers on the TULIPS project. Interviews were predominantly conducted by experienced qualitative researchers author 1 and 7. Author 1 also led data analysis. All but one author involved in data collection and analysis had experience working in inpatient mental health settings. Researchers therefore already held understandings of ward cultures, processes and the local language used, providing context to interviewees’ experiences. This background influenced interpretations with researchers being more likely to focus on salient features of their own ward experiences, such as wards lacking resources and conflict within staff-patient relationships. The interviewers had spent time on the wards as participant observers prior to the interviews but were not well known to the interviewees. Reflexive journals were reflected on during analysis meetings enabling critical reflections, transparency, and credibility [ 15 ] . Researchers discussed excerpts of their journals during analysis meetings, with particular emphasis on how researchers’ professional and personal experiences led to certain transcripts or perspectives being more poignant. For example, there was discussion about psychologists’ characteristics and whether these were influenced by personality or professional training, as these were initially distinct codes. After review of the raw data and critical reflection on the coders’ personal beliefs, it was agreed to code data pertaining to characteristics as a therapeutic skill, but it was noted that patients often perceived therapeutic skills as being part of the psychologist’s personality. Results Four themes combining staff and patient perspectives and one theme from staff perspectives were generated from the interview data. Table 3 demonstrates the contrasts between participant groups experiences within each theme. Perceived enablers and barriers to implementation and engagement, and associated outcomes are discussed across these themes and summarised in Fig. 1 . Table 3 (should appear on page 8) Interviewees Views by Theme and Participant Group Theme Staff Patients Psychologists A unique and respected “part of the team” Psychologists’ presence and active engagement led them to become a part of the team. Psychologists’ independence from the nursing team encouraged patient engagement. To facilitate supervision effectively balancing insider status with independence from the team is needed. Facilitating self-understanding The intervention improved patient wellbeing. The intervention increased self-understanding and coping. - “Bridging” the gap in understanding Attending formulation sessions increased understandings of patient behaviour and compassion. Information sharing meant services were better equipped to support patients. - Beliefs about job role In theory, therapy is lengthy and in-depth which is at odds with wards aims. Nurses must prioritise other activities lack time to deliver nurse-led interventions. - Staff engaged in referral but were less motivated to adapt their own practice to meet patient needs. Staff beliefs about therapy informed who they referred. Putting psychologists on a pedestal Staff lack the confidence needed to deliver the intervention. Preference for engaging therapeutically with psychologists due to their perceived greater time and expertise. Nursing staff can’t be flexible with their time. Ward environments make it difficult for staff to build confidence in intervention delivery Respected but unique “ part of the team ” Psychologists were regularly visible on wards engaging with patients and spending time in the nursing office which afforded them status as a member of the ward team. Psychologists’ regular physical presence coupled with their flexibility and persistence (adding meetings to diaries, reminding staff and re-booking when cancelled) had multiple benefits for ward staff including accessible consultation about how to respond to patients’ behaviours and opportunities for emotional support during an emotionally draining shift. The changeable nature of ward environments meant staff could not always attend scheduled meetings with the psychologist, but psychologists’ physical presence enabled staff to access support in vivo. Things run over but if you’ve got a psychologist there and they’re around and they’re visible you can just say oh have you got two minutes to talk about this. Psychiatrist A Psychologists’ presence was also essential in providing opportunities to develop relationships with staff further enhancing integration within the team. Informal social interactions outside of meetings were especially important for this rapport building. Being around and willing to help with tasks outside the remit of the psychologist’s role afforded respect from nursing staff and led to beliefs that psychologists recognised the difficulties of the nurse’s job. Psychologists also recognised the importance of these relationships for the implementation of the intervention noting they needed to be an insider to facilitate change: In order to influence culture you need to not be a threat and you need to have relationships with people. Psychologist A Developing relationships with psychiatrists also aided psychologists’ integration within the wider multidisciplinary team and led psychiatrists to encourage patients to engage in psychological assessment or intervention. This endorsement from psychiatrists who were senior members of team indicated that the intervention was credible and should be prioritised. It made a huge difference if you’ve got a psychiatrist endorsing it, who is considered someone who is considered, the lead clinician on the ward. I suppose that gives you a bit of kudos by association. Psychologist A The psychologists’ effort to embed themselves within staff teams acted as a mechanism for staff and patient engagement with the intervention. Yet, maintaining some independence from the team by virtue of being from a different professional group was also beneficial. On wards with significant staff conflict, or hierarchal cultures, members of the nursing team felt able to confide in psychologists about their concerns due to their perceived understanding of the ward environment and some degree of impartiality. They are a team member but you’re not directly a team member, so it would be nice sometimes just to, offload to someone. Nursing Assistant A Psychologists perceived impartiality and independence from the nursing team coupled with their provision of a dedicated safe space also fostered patient engagement. These patients described previous negative experiences of care on acute wards leading to a mistrust of nursing staff on the team. We were in a safe space and that’s what the psychologist has to create. A place, you know, someone to talk to that is third-party neutral. That’s important. Patient A 2. Facilitating understanding Patients described how one-to-one sessions with psychologists facilitated greater understanding of how life experiences related to current emotions and behavioural patterns. I understood why I feel the way I do and act the way I do, and when I was able to sort of express myself, then I could understand myself more. Patient D This differed from treatment prior to the intervention where patients described a process of “ telling their story over and over to different people ” [Patient B] without opportunities to understand the reasons for their distress or help in developing coping strategies. Some patients were anxious about the idea of making themselves vulnerable within the context of therapy, particularly for those reporting prior negative experiences of counselling or therapy. However, through showing understanding, psychologists were able to put these anxieties to rest. You feel like [the psychologist] is taking an interest in your particular situation and then, you can then work with them better. You feel they are trying to understand me, not just a condition. Patient J Staff also perceived that the intervention to improved patients’ self-understanding and described associated reductions in self-harm, aggression, and negative affect. What I’ve noticed is that patients feel much safer when they have interactions with the psychologist and the number of incidents decrease, and they feel like there’s somebody really listening and understanding. Psychiatrist B As well as enabling patients’ self-understanding, psychologists facilitated staff knowledge of patient needs through different forums. Staff reported that attending psychologist-led formulation sessions increased their understanding of the meaning, and motivations behind behaviours that typically attracted staff criticism (e.g. aggression, self-harm). I have better understanding of why, if someone’s behaving- if someone displays challenging behaviour should I say it helps me to have a better understanding of where they’re coming from. Occupational Therapist B Patients also welcomed the psychologist sharing aspects of their formulation with staff to enable to improve staff understanding of support needs. [The psychologist] can go to members of staff and say, he struggles with this, struggles with that, so the members of staff on the ward are getting a better insight in how you’re dealing with, the certain situations, which is a massive thing cos some of staff won’t even know. Patient L These examples of knowledge sharing were described in terms of psychologists acting as a bridge between patients and staff, suggesting staff and patients previously felt disconnected. Understanding the functions of patient behaviour also helped to enable compassion and empathy, which staff associated with an increased feeling of reward from their work. If we’d had a service user that is continually displaying aggressive behaviour, some staff find it really difficult to deal with, and they start almost feeling burnt out, and then I think the formulations and the one-to-one sessions have really helped staff take a step back and think about actually this is what’s triggered this behaviour It’s kind of helped people sort of be more empathetic . Ward Manager A Some also patients perceived that staff had become more compassionate and “ less judgemental ” [Patient C] as a result of the intervention. Others believed that care had not improved as levels of compassion were dependent on individual differences among staff suggesting little optimism about future changes in staff behaviour. It was only like a couple of [staff] members that that would do their utmost to cheer you up and make sure you're okay. But a vast majority of them would just like, you might as well not be there at all. Patient K Formulations were also shared with community or home treatment teams. As a result, some patients perceived that step-down services were better equipped to continue supporting recovery. My care coordinator, she had a session with [psychologist], and they spoke about the formulation that we’d done so I don’t have to repeat myself again and sort of talk about a lot of things. Patient D However, some patients described feeling “ disappoint[ed]” [Patient M] at not being able to continue engaging in the intervention after discharge, preventing them from maintaining the level of functioning developed. Although patients still perceived the ward-based intervention to be beneficial, some felt it should extend into the community. I would have liked to continue it to be honest especially as an outpatient because whilst sessions with her with good, it was just, it would have been nice to have it followed up Patient C 3. Beliefs around job role Staff described how acute wards served to stabilise patients and reduce risk with an aim to discharge them as soon as possible. This perception of ward function, combined with staff beliefs that psychological therapy is lengthy, complex, and unsuitable for patients with schizophrenia, led some staff to believe that the intervention was at odds with ward aims. How do you embed the psychology into the purpose of the ward? ‘Cos if that purpose is to be a really acute short stay ward that rapidly turns around people, has bed availability and all those kind of things, that doesn’t tend to