Introduction
Methods
Study design
SMILE intervention
Participant and team selection of qualitative analysis
Interviews
Observations
Data collection
Descriptive data
Interviews
On-site observations of SMILE group sessions
Data analysis
Results
Part 1: quantitative results
Execution of the intervention
Attendance during group sessions
Part 2: qualitative results
Characteristics of interviewees
A. Characteristics of interviewed mental health care professionals | |||||
Nr | Gender | Age | Discipline | Total sessions given | |
HCP1 | Male | 60–69 | Nurse | 15 | |
HCP2 | Female | 40–49 | Activity worker | 20 | |
HCP3 | Female | 50–59 | Nurse | 23 | |
HCP4 | Female | 30–39 | Nurse | 24 | |
HCP5 | Female | 50–59 | Nurse | 30 | |
HCP6 | Female | 50–59 | Nurse | 28 | |
HCP7 | Female | 30–39 | Social worker | 27 | |
HCP8 | Female | 30–39 | Psychologist | 25 | |
HCP9 | Female | 30–39 | Expert-by-experience | 29 | |
HCP10 | Female | 30–39 | Nurse | 28 | |
HCP11 | Male | 50–59 | Nurse | 27 | |
HCP12 | Female | 50–59 | Nurse | 27 | |
HCP13 | Male | 40–49 | Nurse | 24 | |
B. Characteristics of interviewed clients | |||||
Nr | Gender | Age | Diagnosis | Weight change after 6 months | Total attendance |
C1 | Male | 50–59 | Schizophrenia or other psychotic disorder | Gain | 18 |
C2 | Female | 40–49 | Borderline or other personality disorder | Loss | 23 |
C3 | Female | 30–39 | Borderline or other personality disorder | Loss | 23 |
C4 | Male | 50–59 | Schizophrenia or other psychotic disorder | Loss | 14 |
C5 | Male | 40–49 | Schizophrenia or other psychotic disorder | Gain | 18 |
C6 | Female | 40–49 | Depressive or bipolar disorder | Gain | 3 |
C7 | Female | 50–59 | Depressive or bipolar disorder | Loss | 28 |
C8 | Female | 30–39 | Schizophrenia or other psychotic disorder | Gain | 11 |
C9 | Male | 40–49 | Schizophrenia or other psychotic disorder | Loss | 29 |
C10 | Female | 40–49 | Depressive or bipolar disorder | Equal | 23 |
C11 | Female | 50–59 | Schizophrenia or other psychotic disorder | Loss | 20 |
C12 | Female | 50–59 | Post-traumatic stress disorder | Loss | 21 |
C13 | Female | 30–39 | Post-traumatic stress disorder | Loss | 21 |
C14 | Male | 50–59 | Schizophrenia or other psychotic disorder | Loss | 30 |
C15 | Male | 60–69 | Obsessive compulsive disorder | Loss | 29 |
Interviews
Theme | Subtheme | Clients | Healthcare professionals |
---|---|---|---|
1) Positive appraisal of the SMILE intervention | Clients enjoyed participating in the SMILE intervention | Clients perceived the intervention as useful, motivating and enjoyable. Clients had positive experiences with HCPs involved with SMILE. | Not applicable |
HCPs enjoyed conducting the SMILE intervention | Not applicable | HCPs enjoyed conducting the intervention and seeing positive results in clients. | |
2) Suggestions for improvement of the SMILE intervention | Tailoring the SMILE intervention to people with SMI | Not applicable | HCPs find the intervention suitable and interesting for all people with SMI. However, tailoring for the individual characteristics of patients is needed. |
No consensus on frequency of sessions of the SMILE intervention | Transition from weekly to monthly sessions is too big, however monthly sessions can have some benefits. | Believe transition from weekly to monthly sessions is too big, however workload was better during monthly sessions. | |
3) Facilitators of implementation | User-friendly handbook | Not applicable | Handbook was user friendly and provided detailed information which supported HCPs in conducting the intervention. |
Training of HCPs | Not applicable | Information regarding nutrition and other lifestyle related subjects were found important to learn during training. | |
4) Barriers of implementation | SMILE in combination with usual work | Not applicable | It was difficult to combine the SMILE activities with daily tasks. In order to conduct the intervention it is needed for (at least) two HCPs to be involved with SMILE in order to align work activities between HCPs. More time is needed to conduct the intervention. |
Lack of team and management support during implementation | A change in HCPs had a negative influence on the cohesion within the group. | In most teams HCPs felt no support from their other team members. They feel SMILE should be more of a priority within teams or management. A shortage of staff in general had a negative influence on the workload of HCPs during the delivery of SMILE. |
Theme 1: positive appraisal of the SMILE intervention
Clients expressed positive experiences with regard to the HCPs role as group leaders during the execution of the intervention program. Clients valued the way HCPs were able to create a positive, safe and stimulating climate for realizing lifestyle changes. They also positively evaluated the knowledge and competences of the HCPs regarding lifestyle issues and lifestyle promotion.“How the intervention was put together and what it was all about. And that it is important to set goals for yourself every time and that you try to achieve those goals.” (C7)
