Participants
Twenty-one participants completed an interview and 211 participants completed at least one questionnaire. Participant demographics are in Table 1. All interviewees and 71% (n = 149) of questionnaire participants were involved in managing and/or delivering FREED.
Stage 1: inductive thematic analysis and attitude questionnaire
Six overarching themes and 15 subthemes were generated in the inductive analysis (Table 2). Means and SDs for attitude questionnaire subscales are in Table 3 (see Additional file 5 for item-level results) and the results of the MLMs in Table 4. First, we summarise the questionnaire results and then the qualitative subthemes. Where appropriate, responses to the specific questionnaire items have been embedded within the qualitative description.
Overall, ‘positive attitude’ and ‘the importance of early intervention for EDs’ items were rated highly before the FREED training, suggesting that clinicians tended to agree/strongly agree with these statements at the outset. In contrast, there was more indecisiveness for ‘negative attitude’ items with a trend to slightly disagree with some items obtaining an average rating of 4 (‘undecided’). These quantitative findings are largely reflected in three qualitative subthemes, namely, “Hope and enthusiasm: Making sense of early intervention and FREED”, “Conflicting feelings: Eligibility and concerns about non-FREED patients” and “Capacity and competing demands”. These subthemes highlight the high level of enthusiasm and positive perceptions of early intervention on the one hand and the reservations and concerns on the other. The training led to significant improvement in positive but not negative attitudes, which were maintained at the 3-month follow-up. Beliefs about knowledge and skills to deliver early intervention were moderately high before training and obtained the largest training-related improvements. This moderately high rating of perceived knowledge and skills at the outset does not fully align with the “Self-efficacy: Experience, stress, and resilience” subtheme, where clinicians said that it took time to understand and develop confidence with FREED. The training related improvements are reflected in the positive views of the training outlined in the “Practical and ongoing training” subtheme.
Patient
Patient engagement
Patient engagement was identified as a facilitator, whereas ambivalence was a barrier. Fifteen interviewees reported improved engagement for FREED patients and between 88 and 96% (varied by time point) of the questionnaire participants agreed that early intervention would improve treatment uptake. FREED was perceived as contributing to this engagement by providing a “first positive experience” with services (e.g., active engagement, rapid access, flexibility and providing hope for recovery). The 48-hour engagement call was perceived as a particularly valuable and easy aspect of the model to implement.
P010:
“We work with a lot of young people who are ambivalent about change, so that early engagement call is most integral to what we do”.
However, six interviewees reported a notable level of early disengagement or no improved engagement. Specifically, intervening very early, before someone was ready, was thought to result in early disengagement in some cases.
P016:
“…we also had the experience of people who felt it was almost too early an intervention that everything happened too quickly […] but I think the feedback that we’ve had from them both directly and indirectly is for those people who maybe didn’t engage at the start that had a very good first positive experience of treatment […] knowing what was going to be on offer and what the options were so even if they decided that at that particular time that they weren’t quite ready, some of them have come back since”.
Patient complexity and comorbidity
Clinicians spoke about patients feeling like a “FREED patient” (young and limited experience with services). However, in some cases, especially when patients presented with comorbidities, there were questions around appropriateness of FREED vs. other interventions, e.g., “Do you go ahead and diagnose someone with an eating disorder and take them into treatment when it’s been there three months […] or do we understand this more in the context of stress” (P019). A thorough evaluation of the function of the ED behaviours at the outset was seen as important to ensure patients were given the right treatment. Most questionnaire participants did not see FREED as leading to over-diagnosis: 65–73% disagreed that early intervention would result in the overtreatment of mild eating, weight or shape concerns and 78–84% disagreed that it was best to adopt a “watch and wait” approach.
Clinician
Hope and enthusiasm: making sense of early intervention and FREED
P005:
“The team were really, really enthusiastic about it”.
