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
Level | Positive influences on potential implementation | Negative influences on potential implementation | Strategies to promote the use of SDM tool within services |
|---|---|---|---|
Macro level (structural) | Â | Mental Health Act | Introduce additional accountability mechanisms related to the quality of SDM and associated outcomes |
| Â | Protocol driven practice | Introduce quality targets associated with the quality of SDM and use of the tool and promote within services | |
| Â | 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 | |
| Â | Culture | Â | |
| Â | IT systems | Â | |
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 | Â | 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) | Â | |
Role of carer | Crisis/lack of capacity | Â | |
| Â | Perception of services | Â | |
| Â | Institutionalisation | Â | |
 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 | |
| Â | 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) | |
| Â | Â | Treat the use of the tool as an on-going process which is revisited continually | |