lend to lengthy, more consistent interventions. Ward Manager B Narratives around the function of acute wards fed into beliefs that nursing staff’s primary role did not include providing psychological therapy. Staff typically depicted their key responsibilities to be medication administration, risk management and completing paperwork. These beliefs likely limited staff engagement in delivering nurse-led interventions as these were seen as “ low priority ” [Occupational Therapist C]. Although staff busyness with other duties was a significant barrier to intervention implementation, some staff did successfully deliver interventions. These individuals prioritised intervention delivery over other tasks. Some staff described how formulation sessions provided a safe and non-judgemental space to challenge rhetoric around the limits of their job role. For these individuals engaging with psychologists led to perceptions that their responsibilities should include providing therapeutic support to patients. For some staff this change in belief encouraged engagement in intervention delivery. I’m not just there to unlock doors and to give people food, it (formulation sessions) reminds me that, in our everyday interactions with patients on the ward there’s a therapeutic reason for nursing assistants to be here. Nursing Assistant C However, this prioritisation of the intervention was primarily enabled by ward managers buy-in which was felt to be instrumental in enabling staff to prioritise engaging in interventions over other activities. The way that it was talked about within the team was maybe like this is a nice optional extra, but it’s not essential, whereas on the other ward the ward manager really kind of prioritised staff being able to spend time with me. Psychologist B Unlike other members of the multi-disciplinary team, nursing staff also lacked control over their time, meaning that without ward manager support they were unable to dedicate time to the intervention. (Nurses) turn up on shift and you’re told what you’re doing for each hour and psychological work isn’t part of that scheduling. Psychologist C As a result, in the absence of ward manager support, level 2 interventions were most successfully led by staff who were in control of their diaries and not expected to respond to incidents, such as assistant psychologists and occupational therapy staff (including recovery workers and activity co-ordinators). 4. Putting psychologists on a pedestal Psychologists flexible schedule enabled protected time and space to develop therapeutic alliance with patients. This ability to give uninterrupted, quality time was highly valued, and enabled patient engagement. In contrast, nursing staff lacked opportunities to devote time to patients and had other priorities as a part of their role which acted as an obstacle to patients seeking support. If something happens on the ward, and that nurse has to go. You might be allocated a time, but that necessarily might not happen. You can never get through a full meeting, without something happening on the ward, and then you’re more reluctant to speak to them. Patient M Perceptions that psychologists held a higher level of therapeutic training and expertise also motivated patients to engage with psychologist-led sessions. It’s the knowledge and the understanding of one’s emotions or what they’re going through. I’m not saying the nurses aren’t understanding, but when someone’s trained in that speciality of being a psychologist, they just have more of an understanding. Patient M Conversely, beliefs nursing staff were “ not very confident” [Patient N] in delivering psychological interventions reduced patients’ motivation to engage in nurse-led interventions. Nursing staff themselves also reported a lack of confidence, due partly to few opportunities to build experience and skill in intervention delivery. That is one of the difficulties with all the interventions we do is that there is always the sense that you’re learning as you’re going, so-so the first few that you do, it’s almost like you’re not 100% clear what you’re trying to work through with someone. Sometimes that can be off-putting. Nurse A Psychologists felt ward environments were not conducive of staff building confidence and learning new skills, such as those required to deliver interventions. I think you just stay in your comfort zone, when you’re just feeling like you’re spinning plates, or you feel a bit stressed out in a job, so I think, staff confidence has impacted on their delivery of the interventions. Psychologist A Perceptions that support provided by psychologists was superior meant patients did not always see the benefit of engaging in nurse-led interventions. This contributed to a dichotomy in patients’ perceptions of staff, with psychologist who had the luxury of managing their own diary and more training in therapies being put on a pedestal whilst nursing staff who had multiple competing demands and skill sets were described more critically. Psychologists also perceived that ward staff had high expectations of their role. They described how staff would refer patients for therapy who were difficult to manage rather than seeking advice and engaging in intervention delivery to adapt their own practice. In this way, staff’s perception that psychologists filled a gap in treatment was in some ways at odds with one of the main aims of the intervention: to upskill staff to engage more therapeutically with patients. I still think that’s why sometimes people will say oh will you see this person? Often the medic will sort of tickety tick that box that, they’re seeing our psychologist that’s great then they feel okay. Supervisor A Discussion The stepped model of psychological intervention had a positive impact on both patients’ understanding of their emotional distress and also staff members’ understanding of patients’ needs. This improved understanding was facilitated by psychologists’ availability and frequent physical presence on the wards, as well as their focus on relationship building with both staff and patients. However, the nurses’ perceptions that psychological therapy was not part of their role and lack of support from managers to dedicate time to therapy meant that the nurse-led interventions were not delivered frequently or with sufficient skills and confidence. The psychologists’ frequent physical presence on the wards enabled them to be flexible and adaptative in response to the ward environment. This flexibility and adaptation are well-established factors in enabling the successful delivery of complex interventions [ 16 ] but may be particularly important on acute mental health wards due rapid escalations in patient distress and risk and the consequent focus on crisis management [ 17 ] . The focus on relationship building is another well-known factor in the successful delivery of complex interventions and ward-based interventions in particular [ 17 ] . However, previous research has found that psychologists can be seen unwelcome ‘experts’ within teams [ 18 , 19 ] suggesting that psychologists may not routinely invest time in this important foundation for delivery psychological consultation or therapies. The role of psychological formulation in facilitating understanding of patients’ needs has previously been shown in studies focused on both patient perspectives of formulation [ 20 ] and staff perspectives of team formulation [ 20 , 21 ] . The fact that patients reported a contrast between their experiences of therapy with the psychologists and their previous experiences of assessments within ward environments is reflective of the limited availability of psychological therapies on acute wards [ 22 ] . Previous studies have suggested that psychological therapies might not be compatible with acute wards [ 5 , 6 ] and some staff we interviewed echoed these concerns. However, our findings coupled with findings from other research [ 6 ] consistently highlights that patients’ value the opportunity of therapy as an inpatient and do not share staff concerns. The finding that improved understanding of patient needs through team formulation improved staff empathy and compassion is also consistent with previous research exploring the effects of team formulation [ 20 ] and is one of the key rationales for the team formulation process [ 23 ] . Nonetheless, previous research has reported negative effects of team formulation including the perception that formulations devalue staff members’ current ways of working [ 24 ] . The risk of staff perceiving formulation in this way could have been mitigated in our study by the focus psychologists placed on relationship building with staff alongside the provision of formulation and other aspects of the stepped model of care. Although there is evidence that formulations can impact on staff understanding and empathy, both our study and previous research [ 20 , 24 ] suggests some staff do not change their practice as a result of team formulation. Greater attention therefore needs to be paid to ensuring that the recommendations of formulation are fed into care planning. Team formulation meeting in our study and in previous research [ 21 ] were primarily attended by nursing staff, but involving psychiatrists more routinely in the process may help to ensure that the information generated feeds into all aspects of the person’s care. The finding that some nurses viewed psychological therapies as outside of their role may reflect the broad nature of the nurse’s role [ 25 ] . Nurses are frontline staff and represent a large workforce within the health service. Many ward processes and procedures are therefore typically allocated to nurses meaning that they have many competing demands [ 26 ] . In the context of a risk averse environment where blame and accountability are high, the focus of nurse’s time and attention easily gets drawn into processes that are mandatory and auditable and the documentation of these processes [ 27 , 28 ] . Despite competing demands, our study and previous research suggests that nurses can ring fence time to deliver psychological therapies with management support [ 29 , 30 ] . Engaging ward managers in the delivery of the stepped model of care is therefore vital from the outset. The finding that nurse’s lack confidence in delivery the intervention was not surprising given the limited opportunity that some staff had in delivery. Time for psychologists to continue to support and supervise staff in delivering interventions post training is therefore an essential component of any intervention that aims to upskill nurses in delivery psychological interventions. The dichotomy created in patients minds between the psychological therapists and nursing staff was an unintended consequence of the intervention, but reflects the multiple demands on the nurse’s time which prevents the profession being able to dedicate time to one-to-one work with patients and presumably engaging in work that motivated them to join the profession in the first place [ 31 ] . Supporting nurses to be able to develop skills and practice therapeutic work on the wards is therefore essential in recruiting and retaining a motivated and satisfied workforce who are able to deliver the best care possible. Conclusions The TULIPS intervention positively impacted on patients and staff’s ward experience leading to improved self-understanding for patients and greater understanding and compassion among staff. However, the uptake of nurse-led interventions was relatively poor, due to beliefs about the function of acute wards, the remit of the nurse’s role, limited support from ward managers and consequent lack of nurse confidence in intervention delivery. Wider system level changes are needed for nurse-led psychological interventions to be feasible within inpatient settings. Such changes could include a greater focus on psychological interventions during nursing training and as part of continued professional development, the delivery of therapeutic interventions in job role descriptions and the inpatient leads ensuring that staff have protected time to facilitate these tasks. Relevance