“They did very well. They had prepared it well every time and everything. And they also knew a lot of things and they had answers to many issues.” (C7)
“I really liked it, first of all. It is great to get people together who have the same goal. And it's also something that, generally, doesn’t get a lot of attention. And I notice the clients appreciate that we focus on this now.” (HCP8)
Theme 2: suggestions for improvement of the SMILE intervention
HCPs reported that it was sometimes difficult to present information and teach skills in a sufficiently comprehensible way for all participating clients. Some HCPs mentioned that the group diversity could also be beneficial, in particular for clients with lower learning capabilities, because they could learn from ideas and experiences of clients with higher cognitive functioning in the same group.“We did not have to adjust the program itself, but we had to adapt the approach or repeat it more often. Even though it is not part of the program to look back, we did it anyway because there were certain people with mild intellectual disabilities. But, at the end, it was applicable for everyone who participated.” (HCP4)
The contrasting view from other clients and HCPs was that the transition to monthly sessions was experienced as positive. For some clients, the lower intensity of the SMILE intervention offered opportunities to focus on alternative treatment goals, such as starting a new job. For HCPs, the workload lowered substantially in the second phase of the SMILE intervention with monthly sessions, which was considered positive.“Maybe I would do it once every two weeks for another few months and then reduce it to once a month.” (HCP11)
Theme 3: facilitators of implementation
“Well, the handbook was nice to work with. So, I definitely needed the handbook, I couldn't have come up with it myself.” (HCP6)
Theme 4: barriers of implementation
We had anticipated on this barrier by involving at least two team members in conducting the intervention. However, some HCPs mentioned that even with two team members the intervention was difficult to accomplish without additional manpower.“Well, if there was a crisis or something, I was fed up. Then I was like: gosh, I want to deal with that crisis, but I have to lead a SMILE session now. So, that was difficult for me. We held the program from 1 to 3 p.m. and I had a lot of phone calls after that. So, I think the setting could have been a bit less hectic.” (HCP3)
Because of the intensive workload, HCPs often mentioned they lacked time for implementing the SMILE intervention. To be able to promote implementation of the SMILE intervention on a broad scale, more time would be needed.“I also thought it was quite difficult with the two of us. Especially during the weekly sessions. Then it is quite a lot.” (HCP10)
“More time. You really need time for this to unfold properly.” (HCP9)
The HCPs experienced that the SMILE intervention was not prioritized by other team members or by the management. Another reason mentioned for this lack of support was the overall staff shortage. This significantly hindered the implementation of new interventions, including SMILE.“Several team members have other group sessions, and besides, everyone is just busy with their own individual appointments, of course, so everyone is busy.” (HCP7)
Staff shortage also influenced the clients participating in the intervention. In two teams both HCPs discontinued their job, hence their involvement in the SMILE intervention, and substitute HCPs were appointed to continue the intervention. Even though clients felt safe and at ease with the substitute HCP, it may have negatively influenced the cohesion within the group.“And when you want to prepare it well … We have had staff shortages during the weekly sessions and then it is really difficult.” (HCP10)
HCPs emphasized that the whole team should be more involved in the intervention. Involving more team members, aside from the trained SMILE HCPs, would make the intervention an active topic of interest during meetings and daily care. In FACT-teams, all clients have a personal case manager who could play a more explicit role in integrating the content of the SMILE intervention in daily care.“And the new group leader has taken over out of the blue as well as possible, but it is disastrous for a group, but also for the healthcare professionals...” (C2)
"So I think it also falls and stands with the case manager asking: “How are things going with SMILE?”. To mention and discuss that, when she sees them separately... Again, then it is more alive.” (HCP4)