The buy-in and enthusiasm amongst clinicians and senior staff were critical for the successful implementation of FREED. FREED was perceived as important across all EDs and services because of the expectation that it would improve outcomes and recovery, and reduce the intensity of treatment, and impact on the person’s life. These beliefs were core to how clinicians made sense of early intervention and were largely reflected in the questionnaire results. Almost 100% of questionnaire participants agreed that early intervention would improve outcomes and was important or absolutely essential. Most participants also agreed that early intervention would reduce disruptions to life and the burden on family, friends or carers. However, buy-in varied across the interviewed services with some clinicians being more cautious and sceptical of FREED.
Key enthusiastic individuals were driving FREED forward and using a range of activities to facilitate and maintain buy-in. The evidence supporting FREED, the observed impact of FREED on patients, and positive patient feedback were contributors to the narrative of hope around the model and were highly rewarding for clinicians. Clinicians valued the shift from solely focusing on physical parameters and chronicity to a pro-active, flexible, and early intervention-orientated culture.
P004:
“The clinicians have really enjoyed working with it […] seeing improved outcomes for FREED patients means they’ve all got people on their caseload who are doing well”.
Conflicting feelings: eligibility and concerns about non-FREED patients
Clinicians were uncomfortable knowing that some patients were not receiving early intervention, and with the message implied by FREED, i.e., that recovery will be more difficult in later stage illness. Similarly, some worried that FREED would negatively impact non-FREED waiting lists. On average, questionnaire participants were ‘undecided’ about whether early intervention would increase the wait for other patients. Interviewees also reported that FREED can be seen as “light work” relative to standard treatment. These concerns can create tensions within teams, especially when the waiting lists were under pressure.
P003:
“Worries about impact on the rest of the waiting list and how it might negatively impact non-FREED patients can put people off”.
Many expressed a desire to expand the age range for FREED but also recognised it as targeting resources at a peak risk period and allowing for treatment to be tailored to developmental stage.
P007:
“I think sometimes that it would work for a lot more people, not just under 25s, so it’s a hard one ‘cause I’m torn ‘cause I see it really working and I get why we have to do it for that, but I also wish the whole service was early intervention”
Teams who expanded or removed the upper age limit (25 years) either revised back down due to capacity issues or felt that the over 25s did not benefit from FREED in the same way. In contrast, there was no strong desire to change the duration of illness criterion because it was seen as evidence based. The main challenge with the duration of illness criterion was assessing and calculating it.
FREED having a positive impact beyond FREED patients helped counter some of the concerns around the model. Specifically, FREED principles and guides were found to be helpful for non-FREED patients, FREED enabled greater investment and expansion of services, and, in the long-term, FREED was perceived as freeing up resources for the entire service. Similarly, most questionnaire participants agreed that early intervention would reduce the long-term economic cost of EDs and disagreed that it diverts valuable resources away from longer-term EDs.
P009:
“…if we can help these people get them well sooner and reduce the risk that they might relapse that eventually is gonna mean we do have more resources for people who are who tend to be more chronic or might need a higher level of care”.
Self-efficacy: experience, stress, and resilience
Clinical experience with EDs and FREED, people’s confidence in their and others’ ability to implement the model, and stress and resilience were distinct but overlapping barriers and facilitators for FREED. Clinicians new to EDs found adopting FREED easier, whereas those with many years of experience and pre-existing caseloads found the change more difficult. However, more experienced clinicians reported that seeing the detrimental impact of EDs over many years increased their motivation to implement FREED. Clinician stress and anxiety on the one hand, and their resilience on the other, can impact the implementation of FREED. It took time for clinicians and the wider team to understand the model and gain confidence in implementing it.
P015:
“Initially when I heard about it, I was a bit anxious about it”.
The service model
Flexibility and structure
Clinicians valued the clear structure and standardised model, they found that it kept them focused and legitimised and enabled the implementation of early intervention. Equally, if not more important to clinicians, was the adaptability and flexibility of the model. The ability to adapt parts of the model to fit the local context was a key driver in adoption and implementation. Clinicians who were flexible and focused on finding adaptive solutions also facilitated the model. The relationship between the FREED model and flexibility/creativity was reciprocal. FREED pushed and enabled teams and clinicians to be more flexible, which in turn facilitated the implementation of FREED.
P001:
“FREED has allowed me the freedom”.
Champion as invaluable
P014:
“It’s been essential; I don’t think you could do it without the FREED Champion”.
