Pilot implementation of co-designed software for co-production in mental health care planning: a qualitative evaluation of staff perspectives

Figures & data

Figure 1. CPT feature ‘People in my life’. The copyright and all other intellectual property rights in the Care Pathway Tool are owned by Otsuka Health Solutions.

Figure 2. CPT feature ‘Managing my warning signs’. This feature was developed with kind permission of the authors of the card sorting approach by Birchwood et al (Birchwood et al., 2000), who retain the intellectual property rights to it. The copyright and all other intellectual property rights in the Care Pathway Tool are owned by Otsuka Health Solutions.

Table 1. CPT features.

Section of CPT	Software features/touchpoints	Description
My life	My journey	Interactive timeline that combines clinical records including referrals and admissions, with information added by the service user such as important anniversaries or events
	People in my life	Interactive mapping of the key people in a service users’ life, including friends, family and services that people are engaged with, to create a visual network (see Figure 1)
My plan to stay well	Managing my warning signs	Interactive card sorting feature based on the early warning signs of psychosis (Birchwood, Spencer, & McGovern, 2000) (with permission from the authors). Service users could order statements, and discuss their own signs and symptoms, which could inform crisis plans (see Figure 2)
Planning for my future	Goals and actions	Supports setting and reviewing of goals within care planning
Quick notes		Provides opportunity for service users to get involved in writing their progress notes

Table 2. NPT constructs related to CPT implementation.

NPT Construct	Meaning and how it relates to the implementation of the CPT
Coherence	Sense-making and understanding to appreciate the potential of an intervention.
	What do staff see as the purposes and possibilities of the CPT?
Cognitive participation	Commitment and engagement to work with the intervention.
	What promotes participation with the CPT when interacting with service users? How and when do staff introduce the CPT to service users, and what are services users’ initial reactions to the CPT?
Collective action	The work that staff and service users do to engage with an intervention to make it function.
	How do staff and service users interact with the CPT and make it function in practice? How do its different features affect staff and service user interactions?
Reflexive monitoring	Reflecting and appraising the intervention and its effects.
	How do staff evaluate the CPT?

Table 3. How CPT touchpoints affected practitioner and service user interactions.

Features	Description	Analysis of touchpoint
Hardware device
Hardware device that CPT was hosted on	Mobile computer tablet with detachable keyboard and touchscreen	Interviewees spoke of service users liking the ‘physical hands on element’ of the device, with some practitioners handing over the tablet for service users to input information themselves: I think the guy [service user] who was actually using the tool [CPT] himself… he could navigate around it, I think that went really well, that was a really enjoyable support session, because he felt part of it. (Practitioner 01).
		Other service users, whilst happy to engage with the CPT, did not want to operate it: It would be me inputting it, they’d be a bit scared of the technology. (Practitioner 02)
		One interviewee felt that writing and drawing could provide more flexibility than the CPT: I really prefer if I am using my pen and paper… I don’t think we can capture each and everything just while typing at the same time with service users. (Practitioner 10)
Software features of the CPT
My life	Interactive timeline	This feature could take a lot of preparation to use, because of the amount of information recorded: When you initially bring it up then there's a lot of stuff that just suddenly pops up and I'm needing to basically spend a good half an hour or so before I work with the service user to get my head around it myself and then know which bits are useful (Practitioner 03).
My journey		Practitioners were less clear on ways to therapeutically interact with the information. They felt it could be a useful reflective tool for service users to understand their own mental health patterns but needed to be easier to use.
People in my life	Interactive mapping of the key people in a service users’ life (see Figure 1)	A popular feature that was well used. Some practitioners said it enabled service users to appreciate that they had broader support networks than they had initially thought: He actually realised there actually are quite a lot of people in his life, having felt incredibly isolated (Practitioner 12).
		One person spoke of using this feature with caution: There's some people who I work with who are very isolated…so to highlight that by producing a support network where it's basically them in the middle, a GP and the recovery navigator and no friends and family, it's not helpful (Practitioner 03).
My plan to stay well  Managing my warning signs	Card sorting task to identify early warning signs and symptoms of psychosis to inform crisis plans (see Figure 2)	A popular feature that was often used. It initiated discussion and could make difficult conversations easier. Easy to use, swiping the touchscreen rather than typing into the computer tablet. Conversations could enhance service users’ management of their symptoms and inform crisis plans:
		It just opened up this conversation that we would never had had before… We were able to have a much deeper useful conversation about his psychosis and how he manages it and expanding a greater awareness for him of what are kind of indicators if he's relapsing (Practitioner 03).
		Some of the solutions to the warning signs might be, you know make sure I get enough sleep, but they might also be call ((name)) on ((number)), might be very specific. So it's an actual useful document. (Practitioner 12).
Planning for my future  Goals and actions	Setting and reviewing goals within care planning	Perceived to support the co-production of goals within a care plan: It’s a lot more you know produced together rather than me going and rewording a conversation that we’ve had (Practitioner 02).
		The goals and actions, we were using that every session and I personally found it really useful and it kept the sessions more focussed I think. It’s more of a shared set of what a person was working towards (Practitioner 15).
		One difficulty associated with this touchpoint was that the CPT interactive features did not transfer and map easily onto the organisation’s electronic patient record system.
Quick notes	Opportunity for service users to co-write progress notes	Very popular feature that all practitioners used. Practitioners could work with service users to co-produce notes, rather than writing things up after a meeting. Enabled greater transparency, some service users had not been aware that progress notes were written about them: They [service users] thought it was cool because we were doing the notes as we were talking, rather than, me going away and typing it all up without them, so they liked it. (Practitioner 14).
		Others [service users] were quite surprised when I, when I said you know obviously I have to you know keep notes on our visits and that’s come as a shock to a couple of people um and they hadn’t realised that that was the case, so when they had a chance to write the notes, the progress notes, they kind of jumped at the chance…. With the tool [CPT] they’re able to write in their own words what they want said about them. (Practitioner 02).