for clinical practice A stepped model of care with formulations as a foundation is welcomed by patients and ward staff. Patients and staff also benefit from the presence of a ward-based psychologists who can provide regular opportunistic consultation to staff and therapy to patients. However, further work is needed to enable nurses to put psychological therapies into practice on the wards and develop skills in this area. This change will necessitate support from senior ward staff including ward managers but also changes to professional training, continued professional development and job descriptions. Such changes are important in terms of improving patients’ experience of the ward but also helping the recruitment and retention of nurses within inpatient settings. Abbreviations TULIPS: Talk, Understand and Listen in InPatient Settings RCT: Randomised Controlled Trial NICE: The National Institute for Health and Care Excellence UK: United Kingdom NHS; National Health Service CFIR: Consolidated Framework for Implementation Research Declarations Ethics Ethical approval for the TULIPS study with favourable opinion was obtained in July 2019 from the Greater Manchester NHS Research Ethics Committee (IRAS ID: 264686). All participants in the study provided informed consent to participate in audio recorded interviews and for pseudonymised quotes from their interviews to be presented in published reports, articles, or books. Availability of data and materials Participants demographic information is presented within the article. Copies of interview topic guides used within interviews can be requested from the corresponding author. To maintain participants anonymity interview transcripts cannot be published or shared. Conflict of Interests All authors declare that they have no competing interests. Funding The TULIPs Trial was funded by the National Institute of Health Research (NIHR) RP-PG-0216-20009. Berry, Edge and Haddock were also supported by the Manchester Biomedical Research Centre (NIHR 203308). Bucci is funded by a research professorship NIHR300794 from the NIHR and by the National Institute for Health and Care Research (NIHR) Manchester Biomedical Research Centre (BRC; NIHR 203308). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Author contributions The study was designed and supervised by KB, DE and PW. Interviews were conducted primarily by experienced qualitative researchers GG and IJ, with support from HM and SK. Analysis was led by IJ with AB, HM, SK and MS contributing to coding and theme development. The manuscript was drafted by IJ with contributions from HM and editing from KB. Drafts were critically reviewed, and comments provided by KB, SB, DE, GG, FH, GH, KL, OP, MS, RD and PW and the final manuscript was approved by all authors. Project management of the wider trial was provided by FH and HM. Acknowledgements We wish to express our gratitude to the patients and staff who gave their time and shared their experiences during interviews. We would also like to offer our thanks to Tracey Hepburn, Georgia Penn, and Hamish McFarlane for their contributions to transcription. References National Institute for Health and Care Excellence. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care (Update). 2014. https://www.ncbi.nlm.nih.gov/books/NBK11681/ . Accessed 25 March 2024. Penfold N, Nugent A, Clarke H, Colwill A. Standards for Acute Inpatient Services for Working-Age Adults. London: Royal College of Psychiatrist; 2019. Mental Health Taskforce. The Five Year Forward View for Mental Health. 2016. httpa://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf . Accessed: 25 March 2024. Burgess-Barr S, Nicholas E, Venus B, Singh N, Nethercott A, Taylor G, Jacobsen P. International rates of receipt of psychological therapy for psychosis and schizophrenia: systematic review and meta-analysis. Int J Mental Health Syst. 2023;17(1):8. Evlat G, Wood L, Glover N. A systematic review of the implementation of psychological therapies in acute mental health inpatient settings. Clin Psychol Psychother. 2021;28(6):1574–86. Berry K, Raphael J, Wilson H, Bucci S, Drake RJ, Edge D, Emsley R, Gilworth G, Lovell K, Odebiyi B, Price O. A cluster randomised controlled trial of a ward-based intervention to improve access to psychologically-informed care and psychological therapy for mental health in-patients. BMC Psychiatry. 2022;22(1):82. Berry K, Raphael J, Haddock G, Bucci S, Price O, Lovell K, Drake RJ, Clayton J, Penn G, Edge D. Exploring how to improve access to psychological therapies on acute mental health wards from the perspectives of patients, families and mental health staff: qualitative study. BJPsych Open. 2022;8(4):e112. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, Moore L, O’Cathain A, Tinati T, Wight D, Baird J. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350. National Health Service. Acute inpatient mental health care for adults and older adults, NHS England. 2023. https://www.england.nhs.uk/long-read/acute-inpatient-mental-health-care-for-adults-and-older-adults/#:~:text=Older%20adults%20and%20people%20with%20dementia&text=For%20example%2C%20in% 202021%2F22,in%20general%20adult%20acute%20services . Accessed: 25 March 2024. Gubrium JF. Active interviewing. In: Holstein JA, editor. Postmodern interviewing. London: Sage; 2003. pp. 67–80. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Res sport Exerc health. 2019;11(4):589–97. Sprange K, Beresford-Dent J, Mountain G, Thomas B, Wright J, Mason C, Cooper CL. Journeying through dementia randomised controlled trial of a psychosocial intervention for people living with early dementia: embedded qualitative study with participants, Carers and interventionists. Clin Interventions Aging 2021 Feb 4:231–44. Damschroder LJ, Reardon CM, Widerquist MA, Lowery J. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci. 2022;17(1):75. Ortlipp M. Keeping and using reflective journals in the qualitative research process. qualitative Rep. 2008;13(4):695–705. Wood L, Williams C, Billings J, Johnson S. Psychologists’ perspectives on the implementation of psychological therapy for psychosis in the acute psychiatric inpatient setting. Qual Health Res. 2019;29(14):2048–56. Raphael J, Price O, Hartley S, Haddock G, Bucci S, Berry K. Overcoming barriers to implementing ward-based psychosocial interventions in acute inpatient mental health settings: A meta-synthesis. Int J Nurs Stud. 2021;115:103870. Christofides S, Johnstone L, Musa M. Chipping in’: Clinical psychologists’ descriptions of their use of formulation in multidisciplinary team working. Psychol Psychotherapy: Theory Res Pract. 2012;85(4):424–35. McKenna M, Brown LJ, Berry K. Formulation-led care in care homes: staff perspectives on this psychological approach to managing behaviour in dementia care. Int J Older People Nurs. 2022;17(5):e12465. Berry K, Haddock G, Kellett S, Awenat Y, Szpak K, Barrowclough C. Understanding outcomes in a randomized controlled trial of a ward-based intervention on psychiatric inpatient wards: A qualitative analysis of staff and patient experiences. J Clin Psychol. 2017;73(10):1211–25. Bealey R, Bowden G, Fisher P. A systematic review of team formulations in multidisciplinary teams: staff views and opinions. J Humanistic Psychol. 2021 Sep;7:00221678211043002. Staniszewska S, Mockford C, Chadburn G, Fenton SJ, Bhui K, Larkin M, Newton E, Crepaz-Keay D, Griffiths F, Weich S. Experiences of in-patient mental health services: systematic review. Br J Psychiatry. 2019;214(6):329–38. Association of Clinical Psychologists. Team formulation: Key considerations in mental health services. 2022. https://acpuk.org.uk/wp-content/uploads/2022/07/ACP-UK-Team-Formulation-Guidance-v1.pdf . Accessed: 25 March 2024. Geach N, Moghaddam NG, De Boos D. A systematic review of team formulation in clinical psychology practice: definition, implementation, and outcomes. Psychol Psychotherapy: Theory Res Pract. 2018;91(2):186–215. Totman J, Hundt GL, Wearn E, Paul M, Johnson S. Factors affecting staff morale on inpatient mental health wards in England: a qualitative investigation. BMC Psychiatry. 2011;11:1–0. Wyder M, Ehrlich C, Crompton D, McArthur L, Delaforce C, Dziopa F, Ramon S, Powell E. Nurses experiences of delivering care in acute inpatient mental health settings: A narrative synthesis of the literature. Int J Ment Health Nurs. 2017;26(6):527–40. Ball H, Yung A, Bucci S. Staff perspectives on the barriers and facilitators to exercise implementation in inpatient mental health services: A qualitative study. Ment Health Phys Act. 2022;22:100452. Bowers L, Simpson A, Alexander J, Hackney D, Nijman H, Grange A, Warren J. The nature and purpose of acute psychiatric wards: The Tompkins Acute Ward Study. J mental Health. 2005;14(6):625–35. James K, Quirk A, Patterson S, Brennan G, Stewart D. Quality of intervention delivery in a cluster randomised controlled trial: a qualitative observational study with lessons for fidelity. Trials. 2017;18:1–10. Radcliffe JJ, Adeshokan EO, Thompson PC, Bakowski AJ. Meeting the needs of families and carers on acute psychiatric wards: a nurse-led service. J Psychiatr Ment Health Nurs. 2012;19(8):751–7. Edwards K. What prevents one to one care? Nurs Times. 2011;107(1):25–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Mar, 2025 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 21 Jun, 2024 Editor assigned by journal 19 Jun, 2024 Submission checks completed at journal 19 Jun, 2024 First submitted to journal 29 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4495728","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317326314,"identity":"97a78d7d-c69f-49a9-9448-900770c05a8e","order_by":0,"name":"Isobel Johnston","email":"","orcid":"","institution":"Manchester Royal Infirmary, Manchester Greater Manchester Mental Health NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Isobel","middleName":"","lastName":"Johnston","suffix":""},{"id":317326315,"identity":"cfec5b30-a010-448c-be46-564478cbf333","order_by":1,"name":"Dawn 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09:01:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4495728/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4495728/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-025-06721-7","type":"published","date":"2025-03-28T15:57:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60447408,"identity":"dfb32556-e3a5-45bb-96c0-10f6091ce788","added_by":"auto","created_at":"2024-07-16 22:02:45","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":549509,"visible":true,"origin":"","legend":"\u003cp\u003ePerceived Enablers, Barriers, and Outcomes\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4495728/v1/af67ca6297ecf626b4e0aadc.jpeg"},{"id":79605147,"identity":"d4b58f12-8534-4f2a-901c-c88ed44e14db","added_by":"auto","created_at":"2025-03-31 16:10:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1556256,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4495728/v1/c3b4d71e-cf14-42b3-ac6f-1b6b08901bb1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Increasing access to psychological therapy on acute mental health wards: Staff and patient experiences of a stepped psychological intervention","fulltext":[{"header":"Background","content":"\u003cp\u003eIndividuals with serious mental health problems should have access to evidence-based psychological therapies across the care pathway \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Despite clinical guidelines, there is limited access to psychological therapies for these individuals within the United Kingdom, particularly within acute inpatient settings \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. The delivery of psychological therapy on acute wards presents a unique set of challenges including short stays, complex patient needs, ineffective team working and limited suitable space for conducting therapy \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. There is also no evidence-based approach for the delivery of therapy on acute mental health wards and limited research into how to overcome the aforementioned challenges.