Having a dedicated and enthusiastic FREED Champion within the team, was identified as crucial for getting FREED set up, integrated, and sustained. The Champion was a designated person for FREED-related queries and support and provided detailed management and oversight of the pathway. However, the Champion’s role was described as demanding, and required support from senior staff and a FREED mini team.
P009:
“I think FREED Champions work really hard and they do a lot of juggling actually […] I think when a lot of your responsibility is doing these engagement calls you have to hold a lot more people in mind…”.
Meeting people where they are at: care package and resources
The care package and adapting treatment to emerging adults was valued by clinicians and perceived as beneficial for patients. Clinicians found the care package easy to use because the topics were relevant and/or familiar. However, family involvement was described as more challenging because it depends upon the family’s willingness and ability to engage. Other barriers for using the care package were knowing how and remembering to integrate these into treatment. Prompts, reminders, and the online FREED materials were highly valued and supported clinicians to use the care package, particularly for engaging with young people.
P005:
“All of the materials that we get from that, I think that’s really crucial in driving it, so that’s absolutely, that’s a facilitator”.
Implementation strategy
Practical and ongoing training
The FREED training was described as helpful and inspiring, especially practical tasks, such as role playing and discussions within and between services, e.g., “I really liked the fact that there was a lot of experiential exercises” (P019). This is reflected in the questionnaire responses, whereby the training significantly improved positive attitudes, NoMAD scores, and knowledge and skills. Nevertheless, more training was desired, particularly refresher training, calculating DUED, managing early disengagement, and integrating the care package. The implementation support by SLaM/KCL/AHSNs and the Champion providing ongoing training at each site were perceived as vital components of the training.
Being part of something bigger: the FREED network
Being part of a wider initiative (i.e., the FREED Network) contributed towards how important the work felt and made FREED easier to “sell”. The FREED Network and implementation supervision provided a supportive space for sharing successes and challenges, learning, and problem-solving.
P014:
“It’s nice to know that other people are experiencing the same things and it’s really easy to drop an email to people and ask for advice”.
Sharing experiences with local services and at conferences, was important for “taking FREED off the pedestal” and facilitating the spread of the model. The FREED Network data collection and feedback process were valued and created a degree of peer accountability but were experienced as labour-intensive and challenging with limited resources.
P010:
“…even just ‘cause like I said sending in the data every couple of months it keeps us on track […] I think it’s very easy for a service like ours to slip off and just focusing on the more chronic end […] the challenging aspect would be the initial setting up for me [and] getting everyone to fill in the ROMS [Routine Outcome Measures]”.
Service/team
Capacity and competing demands
P008:
“Because obviously it comes down to the capacity”.
Staff capacity and time were the most frequently mentioned barrier and facilitator to implementing FREED. Almost all interviewees expressed concerns about capacity regardless of whether they were currently facing capacity issues. Five teams expressed capacity-related difficulties implementing the model, especially the treatment wait time target. Questionnaire participants were also largely undecided or agreed that early intervention would increase the demand on teams. Interviewees reported that the FREED model can drift and become less of a priority over time because of competing demands. An enthusiastic Champion, a mini team, and the FREED Network were seen as working against this drift. Several strategies were used to manage capacity-related issues, including: (1) providing evidence-based individual treatments in groups; (2) flexibly and carefully balancing FREED and non-FREED caseloads; (3) low-level psychoeducational support; and (4) extending the waiting time targets.
Compatibility and integration
Compatibility (‘fit’) between FREED and the clinician and service as well as integrating FREED into service processes, paperwork, resources, meetings, and culture were facilitators for FREED because it made the model easier to use.
P015:
“It’s part and parcel of the fabric of what we do, so we use it, and we implement it, and I don’t know how much we overly think about it”.
Streamlining referral processes was particularly important to ensure that the referrals were received by the FREED team as quickly as possible. Protected time to deliver FREED, especially for the Champion, was also crucial for implementing the model. Conversely, differences between FREED and the standard way of working and poor integration did sometimes cause tensions and make FREED difficult to deliver.
