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Table 2 Summary table of multi-level positive and negative influences on the implementation of the SDM tool based on qualitative data along with strategies to promote the use of SDM at each level

From: Exploring the potential implementation of a tool to enhance shared decision making (SDM) in mental health services in the United Kingdom: a qualitative exploration of the views of service users, carers and professionals

Level Positive influences on potential implementation Negative influences on potential implementation Strategies to promote the use of SDM tool within services
Macro level (structural)   Mental Health Act Introduce additional accountability mechanisms related to the quality of SDM and associated outcomes
  Protocol driven practice Introduce quality targets associated with the quality of SDM and use of the tool and promote within services
  Resource limitations Seek and act on the feedback from of a range of stakeholders (service users, carers and professionals) about the tool and wider SDM within services and how this might be improved
  Culture  
  IT systems  
Meso level (healthcare) Community setting Culture (risk focussed, paternalism) Provide holistic care
AOT approach Access to professionals Provide recovery focussed care
Information provision Lack of medication choice Provide information about the tool, how it works, available options and what users are entitled to
Activity provision Lack of information sharing Provide wider engagement activities within the Trust
Holistic approach   Provide, promote and utilise mechanisms for service users and carers to feedback about the quality of the tool, SDM and associated outcomes
Micro level influences
 Service user/carer Insight Lack of insight  
New to services Behaviour (delusions, paranoia)  
Role of carer Crisis/lack of capacity  
  Perception of services  
  Institutionalisation  
 Professional Behaviour (compassion, conviction) Focus on psychosis Actively involve carers in the use of the tool
Relationships Limited contact Consider carer involvement in situations (acute illness) where service user involvement is not possible
Communication Offering choice looking like uncertainty Make explicit the purpose and boundaries of SDM within a given situation when using the tool
  Authority and power Highlight varieties and boundaries of SDM possible within different contexts when using the tool (e.g. choice of medication for those detained under the Mental Health Act)
   Treat the use of the tool as an on-going process which is revisited continually