\u003c/p\u003e \u003cp\u003eThe TULIPS (Talk Understand and Listen on Inpatient Settings) project aimed to develop and evaluate a stepped psychological intervention model to increase access to psychological therapy on acute mental health wards and consequently reduce serious incidents, improve patient well-being and functioning, and reduce staff burnout \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Thirty-four wards across England, Wales, and Northern Ireland participated in a cluster randomised control trial (RCT) to evaluate the effectiveness of the intervention. A process evaluation, embedded within the trial, aimed to provide additional insights into staff and patient perspectives on the impact of the intervention and contextual factors that impeded or enhanced intervention delivery \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe process evaluation comprised three stands: semi-structured interviews with intervention users and providers, ethnographic observations on intervention wards, and fidelity assessments of intervention delivery. This study presents findings from qualitative interviews with staff and patients\u0026rsquo; which aimed to explore their views of the intervention, associated outcomes and highlight barriers and enablers to implementation and engagement.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eParticipants were recruited from acute mental health wards randomised to the intervention arm of theTULIPS trial. Acute mental health wards provide mental health treatment to individuals experiencing episodes of acute mental distress and posing risks to themselves or others. The average length of stay in the UK was 40 days in 2021/22 \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, although the range is likely wide.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eThe Intervention\u003c/h2\u003e \u003cp\u003eThe TULIPS intervention involved a stepped model of care with three levels \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Step one was a psychological formulation developed by the psychologist together with the ward team. In step two, nursing staff were trained and supervised by psychologists to deliver brief guided interventions for patients available in groups or on a one-to-one basis. At step three, patients could access up to 16 sessions of psychological therapy with psychologists. At least half a day\u0026rsquo;s training on mental health and psychological formulation was offered to all ward staff. Additional half days on specific problem areas likely to present wards (e.g. psychosis, self-harm, low mood etc) were offered to registered mental health nurses or other ward staff nominated by ward managers.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eSemi-structured interviews with staff and patients were used to create narratives of experiences. These narratives were constructed jointly by interviewees and the interviewer but remained centred in the experience of participants \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Interviews were led by topic guides focused on participants\u0026rsquo; views on the impact of the intervention and barriers and facilitators to delivery and uptake. Topic guides were informed by findings from earlier interviews exploring how to increase access to psychological therapy on acute wards \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e and were piloted with stakeholders (i.e. an individual with experience as an inpatient, a registered nurse from inpatient services and a clinical psychologist).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment and procedure\u003c/h2\u003e \u003cp\u003eInclusion criteria for staff and patients were: (a) present on intervention wards during the study period; (b) informed consent to participate in the study including the audio recording of the interview. An additional inclusion criterion for patients was capacity to provide informed consent and sufficient levels of concentration to partake in an interview, as determined by the care team in conjunction with the researchers.\u003c/p\u003e \u003cp\u003eParticipants were recruited until data saturation was reached. We used two different recruitment routes. Either intervention providers asked potential participants for their consent to be contacted by a researcher, or researchers approached participants directly when they were present on intervention wards during ethnographic observations. Participants were purposively sampled on the basis of direct exposure to the intervention. Efforts were made to recruit individuals from diverse backgrounds and with a variety of job roles. Risk and capacity assessments for patient participants were completed with a named nurse, responsible clinician, or member of patients\u0026rsquo; community mental health team (when interviews took place following discharge). All potential participants were provided with information on the interview process and goals of the research via participant information sheets before informed consent was sought. Interviews were conducted privately and in person (at NHS sites or patient participant\u0026rsquo;s homes) or remotely (on the telephone or using Microsoft Teams) depending on participant choice and risk information.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas gained from 65 participants (33 Patients; 32 Staff). Two patient participants withdrew consent prior to interview due to deteriorations in their mental health. One interview with a patient participant was excluded from analysis due to a poor-quality recording. Interviews with 30 patients and 32 staff members were included in analysis. Interview ranged from 19 to 123 minutes in length (M\u0026thinsp;=\u0026thinsp;53 minutes). Some participants were interviewed on more than one occasion to capture differences in their experience over time. See Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for participant demographics and prior experiences in therapeutic approaches.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e(should appear on/after page 5) Patient Demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimary Diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdditional Diagnoses\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReceived therapy previously?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTherapy received (N\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSetting received in (N\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite British (N\u0026thinsp;=\u0026thinsp;20, 65%)\u003c/p\u003e \u003cp\u003eWhite Irish (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eBlack African (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eMixed White and Black Caribbean (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eMixed White and Black African (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eBlack Caribbean and African (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eBlack Other (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle (N\u0026thinsp;=\u0026thinsp;21, 68%)\u003c/p\u003e \u003cp\u003eMarried (N\u0026thinsp;=\u0026thinsp;3, 10%)\u003c/p\u003e \u003cp\u003eDivorced (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eSeparated (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eWidowed (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eCivil Partnership (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eCommon-Law (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePersonality Disorder (N\u0026thinsp;=\u0026thinsp;11, 37%)\u003c/p\u003e \u003cp\u003eSchizophrenia, Schizoaffective or psychosis (N\u0026thinsp;=\u0026thinsp;9, 30%)\u003c/p\u003e \u003cp\u003eBipolar (N\u0026thinsp;=\u0026thinsp;4, 13%)\u003c/p\u003e \u003cp\u003eAnxiety (N\u0026thinsp;=\u0026thinsp;3, 10%)\u003c/p\u003e \u003cp\u003eDepression (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eObsessive Compulsive Disorder (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eAspergers (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eNo Formal Diagnosis (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnxiety (N\u0026thinsp;=\u0026thinsp;12, 39%)\u003c/p\u003e \u003cp\u003eDepression (N\u0026thinsp;=\u0026thinsp;12, 39%)\u003c/p\u003e \u003cp\u003eOther (N\u0026thinsp;=\u0026thinsp;6, 19%)\u003c/p\u003e \u003cp\u003ePersonality Disorder (N\u0026thinsp;=\u0026thinsp;2, 7%)\u003c/p\u003e \u003cp\u003eNone (N\u0026thinsp;=\u0026thinsp;9, 29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes (N\u0026thinsp;=\u0026thinsp;23, 74%)\u003c/p\u003e \u003cp\u003eNo (N\u0026thinsp;=\u0026thinsp;8, 26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCognitive Behavioural Therapy (N\u0026thinsp;=\u0026thinsp;12, 44%)\u003c/p\u003e \u003cp\u003eTalking Therapy (N\u0026thinsp;=\u0026thinsp;13, 41%)\u003c/p\u003e \u003cp\u003eMindfulness (N\u0026thinsp;=\u0026thinsp;6, 19%)\u003c/p\u003e \u003cp\u003eDialectical Behavioural Therapy (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eOther (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eCognitive Analytical Therapy (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eCounselling (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eFormulation (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eAcceptance Commitment Therapy (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOutpatient (N\u0026thinsp;=\u0026thinsp;11, 49%)\u003c/p\u003e \u003cp\u003eInpatient (N\u0026thinsp;=\u0026thinsp;4, 17%)\u003c/p\u003e \u003cp\u003eInpatient and Outpatient (N\u0026thinsp;=\u0026thinsp;7, 30%)\u003c/p\u003e \u003cp\u003eNot given (N\u0026thinsp;=\u0026thinsp;1, 4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote. Other therapies included art and music therapy.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e(should appear on/after page 5) Staff Demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJob role\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBand\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYears Experience in Mental Health\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYears Experience in Acute\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTraining in psychological interventions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTherapies Trained in (N\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDelivery Setting (N\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite British (N\u0026thinsp;=\u0026thinsp;25, 78%)\u003c/p\u003e \u003cp\u003eBlack African (N\u0026thinsp;=\u0026thinsp;3, 9%)\u003c/p\u003e \u003cp\u003eSouth Asian (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eMixed White and Black Caribbean (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Psychologist (N\u0026thinsp;=\u0026thinsp;6, 19%)\u003c/p\u003e \u003cp\u003eHealthcare Assistant (N\u0026thinsp;=\u0026thinsp;6, 19%)\u003c/p\u003e \u003cp\u003eNurse (N\u0026thinsp;=\u0026thinsp;5, 16%)\u003c/p\u003e \u003cp\u003eWard Manager (N\u0026thinsp;=\u0026thinsp;5, 16%)\u003c/p\u003e \u003cp\u003eOccupational Therapist (N\u0026thinsp;=\u0026thinsp;3, 9%)\u003c/p\u003e \u003cp\u003ePsychiatrist (N\u0026thinsp;=\u0026thinsp;3, 9%)\u003c/p\u003e \u003cp\u003eActivities Co-ordinator (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eDeputy Ward Manager (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eAssistant Psychologist (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBand 2 (N\u0026thinsp;=\u0026thinsp;3, 9%)\u003c/p\u003e \u003cp\u003eBand 3 (N\u0026thinsp;=\u0026thinsp;3, 9%)\u003c/p\u003e \u003cp\u003eBand 4 (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eBand 5 (N\u0026thinsp;=\u0026thinsp;3, 9%)\u003c/p\u003e \u003cp\u003eBand 6 (N\u0026thinsp;=\u0026thinsp;4, 13%)\u003c/p\u003e \u003cp\u003eBand 7 (N\u0026thinsp;=\u0026thinsp;6, 19%)\u003c/p\u003e \u003cp\u003eBand 8a (N\u0026thinsp;=\u0026thinsp;3, 9%)\u003c/p\u003e \u003cp\u003eBand 8b (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eBand 8c \u0026lt; (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003cp\u003eNot applicable (N\u0026thinsp;=\u0026thinsp;3, 9%)\u003c/p\u003e \u003cp\u003eNot Given (N\u0026thinsp;=\u0026thinsp;2, 6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 