An open dialogue: sharing and involvement
Sharing information, involvement in decision making, and encouraging people to reach out if they had ideas or questions created a shared and open dialogue around FREED, which facilitated its use. The FREED huddles, monthly supervision, and dedicated time in other meetings were important avenues for facilitating information sharing, and problem-solving.
P012:
“…involve more people in the team, and talk about it more in our wider team, so then they feel involved and have an understanding of what FREED is”.
Actively involving the wider service was particularly important when using a FREED ‘mini’ team because it can, at times, create a “split” within the ED service. A ‘whole team’ approach to FREED can also be used to guard against this “split” within the team (i.e., everyone in the ED service is involved with managing and/or delivering FREED). However, for a whole team approach to be successful, a considerable amount of time is needed to gain and maintain buy-in and integrate FREED into the whole service.
Wider system
The broader system of care
Poor awareness of EDs and FREED amongst referrers (e.g., primary care) was a prominent barrier to receiving appropriate and early referrals for FREED, especially for newer sites and services who historically had not accepted milder early intervention cases. Wider awareness of EDs and FREED at educational institutions, amongst healthcare professionals and the public was considered as essential for enabling the earliest identification of EDs. FREED associated awareness raising activities were highly valued by clinicians and perceived as a core part of the early intervention work.
P017:
“… the biggest barriers so far is getting the referrals through”.
COVID-19
COVID-19 was primarily a barrier to implementing FREED but did bring about some positive changes (e.g., virtual appointments providing greater flexibility and reduced travel time). COVID-19 disrupted and restricted services (and therefore FREED), which reduced capacity and dramatically limited services. This period was difficult for clinicians because of the elevated risk, changes in working, reduced team communication, and therapy itself was seen as more challenging online. It was difficult to keep early intervention going, and FREED became less of a priority as other COVID-19 related issues took precedence.
P013:
“Early intervention has had to take a little bit of a backseat in that sense just because of how sparse we are with resources”.
Stage 2: Normalisation Process Theory
The qualitative summary of the NPT mechanisms underlying each subtheme is outlined in Table 5. Means and SDs for each NoMAD questionnaire subscale at each time point are in Table 6 (see Additional file 5 for item-level results) and the results of the MLMs in Table 7.
The qualitative and quantitative data suggest that FREED was largely normalised or normalising in many services. In other words, there was a high level of NPT ‘work’ taking place across the subthemes and most NoMAD scores were high. Coherence in terms of understanding the model and its value was high amongst interviewees and questionnaire participants. The FREED training, a key coherence building activity, led to significant improvements in the coherence subscale. However, the qualitative data suggest that coherence was less well-developed for newer sites, especially for the care package and wider team. Cognitive participation (i.e., creating and sustaining engagement) was the highest rated NoMAD subscale, which was reflected in the qualitative data. Specifically, interviewees reported that there were key individuals enrolling and engaging others in FREED work (typically, but not always, the FREED Champion). The FREED Champion, training, network, and mini team were also seen as legitimising FREED and maintaining engagement over time. In keeping with this, the training was found to significantly improve cognitive participation. The ‘work’ associated with collective action was evident across all subthemes as clinicians enacted and integrated FREED into relations, interactions, and contexts. While applying the collective action construct, it became apparent that it was the main NPT mechanism by which established sites differed from newer sites. This aligns with the finding that collective action was the lowest rated NoMAD subscale as many of the questionnaire participants were relatively new to FREED. While the training led to improvements in some features of collective action (e.g., confidence and skills), others, such as the perception of sufficient capacity, were less impacted. Insufficient capacity was the main factor inhibiting normalisation, even when FREED was well-integrated into other aspects of the team. Changes in capacity and fluctuating demand required teams to continually appraise and re-configure the structure and functioning of FREED. All interviewees engaged in formal (data) and informal (practice experience) reflexive monitoring of what was and was not working and whether FREED was worthwhile. It was most evident in the ‘Being part of something bigger: The FREED Network’ and ‘An open dialogue: Sharing and involvement’ subthemes. Responses to the NoMAD questionnaire suggest that the training increased clinician capacity to engage in reflexive monitoring.
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