Table 4 Key factors impacting on implementation of REACT

Coherence

Generally good understanding of REACT. Staff could identify benefits to relatives and staff including: a) standardised information,

Woods, Clinician: One potential benefit is you can very easily offer I suppose everyone with an internet connection really the same information…consistently across the board…And hopefully if it’s used then you can get used to working with a family that have a certain knowledge base which I think would be good.

b) available any time, any place, anywhere;

Woods, IMPART Lead: [Groups] can be very responsive and warm and everything but they’re also yeah you have to get here for 6 o’clock on alternate Tuesdays… [A website is] much more kind of accessible and people can read stuff in their own speed.

c) training for staff;

Seashore, Clinician: …it’s nice to know oh right this is something I have that’s up my sleeve and it kind of gives me a sense of like a purpose […] now I feel like yeah I’m a specialist in carers’ needs and I have a specialist tool for you and I think it’s really useful.

d) hitting national targets;

Woods Clinician: Yeah I think it fits in in terms of reaching the family interventions target and as I said before I think it fits in with the BFT [behavioural family therapy] as well. So it kind of hits a couple of the targets that we’ve got to do I think.

e) reducing staff workloads;

Marsh, Clinician: Yeah I think it’s really good, it’s brilliant, especially as with all the will in the world you’ve only got a certain amount of time when you can do stuff with carers and you’ve got everything else, in that way it’s a really educational tool that anyone can use you know, it’s really good.

f) empowering self- management for relatives

Lakes, REACT Champion: I mean relatives would like to look at it so they can support their own child or son, daughter or whoever you know, their husband, wife, they might need those services and they can take a lead role it in.

g) good fit with other parts of carer services

Ocean, Clinician: Yeah, for instance I’m working with a family that’s a bit there’s quite a lot of conflict and it’s a bit split up at the moment, so my client’s a male client, he was living at home, his mental health brought then such a degree that it was impacting on his marriage and his relationship with his children, so he had a bit of respite over with his mum, so I kind of offered them BFT family intervention with the children and the wife and the grandma, and also offered them access to the REACT website for them to access more information around psychosis and their understanding of the difficulties that the son and husband were going through, to kind of get an understanding about some of the complexities and difficulties and about treatment.

BUT

REACT seen as research, rather than part of the clinical service. This generated some short-term behaviour but impeded long-term commitment as seen as inherently time-limited and the responsibility of the R&D team.

Seashore, IMPART Lead: …I think if REACT had been introduced as not research but just something we’re going to do from now, that by the way we might evaluate, possibly it might have been seen as more of an infrastructural thing, this is what we will do, but yeah. The kiss of death is kind of true, but people switch off as soon as you go this is a person from X university and they’re going to talk about this project. You can see half the team sort of go oh God and fold their arms and how many more minutes have we got to put up with this, no matter what the project is…

Challenges with delivering face to face training to all staff due to shifts, staff turnover etc. Online training manual not well used. Consequently, some staff not familiar with REACT and didn’t understand their role in offering it.

Lakes, Clinician: … I can’t recall anyone going through the modules clearly with us, I think it was like your team signed you up like so [IMPART Lead] as the lead just sent everyone log ins and said off you go, have a look at it yeah, hence why I was thinking some team time to look at it together, so we all feel confident, we can ask questions.

Cognitive participation

“Professional ownership” was important in determining who used REACT

Lakes, Clinician: Yeah I do think there is something a bit odd about a family resource coming from psychiatry not from the family therapists; I do think that is unusual.

Staff feared negative impact on relationships with relatives in case digital support would not be as effective as face-to-face support and relatives may feel “fobbed off”;

Woods, IMPART Lead:…there’s this feeling I think both among the managers and the staff, they don’t quite seem to see a digital intervention as something that’s sort of real and high quality, I think they kind of feel that they’re offering relatives something that’s a little bit sort of weird and tricksy and not quite the real stuff that they as mental health professionals are supposed to be offering and I think that’s quite sort of wide spread, almost just like embarrassment in offering this.

REACT may not be appropriate for everyone – particularly older adults

Moor, Clinician: ..I don’t have a lot of the younger people on my case load, I have the older end, in that you know some of them are in their late 50s coming up to some of them even just going up to 60 age bracket, so even though I try to take my information leaflet along with me and say what REACT is about, and a very, they seem to have accepted that it’s a useful resource, very you know sort of very kind of me to offer it, but because they’re not clued up with computers, that computer age and literacy, they decline, they say thank you but no thank you, we don’t want to bother with it.

REACT content static and sometimes at odds with current practice e.g. REACT provides definitions for the diagnostic terms that relatives may have come across (based on what relatives identified as useful things to include).

