South Ostrobothnia Hospital District in Finland provides public specialized health care services to a population of 200,000. The Adult Psychiatry Department comprises twelve outpatient units and five inpatient wards. The ODP was carried out for improving the treatment of depression with possible co-morbidities at six units, of which five were outpatient clinics and one an 18-bed acute ward. The largest unit had two separate teams, and the rest one team each.
The ODP was launched primarily to tackle several clinical challenges by increasing the use of EBTs. The challenges identified were heterogeneous treatment practices and congested patient flow as a result especially of a marked increase in depressive patients referred to specialized care and deficits in providing integrative treatment for patients with dual diagnoses, i.e. psychiatric patients with comorbid substance abuse. The design and execution of the implementation programme drew on the launchers’ expertise in administration, clinical work and training of health care professionals. No explicit theoretical model or framework for implementation was used. The effectiveness study was designed and performed jointly with the implementation programme. The study protocol of the effectiveness study has been described in detail in the appropriate register (23).
The primary goal of the ODP was the implementation of an advanced systematic and regional model to address the treatment needs of non-psychotic patients. The patients treated for major depression and possible co-morbidities were used as a benchmarking group. This patient group is relatively large in psychiatric care, which makes it reasonable to focus on it. The aim was to reduce the negative gap between the resources and the increasing demands for treatment, and thus make the patient flow more fluent (24,25). A more detailed description of the ODP has been published previously (22).
The implementation plan comprised protocols for training and other programme supports aligned with earlier high-quality training programmes (6). It included workshops with both active and passive training modalities, case consultation groups, written and videotaped self-study material and regular research nurses’ visits to the units involved. A more detailed description and analysis of the plan and the extent of the sustained use of the two EBTs after the active programme phase as well as associated therapist- and intervention-related factors have been reported elsewhere (22).
Setting and sample
A purposeful sampling strategy ‘complete target population’ was used to build the study sample (26). The total number of therapists regularly employed in the units involved in ODP was 72 and they comprised the target group. Enrolment in the training as well as responding the survey was voluntary for them. The study sample of present cross-sectional study comprised 33 ODP trained therapists who were still employed by the target units and were willing to respond to the survey. All members of the sample gave verbal informed consent to participate, see the section “Ethics review and consent to participate” for more detail. The study sample of 33 amounted to 46% of the original target group.
The first author of this article (LHL) was the principal researcher and he gathered the data in March 2014, 4-5 months after the completion of the ODP. A survey was administered in each unit during their regular weekly meeting. In addition, LHL conducted a short semi-structured interview by telephone with the two programme executives responsible for the case consultations and information on the number of participants per session was collected from the list of participants. All authors but the second (JK) of this article were employed in the ODP managing organization. They and all participants knew each other prior to the study as well as the participants were aware about the authors’ interests in terms of the study.
The instruments were specifically designed for the present study. A mixed-methods approach and method triangulation were used to collect and analyse the data. Quantitative data was predominant in the study, determining the magnitude and direction of the results, while the simultaneously and subsequently collected qualitative data was intended to help in explaining the quantitative results (i.e. complementary design, QUAN + qual) (27).
Four different types of measures suitable for each target were used in the questionnaire. These included the Visual Analogue Scale (VAS), school grade rating (SGR, 10 equals excellent, 9 very good, 8 good, 7 satisfactory, 6 moderate, 5 adequate and 4 fail), multiple choice and open-ended questions. The VAS with a continuum of 0-100 points is widely used for measuring different individual attitudes or perceptions (28). In addition, a focused brief semi-structured interview was conducted. The original instruments were administered in Finnish, the therapists’ native language. In reporting the present study, we have adhered to the criteria of Good Reporting of a Mixed Methods Study (GRAMMS) (29) and Consolidated Criteria for Reporting Qualitative Studies (COREQ; Additional file 1) (30).
Six clinical dimensions based on the core characteristics of BA and MI (20,21), were determined as the main clinical goals, and the therapists’ perceptions of progress in each goal were assessed on the VAS scale. The therapists’ overall appraisal of whether the ODP yielded a positive impact on the quality of their own work was examined with SGR (Impact-SGR). The therapists’ overall perceptions of the degree of change in clinical practices that the ODP yielded at team level were also examined on the VAS scale (Change index). The therapists were asked to give SGR to the ODP training intervention. They were also asked to indicate whether they had watched the training videos and attended the case consultations, and in case of “yes” then to give the SGR for that item. Therapists’ perceptions of the manifestation of four possible obstacles were examined on the VAS. Furthermore, six team-related factors, which in general may either promote or hamper the progress of a programme, were introduced to the therapists (Table 1), and they were asked to indicate the direction of each factor regarding the ODP. An option left blank was regarded as neutral.
[insert Table 1 here]
The first survey question elicited therapists’ general perceptions of the goals of the ODP and read: “Name the three most important goals that you perceive the ODP was intended for.” Two open-ended questions were used to collect negative and positive feedback - ‘Censure and Praise’ - on the ODP: a) “Name two major issues which should have been done in some other way during the ODP”, and b) “Name two major issues which succeeded particularly well in executing the ODP”.
The trainer-consultant and research nurse who were responsible for the case consultation groups were interviewed retrospectively using a semi-structured protocol to enhance the information on participation activity in the case consultations.
The quantitative and qualitative items were analysed according to the respective methods as described in next chapters.
Analysis of quantitative variables
Frequencies were calculated for the total number of responses and multiple choices. Means and standard deviations (SD) were calculated for VASs and SGRs. Cronbach’s alpha was calculated to test the reliability of the six-item set for the main clinical goals.
Spearman’s correlations were calculated between the following means: Impact-SGR, perceived support from team leaders, the Change index and each four possible obstacles. Two hierarchical linear regression models were used to predict the Impact-SGR. The first model included the support from team leaders and four possible obstacles as explanatory variables. The second model included the explanatory variables of the first model and the Change index.
Activity rates were calculated for watching videos and attending case consultations.
Qualitative and triangulated analysis
Responses to both open-ended questions - the therapists’ perceptions of the three most important goals of the ODP and the Censure and Praise - were both analysed using qualitative content analysis (31). Manifest expressions were objects of interest. The item Censure and Praise was further analysed by a typological method to form the respective model cases (32). The analysis methods are described in more detail in Additional file 2.
A report on the semi-structured interviews with those responsible for the case consultations was written immediately after the interview on the basis of the notes taken and elaborated after receipt of exact information on attendance rates by session. The first author of this article (LHL) extracted possible explanatory factors pertaining to attendance at the case consultations from both the interview report and the therapists’ responses to the Censure and Praise. The protocol and report on the interview in English translation are presented in Additional file 3.