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Relapse prevention strategies based on monitoring of early warning signs (EWS) are advocated for the management of psychosis. However, there has been a lack of research exploring how staff, carers and patients make sense of the utility of EWS, or how these are implemented in context.
To develop a multiperspective theory of how EWS are understood and used, which is grounded in the experiences of mental health staff, carers and patients.
Twenty-five focus groups were held across Glasgow and Melbourne (EMPOWER Trial, ISRCTN: 99559262). Participants comprised 88 mental health staff, 21 patients and 40 carers from UK and Australia (total n = 149). Data were analysed using constructivist grounded theory.
All participants appeared to recognise EWS and acknowledged the importance of responding to EWS to support relapse prevention. However, recognition of and acting on EWS were constructed in a context of uncertainty, which appeared linked to risk appraisals that were dependent on distinct stakeholder roles and experiences. Within current relapse management, a process of weighted decision-making (where one factor was seen as more important than others) described how stakeholders weighed up the risks and consequences of relapse alongside the risks and consequences of intervention and help-seeking.
Mental health staff, carers and patients speak about using EWS within a weighted decision-making process, which is acted out in the context of relationships that exist in current relapse management, rather than an objective response to specific signs and symptoms.
The feasibility of implementation is insufficiently considered in
clinical guideline development, leading to human and financial resource
To develop (a) an empirically based standardised measure of the
feasibility of complex interventions for use within mental health
services and (b) reporting guidelines to facilitate feasibility
A focused narrative review of studies assessing implementation blocks and
enablers was conducted with thematic analysis and vote counting used to
determine candidate items for the measure. Twenty purposively sampled
studies (15 trial reports, 5 protocols) were included in the psychometric
evaluation, spanning different interventions types. Cohen's kappa (κ) was
calculated for interrater reliability and test–retest reliability.
In total, 95 influences on implementation were identified from 299
references. The final measure – Structured Assessment of FEasibility
(SAFE) – comprises 16 items rated on a Likert scale. There was excellent
interrater (κ = 0.84, 95% CI 0.79–0.89) and test–retest reliability (κ =
0.89, 95% CI 0.85–0.93). Cost information and training time were the two
influences least likely to be reported in intervention papers. The SAFE
reporting guidelines include 16 items organised into three categories
(intervention, resource consequences, evaluation).
A novel approach to evaluating interventions, SAFE, supplements efficacy
and health economic evidence. The SAFE reporting guidelines will allow
feasibility of an intervention to be systematically assessed.
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