Policymakers and research communities have acknowledged that adopting new forms of information and knowledge can contribute to addressing some of the challenges faced by CAMHS, but the process of adopting and implementing new approaches is less well understood [24]. Nature-based approaches have been identified as a potential way to support not only the health of service users but also the health of the staff who support them. However, how to implement this approach within the setting of CAMHS is not well understood. Our findings suggest multiple barriers to implementation, often in the form of organisational or cultural factors, such as the risk averse nature of the service. Our work also elucidates several potential facilitators which may address or mitigate some of these barriers. These potential enablers, such as harnessing the role of firsthand experience, warrant further exploration in the implementation of NBAs in CAMHS.
The cultural tensions raised in our study align with barriers identified when implementing new practices more broadly within CAMHS, including clinician attitudes and flexibility, team culture and ethos, and safety and risk policies [6, 13, 17]. There were clear concerns from staff that the culture of CAMHS may be restrictive in terms of implementing NBAs. Concerns were voiced about a perceived lack of evidence for NBAs, uncertainty around the form and function of NBAs in CAMHS, and the promotion of risk-taking. Peters-Corbett and colleagues’ systematic review found both organisational and individual level barriers similar to those described in our study; with a poor level of knowledge of the approach and its benefits, and negative attitudes towards the approach impeding implementation [13]. Our findings build on this, with staff describing how NBAs were perceived to lack empirical evidence or how communication about the evidence base was poor. Further, participants reflected on the value of different types of evidence when implementing new approaches, with experiential knowledge described by some as particularly important. This aligns with a growing understanding of the value of experiential knowledge in the health literature for informing health services, albeit in this instance from a staff perspective as opposed to a service user perspective [25].
Our findings suggest that approaches such as harnessing the role of firsthand experience and clearer communication from senior leadership could help to mitigate concerns around the evidence base of NBAs. Communication about the evidence behind NBAs and how the approach fits within the CAMHS directive was highlighted as an area which would support staff to implement NBAs, with respondents advocating for consistent and clear communication across all levels of the service. Firsthand experience of the approach was described as central to developing an understanding of the benefits that could be achieved for both staff and service users. Staff felt that experiential knowledge could serve to compliment empirical knowledge, supporting stakeholder buy-in and promoting adoption. Providing experience of NBAs to staff at all levels, clinical and non-clinical, may help to address staff concerns around the evidence base of the approach and may therefore support with buy-in and adoption.
In examining the wider cultural challenges associated with implementing NBAs in mental health services, our findings highlight a significant conflict between a prevailing risk-averse culture and an approach that promotes positive risk-taking. Historically, risk perception in mental health services has been oriented towards risk reduction, leading to norms that can negatively impact decision-making and influence both the treatment and perception of service users [26]. Participants in this study noted that NBAs are often perceived as risky and their implementation would require substantial support, including organisational permission, appropriate tools, resources, training, and dynamic risk assessment processes. Without such support, staff ability to work flexibly, creatively, and in a person-centred manner would be severely impeded [13, 17].
The study participants expressed varied views on risk. While many perceived the risks associated with NBAs as barriers, some recognised risk as a potentially beneficial and normal aspect of working with young people. Case studies have aimed to challenge the definition of individuals with mental health difficulties as inherently 'risky' and to promote the value of collaborative decision-making [26]. Despite existing research and policy advocating for shared decision-making, transforming practice around risk in mental health services necessitates a cultural shift. This shift involves endorsing positive risk-taking and leveraging its potential benefits for recovery [27].
Supporting this call for cultural change, participant perspectives on risk were often shaped by their professional backgrounds and experiences in other workplaces. For instance, those with a background in social work exhibited broader views on risk and demonstrated greater openness to managing risk dynamically. Additionally, staff with more experience felt more confident in engaging in positive risk-taking. Effective implementation strategies must therefore consider risk on both cultural and individual levels, aiming to foster more positive perceptions of risk across the service and equip individuals with the confidence to manage risk appropriately [28].
While our interview findings described a cultural tension around implementing NBAs in CAMHS, the survey data provide tentative support to suggest that a cultural shift could be beginning; with ‘permission’ to engage in NBAs perceived not only by those who attended training but across a broader sample of staff. Existing research confirms the importance of staff attitudes and team culture for implementation of NBAs [6] but how this shift might be facilitated is less well understood. Approaches for promoting implementation of NBAs in CAMHS centred on the need for buy-in and governance support, through which many of the cultural barriers stated above could be mitigated.
Buy-in and governance support and involving a range of stakeholders were raised by staff in this study as factors which could support cultural change. In line with research on other interventions in children and young people's mental health care, the need for buy-in and governance support was highlighted as critical for supporting implementation on the ground [13]. Staff reflected that passive support through training opportunities was not enough. For buy-in across all levels of the service, more active support was sought by staff. Our findings highlight several different ways in which senior leadership could support the implementation of approaches such as protecting staff time for training and preparation; access to space; consistent and clear communication across all levels of the service; providing support in the form of resource (administrative, caseload, or physical) and management of staff capacity to implement new approaches. These actions were described as going hand in hand with buy-in, in terms of senior management showing this approach is valued, and that staff are valued. In turn, these clear actions from senior management may help to promote cultural change and a shift in staff attitudes to NBAs within the CAMHS setting.
Participants described how the cultural change required to support approaches such as NBAs within CAMHS may differ by context, with contextual differences likely to play a significant role in the implementation of NBAs. While existing research indicates additional challenges in settings like schools [16], our findings suggest that the school context may also present unique benefits. The implementation context—whether clinical or non-clinical, such as schools, in-patient units, or CAMHS clinics—affects the extent to which existing practices align with flexible and adaptable working methods, such as holding sessions outside clinic rooms. In environments where staff are already accustomed to working flexibly, NBAs align more closely with their usual practices, making implementation smoother. For instance, in schools, where dynamic risk management and adaptable session locations are more common, staff found NBAs to be more compatible with their routine practices. This underscores the importance of considering the different contexts within CAMHS when implementing NBAs [19].
In contexts where the implementation of NBAs necessitates very different ways of working, the involvement of stakeholders across the service, including service users, parents, clinicians, and management may help to mitigate barriers to implementation. Similarly to other studies of intervention implementation in healthcare settings [13, 17], this was thought to be particularly important for NBAs, which represent a departure from familiar ways of working for clinicians and potentially also to service user expectations. In line with one other study of NBAs in CAMHS [6], activities such as presentations to management and asking for input from CYP were thought to support clinicians when putting NBAs into practice.
Strengths and limitations
This research has been strengthened by a mixed methods approach which has facilitated capture of a range of perspectives across the trust and enabled a deeper exploration of the topic, using the survey findings to inform the interviews. The collaboration between researchers and clinicians is another strength of this work which has enabled access and insights which would not otherwise have been possible. Our sample may also have been limited to those who were interested in, and therefore potentially more open to, the idea of NBAs. Our mixed methods approach aimed to reduce this bias and to sample more widely across the Trust.