year (N\u0026thinsp;=\u0026thinsp;11, 34%)\u003c/p\u003e \u003cp\u003e1\u0026ndash;2 years (N\u0026thinsp;=\u0026thinsp;3, 9%)\u003c/p\u003e \u003cp\u003e2\u0026ndash;5 years (N\u0026thinsp;=\u0026thinsp;5, 16%)\u003c/p\u003e \u003cp\u003e5\u0026ndash;10 years (N\u0026thinsp;=\u0026thinsp;8, 25%)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years (N\u0026thinsp;=\u0026thinsp;5, 16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 year (N\u0026thinsp;=\u0026thinsp;4, 13%)\u003c/p\u003e \u003cp\u003e1\u0026ndash;2 years (N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003e2\u0026ndash;5 years (N\u0026thinsp;=\u0026thinsp;6, 19%)\u003c/p\u003e \u003cp\u003e5\u0026ndash;10 years (N\u0026thinsp;=\u0026thinsp;9, 28%)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years (N\u0026thinsp;=\u0026thinsp;12, 38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes (N\u0026thinsp;=\u0026thinsp;21, 66%)\u003c/p\u003e \u003cp\u003eNo (N\u0026thinsp;=\u0026thinsp;11, 34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCognitive Behavioural Therapy (N\u0026thinsp;=\u0026thinsp;11, 52%)\u003c/p\u003e \u003cp\u003eMindfulness (N\u0026thinsp;=\u0026thinsp;11, 52%)\u003c/p\u003e \u003cp\u003eOther (N\u0026thinsp;=\u0026thinsp;7, 33%)\u003c/p\u003e \u003cp\u003eDialectical Behavioural Therapy (N\u0026thinsp;=\u0026thinsp;5, 24%)\u003c/p\u003e \u003cp\u003eCognitive Analytical Therapy (N\u0026thinsp;=\u0026thinsp;5, 24%)\u003c/p\u003e \u003cp\u003eAcceptance Commitment Therapy (N\u0026thinsp;=\u0026thinsp;5, 24%)\u003c/p\u003e \u003cp\u003eCompassion Focused (N\u0026thinsp;=\u0026thinsp;4, 19%)\u003c/p\u003e \u003cp\u003eSchema Therapy (N\u0026thinsp;=\u0026thinsp;3, 14%)\u003c/p\u003e \u003cp\u003eMeta Cognitive Therapy (N\u0026thinsp;=\u0026thinsp;2, 10%)\u003c/p\u003e \u003cp\u003eEye Movement Desensitization and Reprocessing (N\u0026thinsp;=\u0026thinsp;2, 10%)\u003c/p\u003e \u003cp\u003eTalking Therapy (N\u0026thinsp;=\u0026thinsp;2, 10%)\u003c/p\u003e \u003cp\u003eCounselling\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003cp\u003eFormulation\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1, 3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInpatient (N\u0026thinsp;=\u0026thinsp;8, 38%)\u003c/p\u003e \u003cp\u003eOutpatient (N\u0026thinsp;=\u0026thinsp;3, 10%)\u003c/p\u003e \u003cp\u003eInpatient and Outpatient (N\u0026thinsp;=\u0026thinsp;5, 24%)\u003c/p\u003e \u003cp\u003eNot Given (N\u0026thinsp;=\u0026thinsp;5, 24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eAll interviews were audio recorded, transcribed verbatim and analysed inductively using reflexive thematic analysis \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. The coding was carried out with Nvivo 12 software. The following stages of analysis were completed separately for the staff and patient interviews. Firstly, a small team of three researchers coded the same transcript. A consensus meeting was then held to discuss differences in interpretation, develop a shared meaning and create a code book. Transcripts were then randomly assigned to coders and the codebook applied. All data felt to be incongruent with the codebook was labelled with \u0026lsquo;other\u0026rsquo; and discussed during regular coding meetings leading to adaptations of the codebook. These meetings also facilitated discussions of emerging themes, reflections and renaming and reorganising of codes. In addition to the initial consensus checking, 30% of transcripts were coded by at least two researchers. Where there were discrepancies in coding these were overcome through discussion, review of reflexive diaries and the raw data. Once all transcripts from that participant group were coded, theme development meetings were held where codes were organised into domain summaries. During the meetings emergent themes discussed throughout the analysis were expanded on and additional themes were identified through reviewing the final codebook and raw data. This process was iterative and reflexive, informed by researchers\u0026rsquo; knowledge of the data, experience conducting interviews and awareness of the wider study \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Initial themes (eight staff themes and six patient themes) were written up by author1 and refined based on feedback from the coding team.\u003c/p\u003e \u003cp\u003eInitial themes where then presented to three members of the TULIPS patient and carer group during validation workshops \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. All members had a lived experienced of inpatient wards as a patient or carer. Quotes felt to be most representative of each theme were presented without interpretation and members were asked open questions to encourage discussion and gain their perceptions of the raw data. Interpretations were explored and detailed minutes taken. These interpretations were then compared with the research teams and helped to further refine or validate themes. Participants themselves did not provide feedback on transcripts or themes.\u003c/p\u003e \u003cp\u003eOnce the aforementioned steps were completed for both staff and patient data, associated themes were organised into the domains of the Consolidated Framework for Implementation Science Research (CFIR) \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. When themes from staff and patient interviews were associated with the same domain these were extracted, compared and, where appropriate, interwoven to create rich themes accounting for both staff and patient perspectives. We initially aimed to conduct a framework analysis informed by CFIR but after indexing we found our data transcended the domains. Instead, our analysis remained thematic with CFIR being utilised only to organise and combine datasets, but not influencing interpretations. Analysis continued throughout the writing process with feedback from the wider study team contributing to refinements in themes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eReflexivity\u003c/h2\u003e \u003cp\u003eAll authors involved in the collection and analysis of data were female and employed researchers on the TULIPS project. Interviews were predominantly conducted by experienced qualitative researchers author 1 and 7. Author 1 also led data analysis. All but one author involved in data collection and analysis had experience working in inpatient mental health settings. Researchers therefore already held understandings of ward cultures, processes and the local language used, providing context to interviewees\u0026rsquo; experiences. This background influenced interpretations with researchers being more likely to focus on salient features of their own ward experiences, such as wards lacking resources and conflict within staff-patient relationships. The interviewers had spent time on the wards as participant observers prior to the interviews but were not well known to the interviewees.\u003c/p\u003e \u003cp\u003eReflexive journals were reflected on during analysis meetings enabling critical reflections, transparency, and credibility \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Researchers discussed excerpts of their journals during analysis meetings, with particular emphasis on how researchers\u0026rsquo; professional and personal experiences led to certain transcripts or perspectives being more poignant. For example, there was discussion about psychologists\u0026rsquo; characteristics and whether these were influenced by personality or professional training, as these were initially distinct codes. After review of the raw data and critical reflection on the coders\u0026rsquo; personal beliefs, it was agreed to code data pertaining to characteristics as a therapeutic skill, but it was noted that patients often perceived therapeutic skills as being part of the psychologist\u0026rsquo;s personality.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFour themes combining staff and patient perspectives and one theme from staff perspectives were generated from the interview data. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e demonstrates the contrasts between participant groups experiences within each theme. Perceived enablers and barriers to implementation and engagement, and associated outcomes are discussed across these themes and summarised in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e(should appear on page 8) Interviewees Views by Theme and Participant Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStaff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePsychologists\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA unique and respected \u0026ldquo;part of the team\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychologists\u0026rsquo; presence and active engagement led them to become a part of the team.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePsychologists\u0026rsquo; independence from the nursing team encouraged patient engagement.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo facilitate supervision effectively balancing insider status with independence from the team is needed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitating self-understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe intervention improved patient wellbeing.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe intervention increased self-understanding and coping.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ldquo;Bridging\u0026rdquo; the gap in understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttending formulation sessions increased understandings of patient behaviour and compassion.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInformation sharing meant services were better equipped to support patients.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeliefs about job role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn theory, therapy is lengthy and in-depth which is at odds with wards aims. Nurses must prioritise other activities lack time to deliver nurse-led interventions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStaff engaged in referral but were less motivated to adapt their own practice to meet patient needs. Staff beliefs about therapy informed who they referred.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePutting psychologists on a pedestal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStaff lack the confidence needed to deliver the intervention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePreference for engaging therapeutically with psychologists due to their perceived greater time and expertise.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNursing staff can\u0026rsquo;t be flexible with their time. Ward environments make it difficult for staff to build confidence in intervention delivery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eRespected but unique \u0026ldquo;\u003c/b\u003e \u003cb\u003epart of the team\u003c/b\u003e \u003cb\u003e\u0026rdquo;\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003ePsychologists were regularly visible on wards engaging with patients and spending time in the nursing office which afforded them status as a member of the ward team. Psychologists\u0026rsquo; regular physical presence coupled with their flexibility and persistence (adding meetings to diaries, reminding staff and re-booking when cancelled) had multiple benefits for ward staff including accessible consultation about how to respond to patients\u0026rsquo; behaviours and opportunities for emotional support during an emotionally draining shift. The changeable nature of ward environments meant staff could not always attend scheduled meetings with the psychologist, but psychologists\u0026rsquo; physical presence enabled staff to access support in vivo.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThings run over but if you\u0026rsquo;ve got a psychologist there and they\u0026rsquo;re around and they\u0026rsquo;re visible you can just say oh have you got two minutes to talk about this.