Table 4. Facilitators supporting engagement and uptake of new technology in mental health practice.

Technology and its implementation	Staff implementers of technology	Engaging service users with technology
Substantial testing of the design (look and feel), and functionality of technology as well as early pilot testing that identifies potential bugs and obstacles before introduction into everyday clinical practice.	Staff are interested in engaging and using technology in practice, the aims of the technology are clearly communicated to staff, and staff support these aims. Staff attitudes to technology will be affected by wider use of health interactive technology, as well as use in other areas of life, and may improve through a process of normalisation.	Service users’ mental states (e.g. attention and arousal levels, symptoms of psychosis) and capacity for reflective thinking vary over time, so care is needed in timing the introduction of technology, regulating the pace of use, and choosing the most relevant tool to address service users’ care needs.
System interoperability issues identified and tackled at an early stage in development.	Staff are given time, support and training to learn about and use the technology, including how the technology can be used with service users. Guidance given about potential obstacles to adoption by service users and strategies developed to work with these.	Visual and interactive features can help to engage service users to reflect on and discuss important issues that support their recovery (e.g. social support, goals, managing symptoms).
Ongoing monitoring of staff and service user experiences of implementation as it progresses.	Staff are not limited by organisational risk management as to how often they use the technology and who with. Organisational support for clinical decision-making as to when it is appropriate to use the technology in practice, may support wider usage.	By providing structured therapeutic prompts, the technology can enable wider discussions with service users, that clinical staff may not easily be able to introduce otherwise. e.g. Managing my warning signs.
Good integration with existing IT systems to reduce recording workload.	Skilled therapeutic relationships between practitioners and service users can help to overcome mistrust of technology, barriers due to mental state (e.g. paranoia), and enable co-working with interactive technology.	Simple to use and engaging features can support service users to engage with and take control of technology e.g. mobile computer tablet with detachable keyboard and touchscreen.
The technology allows access to multiple electronic medical records and systems that staff use in their daily practice with service users.	Staff can access longer term support to understand how to use technology with different service users (i.e. sharing practice and different techniques of working with service users). Early adopters of the technology may have important insights and experiences that help later adopters work with different service users’ responses and reactions to the technology.	Service users have access to information held by the technology and are able to influence how they interact with that information.
Security concerns do not hamper staff usage of the technology with service users.	The technology is piloted with staff who have maximum opportunities to use it, to encourage habitual and routine use in everyday practice.	The technology offers opportunities to record shared decision-making and enables service users to write their own care plans and progress notes.

Birchwood, M., Spencer, E., & McGovern, D. (2000). Schizophrenia: Early warning signs. Advances in Psychiatric Treatment, 6(2), 93–101. doi:10.1192/apt.6.2.93

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Data availability

The datasets generated during the current study are not publicly available due to the confidential nature of the participant interviews and the data containing information that could compromise research participant privacy/consent.