This study details the process for developing a tailored implementation plan to support the implementation and sustainment of a new clinical approach to managing suicidality in the setting of an Australian public mental health service. This study provides novel insights into implementation facilitators and barriers to using a clinical suicide prevention EBP within an Australian mental health service. It also provides a case study of the collaborative development of a tailored implementation plan to support ongoing sustainment of the EBP after research support ceases.
By using the EPIS framework, we were able to systematically identify a range of implementation barriers. Most identified barriers related to the EPIS domain of Inner Context, followed by Innovation Characteristics, with only a few barriers identified for Outer Context and none related to Bridging Factors. This pattern of results likely reflected participants’ primary focus on overcoming immediate barriers to using CAMS in routine care, associated mainly with internal processes and elements of the model itself such as associated paperwork. Prioritised barriers and associated strategies related to Inner Context align with previous studies, indicating that strong internal processes are needed to support the sustained use of training (26). For example, developing a positive implementation climate whereby managers and team leaders communicate the value of CAMS, conduct regular progress reviews and supervision in using CAMS, and establish structures to review fidelity (27). Another study, conducted in US community mental health settings, similarly found that implementation success correlated with active leadership, where barriers were addressed as they arise and workflow was redesigned for changes in practice (28). The relatively low focus on Outer Context and Bridging Factors in the present study also likely reflects the profile of participants, who were predominantly frontline workers whose primary role is to care for clients, rather than consider broader systemic and network factors that may have a more indirect effect on care delivery. By combining research expertise with local service and care delivery expertise, the present study was able to identify implementation strategies that were perceived as important for fidelity as well as feasible to implement.
Lewis and colleagues’ (2018) methodology provided a structured, collaborative way to engage stakeholders to integrate both empirical research and practice expertise. The large geographic areas covered by stakeholders in the present study (LHD coverage of 136,898 km2, which is more than the total area of Greece) and the CAMS trainers based in the United States meant that it was cost-prohibitive to arrange in-person meetings for all project activities. By using digital solutions to collaboration (via email, phone, and videoconferencing), the present study adds to growing evidence for the remote development of tailored implementation strategies and plans that are both evidence- and practice-informed (29). This methodology may therefore be useful in guiding future implementation efforts, with appropriate modifications based on the innovation, setting and stage of implementation.
The present study modified Lewis et al.’s (2018) implementation blueprint methodology in two main ways. First, instead of creating a plan prior to implementation to include preparation, implementation and sustainment phases, the present study identified facilitators and barriers during the implementation phase. Although this meant a less rigorous approach to preparation, it had the advantage of exploring facilitators and barriers to implementation based on participants’ actual experiences of using a new approach to care rather than their anticipated experiences. Second, rather than using a mixed-methods approach to action planning, the present study used only qualitative data due to low response rates to the quantitative survey. While this meant less data was collected, interviews and focus groups were able to provide a rich and nuanced understanding of barriers.
Despite the known challenges of implementing new models of care into health care settings and Australia’s focus on national mental health and suicide prevention strategies, there is surprisingly little research on implementation of suicide prevention programs in Australian care settings. Findings suggest that mental health organisations seeking to implement new programs or approaches to care should ensure that internal organisational structures and processes are adequately prepared, and that the EBP being implemented is appropriate for the local context in terms of client profile and staff skills. Strategies should ideally be integrated with existing systems and procedures to avoid adding burden to an already heavy workload (e.g., using existing team meetings as a forum to discuss issues and experiences). Having a clear plan for developing implementation strategies, which includes contingency procedures, is key to ensuring rigorous implementation efforts are sustained in practice.
There are several limitations to the present study. Firstly, not all identified barriers were amenable or feasible to change. This was particularly the case for outer-context and structural barriers, for example, funding, staff shortages, integration of CAMS with existing record keeping systems, and geographical challenges of providing care across vast rural and remote settings. Although some of these barriers were addressed by the service outside of formal action planning, several of these challenges would have required significant resourcing to overcome and were therefore not feasible to address in the present study. It should be noted that some of these barriers are also likely to be challenges for mental health care delivery in general for this region, rather than being specific to CAMS. Second, data collection identified both facilitators and barriers to implementation, however, implementation strategies focused on barriers. Facilitators were used to aid overcoming barriers in a few cases. In future studies, facilitators might be considered in a more in-depth manner and used to assist in the selection of implementation strategies. Finally, the extent to which the implementation strategies were applied or their effectiveness on outcomes is not yet known. The initial research design included follow up interviews to investigate progress on the proposed strategies, however these plans were delayed as bushfires in New South Wales in late 2019 and early 2020 reduced participants’ capacity to participate in this research, which was further complicated by the COVID-19 pandemic. These real-world unanticipated events are a reality of applied implementation research. It would be valuable to conduct further research in the Murrumbidgee LHD to both evaluate the tailored implementation plan and to understand how the dynamic outer context factors have influenced implementation and adaptation of the CAMS intervention, particularly given the likely impact of both bushfires and the COVID-19 pandemic on mental health.