\u003c/em\u003e \u003cb\u003ePsychiatrist A\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePsychologists\u0026rsquo; presence was also essential in providing opportunities to develop relationships with staff further enhancing integration within the team. Informal social interactions outside of meetings were especially important for this rapport building. Being around and willing to help with tasks outside the remit of the psychologist\u0026rsquo;s role afforded respect from nursing staff and led to beliefs that psychologists recognised the difficulties of the nurse\u0026rsquo;s job. Psychologists also recognised the importance of these relationships for the implementation of the intervention noting they needed to be an insider to facilitate change:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIn order to influence culture you need to not be a threat and you need to have relationships with people.\u003c/em\u003e \u003cb\u003ePsychologist A\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDeveloping relationships with psychiatrists also aided psychologists\u0026rsquo; integration within the wider multidisciplinary team and led psychiatrists to encourage patients to engage in psychological assessment or intervention. This endorsement from psychiatrists who were senior members of team indicated that the intervention was credible and should be prioritised.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt made a huge difference if you\u0026rsquo;ve got a psychiatrist endorsing it, who is considered someone who is considered, the lead clinician on the ward. I suppose that gives you a bit of kudos by association.\u003c/em\u003e \u003cb\u003ePsychologist A\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe psychologists\u0026rsquo; effort to embed themselves within staff teams acted as a mechanism for staff and patient engagement with the intervention. Yet, maintaining some independence from the team by virtue of being from a different professional group was also beneficial. On wards with significant staff conflict, or hierarchal cultures, members of the nursing team felt able to confide in psychologists about their concerns due to their perceived understanding of the ward environment and some degree of impartiality.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThey are a team member but you\u0026rsquo;re not directly a team member, so it would be nice sometimes just to, offload to someone.\u003c/em\u003e \u003cb\u003eNursing Assistant A\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePsychologists perceived impartiality and independence from the nursing team coupled with their provision of a dedicated safe space also fostered patient engagement. These patients described previous negative experiences of care on acute wards leading to a mistrust of nursing staff on the team.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe were in a safe space and that\u0026rsquo;s what the psychologist has to create. A place, you know, someone to talk to that is third-party neutral. That\u0026rsquo;s important.\u003c/em\u003e \u003cb\u003ePatient A\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2. Facilitating understanding\u003c/h2\u003e \u003cp\u003ePatients described how one-to-one sessions with psychologists facilitated greater understanding of how life experiences related to current emotions and behavioural patterns.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI understood why I feel the way I do and act the way I do, and when I was able to sort of express myself, then I could understand myself more.\u003c/em\u003e \u003cb\u003ePatient D\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis differed from treatment prior to the intervention where patients described a process of \u0026ldquo;\u003cem\u003etelling their story over and over to different people\u003c/em\u003e\u0026rdquo; \u003cb\u003e[Patient B]\u003c/b\u003e without opportunities to understand the reasons for their distress or help in developing coping strategies.\u003c/p\u003e \u003cp\u003eSome patients were anxious about the idea of making themselves vulnerable within the context of therapy, particularly for those reporting prior negative experiences of counselling or therapy. However, through showing understanding, psychologists were able to put these anxieties to rest.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eYou feel like [the psychologist] is taking an interest in your particular situation and then, you can then work with them better. You feel they are trying to understand me, not just a condition.\u003c/em\u003e \u003cb\u003ePatient J\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStaff also perceived that the intervention to improved patients\u0026rsquo; self-understanding and described associated reductions in self-harm, aggression, and negative affect.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWhat I\u0026rsquo;ve noticed is that patients feel much safer when they have interactions with the psychologist and the number of incidents decrease, and they feel like there\u0026rsquo;s somebody really listening and understanding.\u003c/em\u003e \u003cb\u003ePsychiatrist B\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs well as enabling patients\u0026rsquo; self-understanding, psychologists facilitated staff knowledge of patient needs through different forums. Staff reported that attending psychologist-led formulation sessions increased their understanding of the meaning, and motivations behind behaviours that typically attracted staff criticism (e.g. aggression, self-harm).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI have better understanding of why, if someone\u0026rsquo;s behaving- if someone displays challenging behaviour should I say it helps me to have a better understanding of where they\u0026rsquo;re coming from.\u003c/em\u003e \u003cb\u003eOccupational Therapist B\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePatients also welcomed the psychologist sharing aspects of their formulation with staff to enable to improve staff understanding of support needs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e[The psychologist] can go to members of staff and say, he struggles with this, struggles with that, so the members of staff on the ward are getting a better insight in how you\u0026rsquo;re dealing with, the certain situations, which is a massive thing cos some of staff won\u0026rsquo;t even know.\u003c/em\u003e \u003cb\u003ePatient L\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese examples of knowledge sharing were described in terms of psychologists acting as a \u003cem\u003ebridge\u003c/em\u003e between patients and staff, suggesting staff and patients previously felt disconnected. Understanding the functions of patient behaviour also helped to enable compassion and empathy, which staff associated with an increased feeling of reward from their work.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIf we\u0026rsquo;d had a service user that is continually displaying aggressive behaviour, some staff find it really difficult to deal with, and they start almost feeling burnt out, and then I think the formulations and the one-to-one sessions have really helped staff take a step back and think about actually this is what\u0026rsquo;s triggered this behaviour It\u0026rsquo;s kind of helped people sort of be more empathetic\u003c/em\u003e. \u003cb\u003eWard Manager A\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome also patients perceived that staff had become more compassionate and \u0026ldquo;\u003cem\u003eless judgemental\u003c/em\u003e\u0026rdquo; [Patient C] as a result of the intervention. Others believed that care had not improved as levels of compassion were dependent on individual differences among staff suggesting little optimism about future changes in staff behaviour.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt was only like a couple of [staff] members that that would do their utmost to cheer you up and make sure you're okay. But a vast majority of them would just like, you might as well not be there at all.\u003c/em\u003e \u003cb\u003ePatient K\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFormulations were also shared with community or home treatment teams. As a result, some patients perceived that step-down services were better equipped to continue supporting recovery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e My care coordinator, she had a session with [psychologist], and they spoke about the formulation that we\u0026rsquo;d done so I don\u0026rsquo;t have to repeat myself again and sort of talk about a lot of things.\u003c/em\u003e\u003cb\u003ePatient D\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some patients described feeling \u0026ldquo;\u003cem\u003edisappoint[ed]\u0026rdquo;\u003c/em\u003e [Patient M] at not being able to continue engaging in the intervention after discharge, preventing them from maintaining the level of functioning developed. Although patients still perceived the ward-based intervention to be beneficial, some felt it should extend into the community.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI would have liked to continue it to be honest especially as an outpatient because whilst sessions with her with good, it was just, it would have been nice to have it followed up\u003c/em\u003e \u003cb\u003ePatient C\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3. Beliefs around job role\u003c/h2\u003e \u003cp\u003eStaff described how acute wards served to stabilise patients and reduce risk with an aim to discharge them as soon as possible. This perception of ward function, combined with staff beliefs that psychological therapy is lengthy, complex, and unsuitable for patients with schizophrenia, led some staff to believe that the intervention was at odds with ward aims.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eHow do you embed the psychology into the purpose of the ward? \u0026lsquo;Cos if that purpose is to be a really acute short stay ward that rapidly turns around people, has bed availability and all those kind of things, that doesn\u0026rsquo;t tend to lend to lengthy, more consistent interventions.\u003c/em\u003e \u003cb\u003eWard Manager B\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNarratives around the function of acute wards fed into beliefs that nursing staff\u0026rsquo;s primary role did not include providing psychological therapy. Staff typically depicted their key responsibilities to be medication administration, risk management and completing paperwork. These beliefs likely limited staff engagement in delivering nurse-led interventions as these were seen as \u0026ldquo;\u003cem\u003elow priority\u003c/em\u003e\u0026rdquo; [Occupational Therapist C]. Although staff busyness with other duties was a significant barrier to intervention implementation, some staff did successfully deliver interventions. These individuals prioritised intervention delivery over other tasks.\u003c/p\u003e \u003cp\u003e Some staff described how formulation sessions provided a safe and non-judgemental space to challenge rhetoric around the limits of their job role. For these individuals engaging with psychologists led to perceptions that their responsibilities should include providing therapeutic support to patients. For some staff this change in belief encouraged engagement in intervention delivery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI\u0026rsquo;m not just there to unlock doors and to give people food, it (formulation sessions) reminds me that, in our everyday interactions with patients on the ward there\u0026rsquo;s a therapeutic reason for nursing assistants to be here.\u003c/em\u003e\u003cb\u003eNursing Assistant C\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, this prioritisation of the intervention was primarily enabled by ward managers buy-in which was felt to be \u003cem\u003einstrumental\u003c/em\u003e in enabling staff to prioritise engaging in interventions over other activities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe way that it was talked about within the team was maybe like this is a nice optional extra, but it\u0026rsquo;s not essential, whereas on the other ward the ward manager really kind of prioritised staff being able to spend time with me.