Qualitative Interview Data (Findings from thematic analysis)
Overall, the findings from the qualitative interviews are organised around three main themes 1) the impact of the ‘Florence’ intervention on routine community mental health care 2) the acceptability of the Florence intervention amongst servicer users and community mental health professionals 3) recommendations for future development of the Florence intervention. The thematic analysis is presented below, further examples of illustrative quotes for each theme can be found in Table 4.
Theme 1: The impact of the ‘Florence’ intervention in community mental health care
Service users in the intervention arm of the trial highlighted several ways that the clinical care was impacted by the use of the ‘Florence’ intervention, these included: 1) ‘Florence’ facilitating communication with clinicians 2) valuing medication reminders, and 3) helping people to focus on feelings.
1.1: Florence facilitating service user-clinician communication
Most participants felt that the structure of care they received did not change as a result of using ‘Florence’, however, a few service users reported an increase in the number of meetings with their care coordinator and more responsive care (e.g. a low wellbeing score led to a phone call from a clinician). Some participants spoke about conversations that had been initiated with their care-coordinator about using ‘Flo/rence’ and agreeing on collaborative working. Frequent contact with the clinical team or knowledge that they could contact them if they needed was important for several participants. This was recognised as providing comfort and demonstrating that there was consistent support available from the healthcare team, emphasis was placed by some on the specific advice provided by clinicians.
“Probably constant communication, a good care coordinator who understands me for when I feel like I’m going off the rails. I can email them, and they respond well. So, email and understanding from care coordinator.” [Flo, SU, 021]
Patients also spoke about valuing the quality of the therapeutic relationship with their healthcare team; ‘they’re a really good team’, the demonstration of support and understanding was recognised as integral to the interaction.
1.2: The value of ‘Florence’ medication adherence reminders
A large proportion of participants who had trialled the ‘Florence’ intervention had an overwhelmingly positive experience of receiving medication reminders. A few participants indicated that the ‘Florence’ system had helped them to get into the routine of taking medication and that thereafter they no longer needed the medication reminders. One clinician commented that a participant had been able to take more responsibility for their medication which had enabled them to function more independently from family members and develop mutually supportive relationships:
“[Name] has been able to individuate from [their] mother, by taking more responsibility for [their] own care, and this in turn has led to their relationship being more some symbiotic; mutually supportive.” [Flo, CC, 009]
Another clinician suggested that ‘Florence’ might be a useful tool for promoting self-management skills in periods of vulnerability and reduced function, such as on discharge from inpatient care and may not be necessary as a long-term intervention.
1.3: Florence supporting service users and clinicians to focus on feelings
Most participants described an initial positive experience of reflecting on their daily functioning by giving a wellbeing score, some found this more cumbersome over time, leading to reduced frequency or discontinued responses. Many participants felt that it was helpful to be asked how they are on a daily basis and be prompted to reflect on their wellbeing. The ability to monitor progress using graphs alongside receiving positive messages on a regular basis was valued, encouraging empowerment and addressing power imbalances between service users and clinicians:
“The message, well 3, “thank you, I’m glad you’re coping well is very nice”. It’s tailored to your needs.” [Flo, SU, 028]
A clinician commented on how it’s helped a service user to keep track of mood and increased her awareness of their well-being. Another clinician commented on the impact of the well-being aspect of ‘Florence’ on recovery:
“It also helped them to think about how they were doing from day-to-day in themselves which in turn helped them further develop their reflective capacity and therefore recovery.” [Flo, CC, 009]
Some participants found the scoring a little challenging and acknowledged that sometimes they censored their responses and at other times avoided contact with their care coordinator. Some felt cautious about being monitored ‘they never used to check up on me before,” whilst others acknowledged this could be a useful gateway to accessing care and averting crises.
Theme 2: The acceptability of the Florence intervention amongst servicer users and community mental health professionals
2.1 Satisfaction with Florence
Service users and staff were broadly satisfied with the utility of the text messaging tool, 27 out of 42 staff (64%) thought that ‘Florence’ would be a useful service for their clients and generally, clinicians thought that some service users would be open to using this digital technology:
“yes, people expressed they would like to be asked about their mood and perhaps use the ‘Florence’ similarly to a mood diary. It seems useful for people who are actively looking to engage with their mental health.” [TAU, CC, 066]
Service user participants were asked if they would continue using the system, 16 people (64%) said they would continue using the ‘Florence’ system. Several people expressed that that system was ‘excellent’, and one participant thought it should be ‘scaled up’:
“They should use this on a larger scale, more frequency of texts.” [Flo, SU, 009]
Some participants expressed retrospectively how they were pleasantly surprised by the impact of this intervention and that they were still using it. Some were surprised to see a quick response from their clinician when a low score was recorded:
“The first time I got a call from [name of care-coordinator] when I scored really low and she called me I was quite surprised because I didn’t know that they got the feedback.” [Flo, SU, 046]
Similar to service user perspectives, one clinician also discussed the helpfulness of the alert when well-being scores were very low, supporting access to care and preventing crisis:
“Flagging up when a service user is not doing well is helpful in Flo” [CC, 025]
Other clinicians highlighted it could be useful in helping service users to develop self-management skills, that medication reminders were well received, that it was simple to use, and that it could act as a conduit between the service user and the care coordinator.
2.2. Usability of Florence
Some service users reported that they were hesitant about using the ‘Florence’ system at first and were uncertain about its utility, however, acknowledged that they adjusted to the system and felt it was ‘fairly straight forward’ with easy to read and clear questions. One person said that they did not use all the functions of ‘Florence’ such as the help codes and questioned their understanding of using the system. Some of the respondents who wanted to continue using the system offered ways they would like to tailor the use whilst a few participants spoke about technical challenges experienced (e.g. scores not being received by the care-coordinator).
Theme 3: Recommendations for the development of the Florence intervention
Service user participants made recommendations about how the ‘Florence’ system could be adapted for future use in the services.
3.1: Personalisation of Florence
Personalisation of the system based on the service user’s individual need and their daily routines was important to many of the participants. Some people felt that the frequency and timing of completing wellbeing scores could be adapted to be less or more frequent depending on individual need. The time that they received wellbeing score reminders was not always suitable for many respondents:
’10 in the morning it’s too early and some people’s days haven’t started’.
Another participant suggested alternative formats for the wellbeing scores such as using an emoji, whilst another wanted to reply with more detail and put how they were feeling in words rather than using a score:
“It would be good to be able to text back something else, like words. I know there were a list of words that I could have text back, but I really want to text back what I’m feeling. […] Every number I know corresponds to how I was feeling. 6 was I’m on top of the world and 0 meant I’m going to go and jump off a bridge, but what does 3 mean…?” [Flo, SU, 063]
Some expressed that they would like more flexibility or control of the functions, such as be able to submit well-being scores after 10.30pm or the ability to tailor the timing of reminders.
3.2. Practical considerations of implementing ‘Florence’
Some members of staff provided recommendations for the usefulness of ‘Florence’ whilst others expressed specific use for ‘Florence’, such as when supporting service users to make transitions, or for use in an outreach format rather than offered as part of routine care. One staff member expressed concerns about the automated nature of the system:
“Service users to have more responsibility and power on sharing their information with clinicians, therefore no automatic response, but a choice of whether to share the last weeks or days score with care coordinator. This may increase service user autonomy.” [Flo, CC 25]
One clinician felt that more guidance and a prompt to remind them to discuss ‘Florence’ with their service users should be considered. Whilst others described contextual barriers they experienced whilst implementing Florence, such as the perceived increase in team workload alongside the consideration of other digital technology being trialled within the care offer.