Marsh REACT Champion: I think the first description was one of schizophrenia and I wasn’t impressed with that ‘cos I think that is scary for having that as your first introduction to psychosis…We wouldn’t ever give somebody a diagnosis of schizophrenia within the first year probably anyway.

REACT roles allocated, but no choice and not volunteered.

Lakes, Clinician: What I’ve done in Grebe is I have a carers’ champion, and then I have [name] who’s the React supporter, and I’ve actually paired them up so that they support each other, because there’s a lot of work to be done through the carers’ champion that could be useful to React, so it was easier to do that, so they’re both doing a dual role, so I think that might be something that I’ll do in the team, but again we’re both small teams and it can be a lot of work you know

Negative experiences of IT systems in all trusts, leading to negative attitudes towards IT in general.

Woods, IMPART Lead: I think also all the IT systems at work are pretty awful really, we’ve got terribly slow internet and frequent problems logging in to the most basic things, and I think there’s something about the sort of rubbish nature of the IT systems and you’ve seen the phones the staff get given that don’t really do the internet, and I think there’s something about all that that sort of I think it just creates a mind-set where you know people may be sort of inhabitants of the digital world outside work but somehow at work it doesn’t really seem like we are in that age…

Collective Action

Despite recognising value, REACT was difficult to prioritise. In the context of limited resources, priority was given to activity

a) focussed on service user outcome,

Ocean, Clinician: I have given it to a couple of people when I’ve done first assessments and yeah it probably isn’t seen as a priority with me…You go in and start work and developing care plans and things with the clients [and] maybe you don’t always then focus on the carer.

b) linked to financial incentives

Lakes, REACT Champion: If we’ve got our managers saying well…there’s £20 m to this physical health target…it’s quite disheartening for the nurses because all you want to do is serve your patient and in essence you’ve got to come off clinical duty so you can prioritise this target…There’s money attached to absolutely everything.

Changing and competing externally driven priorities made strategic planning for new interventions difficult

Woods, Clinician: I think there’s an awful lot of new stuff happening right now, which makes it quite difficult for people to know what they should be focusing on […] you know one week we’re saying this is the absolute priority, and then the next week we’re saying, actually that’s no longer absolute priority.

Most teams had high caseloads, low staffing levels and poor morale.

Seashore, IMPART Lead: The manager in my team is very supportive of it, but I think it’s care coordinators being over-worked by other demands you know. We’ve got someone leaving now and we’re not allowed to have a locum in place of them, they’ve got more caseload, they’ve got to do the CPAs, they’ve got to do the safeguarding, they’ve got to do the…. Well those are subjects, that feels more a priority than signing people up…

REACT not sufficiently user friendly or robust for staff

Seashore, Clinician: I think everyone would be able to use it, would have the kind of capability to use it, it would just be getting that initial like getting on it and having I think the log ins and things like that were a little bit difficult because everyone’s got so many log ins for different things, and people forget their passwords and that makes it a little bit more difficult.

REACT did not always work on the IT equipment available to staff

Moor, REACT Supporter: …..there was one bit I couldn’t get on because of the browsers that we use, but that’s an issue. …….[..]..I’d have to get on and show you, but that’s an issue internally…It’s unsupported, I need a better browser. I get that with anything external and I have got Chrome, so I don’t know whether that would.

Online was “out of sight, out of mind” for staff

Woods IMPART Lead: People just forget it…When you’re doing an assessment, when you’re meeting a family member, you have a thousand and one things on your mind that you’d like to assess and write down and stuff and it’s difficult to remember the spiel.

React Supporters not confident or supported to respond to forum or direct messages online….,

Marsh, Clinician: I think that’s probably still a grey area because so far I think what our trust is good at is managing sort of clinical risk […] Online is a different thing, I think we’re not exposed to it enough and therefore we haven’t outlined how that would work, so I think you know managing a forum, as far as I’m aware there’s no formal training for that in the trust, so that’s quite bespoke.

Reflexive monitoring

Feedback from relatives was very important in motivating staff behaviour.

Ocean REACT Supporter: I’ve had such nice feedback from people really, relatives really sort of saying I’m so glad you told me about this, ‘cos I’ve been Googling and trying to find stuff out and it’s all just coming back and I don’t understand it, whereas this is kind of it’s easier to access and it’s user-friendly I think.

Lack of feedback from relatives and low activity on forum were demotivating for staff.

Marsh Clinician: So we did discuss it a while ago and I remember people were saying that they weren’t sure whether the people were actually using it or not, you know whether we can see that or not, which would be good to know, if people are using it.