\u003c/em\u003e \u003cb\u003ePsychologist B\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnlike other members of the multi-disciplinary team, nursing staff also lacked control over their time, meaning that without ward manager support they were unable to dedicate time to the intervention.\u003c/p\u003e \u003cp\u003e \u003cem\u003e(Nurses) turn up on shift and you\u0026rsquo;re told what you\u0026rsquo;re doing for each hour and psychological work isn\u0026rsquo;t part of that scheduling.\u003c/em\u003e \u003cb\u003ePsychologist C\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAs a result, in the absence of ward manager support, level 2 interventions were most successfully led by staff who were in control of their diaries and not expected to respond to incidents, such as assistant psychologists and occupational therapy staff (including recovery workers and activity co-ordinators).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4. Putting psychologists on a pedestal\u003c/h2\u003e \u003cp\u003ePsychologists flexible schedule enabled protected time and space to develop therapeutic alliance with patients. This ability to give uninterrupted, quality time was highly valued, and enabled patient engagement. In contrast, nursing staff lacked opportunities to devote time to patients and had other priorities as a part of their role which acted as an obstacle to patients seeking support.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIf something happens on the ward, and that nurse has to go. You might be allocated a time, but that necessarily might not happen. You can never get through a full meeting, without something happening on the ward, and then you\u0026rsquo;re more reluctant to speak to them.\u003c/em\u003e \u003cb\u003ePatient M\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePerceptions that psychologists held a higher level of therapeutic training and expertise also motivated patients to engage with psychologist-led sessions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt\u0026rsquo;s the knowledge and the understanding of one\u0026rsquo;s emotions or what they\u0026rsquo;re going through. I\u0026rsquo;m not saying the nurses aren\u0026rsquo;t understanding, but when someone\u0026rsquo;s trained in that speciality of being a psychologist, they just have more of an understanding.\u003c/em\u003e \u003cb\u003ePatient M\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely, beliefs nursing staff were \u0026ldquo;\u003cem\u003enot very confident\u0026rdquo;\u003c/em\u003e [Patient N] in delivering psychological interventions reduced patients\u0026rsquo; motivation to engage in nurse-led interventions. Nursing staff themselves also reported a lack of confidence, due partly to few opportunities to build experience and skill in intervention delivery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThat is one of the difficulties with all the interventions we do is that there is always the sense that you\u0026rsquo;re learning as you\u0026rsquo;re going, so-so the first few that you do, it\u0026rsquo;s almost like you\u0026rsquo;re not 100% clear what you\u0026rsquo;re trying to work through with someone. Sometimes that can be off-putting.\u003c/em\u003e \u003cb\u003eNurse A\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePsychologists felt ward environments were not conducive of staff building confidence and learning new skills, such as those required to deliver interventions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think you just stay in your comfort zone, when you\u0026rsquo;re just feeling like you\u0026rsquo;re spinning plates, or you feel a bit stressed out in a job, so I think, staff confidence has impacted on their delivery of the interventions.\u003c/em\u003e \u003cb\u003ePsychologist A\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePerceptions that support provided by psychologists was superior meant patients did not always see the benefit of engaging in nurse-led interventions. This contributed to a dichotomy in patients\u0026rsquo; perceptions of staff, with psychologist who had the luxury of managing their own diary and more training in therapies being put on a pedestal whilst nursing staff who had multiple competing demands and skill sets were described more critically.\u003c/p\u003e \u003cp\u003ePsychologists also perceived that ward staff had high expectations of their role. They described how staff would refer patients for therapy who were difficult to manage rather than seeking advice and engaging in intervention delivery to adapt their own practice. In this way, staff\u0026rsquo;s perception that psychologists filled a gap in treatment was in some ways at odds with one of the main aims of the intervention: to upskill staff to engage more therapeutically with patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI still think that\u0026rsquo;s why sometimes people will say oh will you see this person? Often the medic will sort of tickety tick that box that, they\u0026rsquo;re seeing our psychologist that\u0026rsquo;s great then they feel okay.\u003c/em\u003e \u003cb\u003eSupervisor A\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe stepped model of psychological intervention had a positive impact on both patients\u0026rsquo; understanding of their emotional distress and also staff members\u0026rsquo; understanding of patients\u0026rsquo; needs. This improved understanding was facilitated by psychologists\u0026rsquo; availability and frequent physical presence on the wards, as well as their focus on relationship building with both staff and patients. However, the nurses\u0026rsquo; perceptions that psychological therapy was not part of their role and lack of support from managers to dedicate time to therapy meant that the nurse-led interventions were not delivered frequently or with sufficient skills and confidence.\u003c/p\u003e \u003cp\u003eThe psychologists\u0026rsquo; frequent physical presence on the wards enabled them to be flexible and adaptative in response to the ward environment. This flexibility and adaptation are well-established factors in enabling the successful delivery of complex interventions \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e but may be particularly important on acute mental health wards due rapid escalations in patient distress and risk and the consequent focus on crisis management \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The focus on relationship building is another well-known factor in the successful delivery of complex interventions and ward-based interventions in particular \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. However, previous research has found that psychologists can be seen unwelcome \u0026lsquo;experts\u0026rsquo; within teams \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e suggesting that psychologists may not routinely invest time in this important foundation for delivery psychological consultation or therapies.\u003c/p\u003e \u003cp\u003eThe role of psychological formulation in facilitating understanding of patients\u0026rsquo; needs has previously been shown in studies focused on both patient perspectives of formulation \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e and staff perspectives of team formulation \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. The fact that patients reported a contrast between their experiences of therapy with the psychologists and their previous experiences of assessments within ward environments is reflective of the limited availability of psychological therapies on acute wards \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. Previous studies have suggested that psychological therapies might not be compatible with acute wards \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e and some staff we interviewed echoed these concerns. However, our findings coupled with findings from other research \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e consistently highlights that patients\u0026rsquo; value the opportunity of therapy as an inpatient and do not share staff concerns.\u003c/p\u003e \u003cp\u003eThe finding that improved understanding of patient needs through team formulation improved staff empathy and compassion is also consistent with previous research exploring the effects of team formulation \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e and is one of the key rationales for the team formulation process \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Nonetheless, previous research has reported negative effects of team formulation including the perception that formulations devalue staff members\u0026rsquo; current ways of working \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. The risk of staff perceiving formulation in this way could have been mitigated in our study by the focus psychologists placed on relationship building with staff alongside the provision of formulation and other aspects of the stepped model of care. Although there is evidence that formulations can impact on staff understanding and empathy, both our study and previous research \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e suggests some staff do not change their practice as a result of team formulation. Greater attention therefore needs to be paid to ensuring that the recommendations of formulation are fed into care planning. Team formulation meeting in our study and in previous research \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e were primarily attended by nursing staff, but involving psychiatrists more routinely in the process may help to ensure that the information generated feeds into all aspects of the person\u0026rsquo;s care.\u003c/p\u003e \u003cp\u003eThe finding that some nurses viewed psychological therapies as outside of their role may reflect the broad nature of the nurse\u0026rsquo;s role \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Nurses are frontline staff and represent a large workforce within the health service. Many ward processes and procedures are therefore typically allocated to nurses meaning that they have many competing demands \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. In the context of a risk averse environment where blame and accountability are high, the focus of nurse\u0026rsquo;s time and attention easily gets drawn into processes that are mandatory and auditable and the documentation of these processes \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. Despite competing demands, our study and previous research suggests that nurses can ring fence time to deliver psychological therapies with management support \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Engaging ward managers in the delivery of the stepped model of care is therefore vital from the outset.\u003c/p\u003e \u003cp\u003eThe finding that nurse\u0026rsquo;s lack confidence in delivery the intervention was not surprising given the limited opportunity that some staff had in delivery. Time for psychologists to continue to support and supervise staff in delivering interventions post training is therefore an essential component of any intervention that aims to upskill nurses in delivery psychological interventions. The dichotomy created in patients minds between the psychological therapists and nursing staff was an unintended consequence of the intervention, but reflects the multiple demands on the nurse\u0026rsquo;s time which prevents the profession being able to dedicate time to one-to-one work with patients and presumably engaging in work that motivated them to join the profession in the first place \u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. Supporting nurses to be able to develop skills and practice therapeutic work on the wards is therefore essential in recruiting and retaining a motivated and satisfied workforce who are able to deliver the best care possible.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe TULIPS intervention positively impacted on patients and staff\u0026rsquo;s ward experience leading to improved self-understanding for patients and greater understanding and compassion among staff. However, the uptake of nurse-led interventions was relatively poor, due to beliefs about the function of acute wards, the remit of the nurse\u0026rsquo;s role, limited support from ward managers and consequent lack of nurse confidence in intervention delivery. Wider system level changes are needed for nurse-led psychological interventions to be feasible within inpatient settings. Such changes could include a greater focus on psychological interventions during nursing training and as part of continued professional development, the delivery of therapeutic interventions in job role descriptions and the inpatient leads ensuring that staff have protected time to facilitate these tasks.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRelevance for clinical practice\u003c/h2\u003e \u003cp\u003eA stepped model of care with formulations as a foundation is welcomed by patients and ward staff. Patients and staff also benefit from the presence of a ward-based psychologists who can provide regular opportunistic consultation to staff and therapy to patients. However, further work is needed to enable nurses to put psychological therapies into practice on the wards and develop skills in this area. This change will necessitate support from senior ward staff including ward managers but also changes to professional training, continued professional development and job descriptions. Such changes are important in terms of improving patients\u0026rsquo; experience of the ward but also helping the recruitment and retention of nurses within inpatient settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTULIPS: Talk, Understand and Listen in InPatient Settings\u003c/p\u003e\n\u003cp\u003eRCT: Randomised Controlled Trial\u003c/p\u003e\n\u003cp\u003eNICE: The National Institute for Health and Care Excellence\u003c/p\u003e\n\u003cp\u003eUK: United Kingdom\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNHS; National Health Service\u003c/p\u003e\n\u003cp\u003eCFIR: Consolidated Framework for Implementation Research\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the TULIPS study with favourable opinion was obtained in July 2019 from the Greater Manchester NHS Research Ethics Committee (IRAS ID: 264686). \u0026nbsp;All participants in the study provided informed consent to participate in audio recorded interviews and for pseudonymised quotes from their interviews to be presented in published reports, articles, or books.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants demographic information is presented within the article. Copies of interview topic guides used within interviews can be requested from the corresponding author. To maintain participants anonymity interview transcripts cannot be published or shared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe TULIPs Trial was funded by the National Institute of Health Research (NIHR) RP-PG-0216-20009. Berry, Edge and Haddock were also supported by the Manchester Biomedical Research Centre (NIHR 203308). Bucci is funded by a research professorship NIHR300794 from the NIHR and by the National Institute for Health and Care Research (NIHR) Manchester Biomedical Research Centre (BRC; NIHR 203308). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was designed and supervised by KB, DE and PW. Interviews were conducted primarily by experienced qualitative researchers GG and IJ, with support from HM and SK. Analysis was led by IJ with AB, HM, SK and MS contributing to coding and theme development. The manuscript was drafted by IJ with contributions from HM and editing from KB. Drafts were critically reviewed, and comments provided by KB, SB, DE, GG, FH, GH, KL, OP, MS, RD and PW and the final manuscript was approved by all authors. Project management of the wider trial was provided by FH and HM.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to express our gratitude to the patients and staff who gave their time and shared their experiences during interviews. We would also like to offer our thanks to Tracey Hepburn, Georgia Penn, and Hamish McFarlane for their contributions to transcription.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNational Institute for Health and Care Excellence. 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Overcoming barriers to implementing ward-based psychosocial interventions in acute inpatient mental health settings: A meta-synthesis. Int J Nurs Stud. 2021;115:103870.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristofides S, Johnstone L, Musa M. Chipping in\u0026rsquo;: Clinical psychologists\u0026rsquo; descriptions of their use of formulation in multidisciplinary team working. Psychol Psychotherapy: Theory Res Pract. 2012;85(4):424\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKenna M, Brown LJ, Berry K. Formulation-led care in care homes: staff perspectives on this psychological approach to managing behaviour in dementia care. Int J Older People Nurs. 2022;17(5):e12465.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerry K, Haddock G, Kellett S, Awenat Y, Szpak K, Barrowclough C. Understanding outcomes in a randomized controlled trial of a ward-based intervention on psychiatric inpatient wards: A qualitative analysis of staff and patient experiences. J Clin Psychol. 2017;73(10):1211\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBealey R, Bowden G, Fisher P. A systematic review of team formulations in multidisciplinary teams: staff views and opinions. J Humanistic Psychol. 2021 Sep;7:00221678211043002.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStaniszewska S, Mockford C, Chadburn G, Fenton SJ, Bhui K, Larkin M, Newton E, Crepaz-Keay D, Griffiths F, Weich S. Experiences of in-patient mental health services: systematic review. Br J Psychiatry. 2019;214(6):329\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssociation of Clinical Psychologists. Team formulation: Key considerations in mental health services. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://acpuk.org.uk/wp-content/uploads/2022/07/ACP-UK-Team-Formulation-Guidance-v1.pdf\u003c/span\u003e\u003cspan address=\"https://acpuk.org.uk/wp-content/uploads/2022/07/ACP-UK-Team-Formulation-Guidance-v1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed: 25 March 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeach N, Moghaddam NG, De Boos D. A systematic review of team formulation in clinical psychology practice: definition, implementation, and outcomes. Psychol Psychotherapy: Theory Res Pract. 2018;91(2):186\u0026ndash;215.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTotman J, Hundt GL, Wearn E, Paul M, Johnson S. Factors affecting staff morale on inpatient mental health wards in England: a qualitative investigation. BMC Psychiatry. 2011;11:1\u0026ndash;0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWyder M, Ehrlich C, Crompton D, McArthur L, Delaforce C, Dziopa F, Ramon S, Powell E. Nurses experiences of delivering care in acute inpatient mental health settings: A narrative synthesis of the literature. Int J Ment Health Nurs. 2017;26(6):527\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBall H, Yung A, Bucci S. Staff perspectives on the barriers and facilitators to exercise implementation in inpatient mental health services: A qualitative study. Ment Health Phys Act. 2022;22:100452.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowers L, Simpson A, Alexander J, Hackney D, Nijman H, Grange A, Warren J. The nature and purpose of acute psychiatric wards: The Tompkins Acute Ward Study. J mental Health. 2005;14(6):625\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJames K, Quirk A, Patterson S, Brennan G, Stewart D. Quality of intervention delivery in a cluster randomised controlled trial: a qualitative observational study with lessons for fidelity. Trials. 2017;18:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRadcliffe JJ, Adeshokan EO, Thompson PC, Bakowski AJ. Meeting the needs of families and carers on acute psychiatric wards: a nurse-led service. J Psychiatr Ment Health Nurs. 2012;19(8):751\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdwards K. What prevents one to one care? Nurs Times. 2011;107(1):25\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical Psychology, Mental Health Nursing, Mental Health Services, Interviews, Qualitative Research","lastPublishedDoi":"10.21203/rs.3.rs-4495728/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4495728/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePsychological therapies are recommended for people with serious mental health problems. However, access is limited, particularly in inpatient mental health settings. The Talk, Understand and Listen in InPatient Settings (TULIPS) study is a large multi-centre cluster-randomised controlled trial which aimed to evaluate a stepped psychological intervention model to increase access to therapies for inpatients. This paper presents findings from the embedded process evaluation focusing on the contextual factors influencing intervention delivery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThirty-two staff and 31 patients from wards receiving the intervention participated in semi-structured interviews. Data was analysed using reflexive thematic analysis. Staff and patient data were analysed separately but perspectives were compared and interwoven resulting in five themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePatients reported sessions with psychologists facilitated greater self-understanding and coping. Staff and patients reflected that formulations improved staff understanding of patient presentations. This understanding was associated with improved staff-patient relationships, more person focused practice and reduced conflict and burnout. Psychologists\u0026rsquo; frequent physical presence on the wards and support of nursing teams enabled staff buy-in. However, significant barriers in resource, skill and confidence inhibited the delivery of nurse-led interventions within the stepped care model, as did perceptions that intervention delivery was outside the remit of nursing staff\u0026rsquo;s role.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study provides evidence that a stepped psychological intervention on acute mental health wards could improve patient coping and ward experience for patients and staff. Future studies should target nursing staff confidence and skill in the delivery of psychological interventions.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov Identifier: NCT03950388. Registered 15th May 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://clinicaltrials.gov/ct2/show/NCT03950388\u003c/span\u003e\u003cspan address=\"https://clinicaltrials.gov/ct2/show/NCT03950388\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e","manuscriptTitle":"Increasing access to psychological therapy on acute mental health wards: Staff and patient experiences of a stepped psychological intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-16 22:02:41","doi":"10.21203/rs.3.rs-4495728/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-21T12:39:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-19T10:37:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-19T10:37:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-05-29T09:00:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dbedf30f-33fb-4e88-8446-85bc1c519ed9","owner":[],"postedDate":"July 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T16:07:19+00:00","versionOfRecord":{"articleIdentity":"rs-4495728","link":"https://doi.org/10.1186/s12888-025-06721-7","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2025-03-28 15:57:16","publishedOnDateReadable":"March 28th, 2025"},"versionCreatedAt":"2024-07-16 22:02:41","video":"","vorDoi":"10.1186/s12888-025-06721-7","vorDoiUrl":"https://doi.org/10.1186/s12888-025-06721-7","workflowStages":[]},"version":"v1","identity":"rs-4495728","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4495728","identity":"rs-4495728","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}