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Abstract

Due to a drastic increase in child and adolescent mental health difficulties worldwide, there is a constant need to evaluate current practices and further develop person-centred practices. The importance of person-centred practices is highlighted in research worldwide. This study will look into the potential development of person-centred practices within a child and adolecent mental health in-patient unit, the Young People’s Unit. Initially the current care practices, and person-centred moments were explored, which then lead to the development of pathways to create person-centred practices. This study followed a philosophical inquiry based on the SECI model and the concept of Ba developed by Ikujiro Nonaka. Data was collected from 15 young persons admitted to the Young People’s Unit. 15 main caregivers and the healthcare professionals which were part of the multi-discplinary team within the unit. 3 Different methods were used, the Draw, Write & Tell with the young persons, semi-structured interviews with the main caregivers, and observations by the researcher using the WCCAT-R tool and the world cafe method with the multidisciplinary team. The use of different methods ensured that the methods used were age appropriate. The externalistion and combination stage of the SECI model were done collaboratively with two young persons, two main care givers and 2 healthcare professionals who were initially participants in the data collection of the research. The involvement of different stakeholder in the data analysis resulted in the investigation of different aspects of the data which otherwise may have been missed. This study also looks into how Ba was created throughout the research process, and shows how this is congruent with the principles which are adopted in person-centred research.

Keywords

SECI model concept of Ba person-centred practices philosophical inquiry child and adolescent mental health services qualitative research

Introduction

The global prevalence of mental health disorders in children and young people has increased in recent years (Collishaw & Sellers, 2020; Comeau et al., 2019; Patton et al., 2016; Rockville, 2022). In their systematic review, Sacco et al. (2022) identified that among children in Europe aged 5–18 years, the prevalence of mental health conditions was 15.5%. The National Health Service England (NHS) reported that since 2017, the number of young people between the ages of 7–16 and 17–24 years who experienced a probable mental disorder rose to 18% and 22% respectively, with the steepest increase for children between the ages of 17 and 19 years (NHS, 2022).

These statistics reflect a pressing need to further develop child and adolescent mental health services to respond to these increases. The development of person-centred practices is essential in improving mental health services, as it ensures that quality and efficient services are received by everyone, whilst ensuring that each person’s personal needs and preferences are respected (WHO, 2024).

This paper presents a research protocol that focuses on the foundational steps towards development of person-centred practices within an in-patient child and adolescent mental health unit in Malta. The protocol demonstrates how the organisational theories of SECI and Ba underpinned the development of this person-centred research. Following the principles of SECI and Ba, the research was designed to include experiences of all persons involved in the service including the young persons, their main caregivers and healthcare professionals. This involvement was within data generation and data analysis phases, the latter working with collaborative methods to begin the development of person-centred practice pathways. Each of these stages of the protocol will be presented in turn.

Study Background

This research study is based in Malta, a Mediterranean island with a population of around 500, 000 people. Balzan (2021) conducted a study in Malta with school-aged children and determined that 40% of young people between 5 – 16 years were at risk of developing mental health disorders. Furthermore, in another study by Richmond Foundation Malta (2022), from a total of 390 young people, 34.8 % and 26% of young people (13 – 25 years) reported frequent feelings of anxiety and depression respectively. These statistics highlight the urgent need to investigate current child and adolescents’ mental health services and work towards further development.

The mental health services in Malta are part of the public health services which are offered free of charge to all citizens. These services include in-patient, out-patient, community, and crisis services. The current study is taking place at the Young People’s Unit (YPU) which is a child and adolescent mental health in-patient unit. The YPU is based within the only mental health hospital in Malta and has a maximum capacity of 10 young persons between the ages of 13–18 years old. Young persons can be admitted voluntarily or involuntarily after an assessment by a multidisciplinary team. The maximum admission stay is 10-weeks. The multidisciplinary team involved in the care of young persons is formed of psychiatric nurses, general nurses, social worker, occupational therapist, psychologists, academic educational staff, and psychiatrists.

Person-Centred Practices

Healthcare systems around the world are striving to develop person-centred practices and person-centred cultures, as such practices ensure the highest possible standard of care where each person takes an active role in their care. (Kluge, 2020; Santana et al., 2018). The core values of people-centred health care services are that people are at the centre of the service provision, through the encouragement of active participation of the person(s) receiving care (RCN, 2016; WHO, 2015). The delivery of person-centred care (PCC) relies on the standard of care given directly to the person, as well as active involvement of families and caregivers (Santana et al., 2018). The World Health Organisation (WHO) noted that healthcare provision is often ‘fragmented and of poor quality’ (WHO, 2015), thus urging all member states to adopt the framework of integrated people-centred health services (WHO, 2016).

The development of person-centred practices requires a change in focus from the person as sick, to one who is agentic in receipt of services, therefore having a social role. Categorising individuals as a ‘patient’ may reinforce paternalistic behaviours of healthcare professionals to exercise control through ‘their’ expert knowledge (Phelan et al., 2020). Conversely, by being person-centred, health care teams acknowledge and support the emotions and perspectives of the person alongside their symptoms (Todres et al., 2009).

McCormack and McCance (2017) developed a theoretical ‘Person-Centred Practice Framework’ that serves as a foundation for the development of person-centred practices. Contrary to other frameworks that are not necessarily applicable to all health care professionals, the person-centred practice framework has been adopted and evaluated worldwide within healthcare services inclusive of colleagues from different health disciplines (Phelan et al., 2020). The framework comprises four domains: prerequisites, the care environment, person-centred processes, and person-centred outcomes (McCormack & McCance, 2017). One domain will lead to the next, and all domains should be present to ultimately achieve person-centred outcomes. The prerequisite domain focuses on the characteristics of healthcare professionals, individually and collectively as a team. The characteristics of the individual are crucial in the development of person-centred practitioners. The care environment domain encourages shared decision-making and power, positive and supportive staff relationships, appropriate skill mix and an adequate physical environment (McCormack et al., 2007). This may enable the development of person-centred processes that involve the provision of holistic care, whereby actions are taken to generate shared decision-making with all service recipients and their supporters. With knowledge of and respect for the person’s values and beliefs, the service providers work to cultivate a healthful care provision culture that facilitates person-centred outcomes such as enhancement of positive and authentic connections within health care experiences.

Developing person-centred practices in child and adolescent mental health services offers additional challenges. From a legal perspective in Malta, where this study is based, a child under 16 years of age requires the consent of a legal guardian to receive (or refuse) healthcare services (Mental Health Act, 2013). This often leads to little or no involvement of the young person in their care. This issue has been highlighted in the literature with children often describing that they feel that they should comply with treatment (Coyne & Gallagher, 2011; Coyne & Harder, 2011). Furthermore, young people receiving mental health services have often felt that the services provided are, like the caution shared by the WHO (2015), “impersonal, fragmented and inadequate” (Frauenholtz & Mendenhall, 2020, p. 482).

The literature exploring children as persons offers insight into how the perspective shifts have informed healthcare practices. A child is often viewed as a person who is not yet developed (Schapiro, 1999; Cveček & Schwall, 2022), thus positioning adults to have a moral obligation towards children (Engelhardt, 1996). Kant and Korsgard defined a person as being a rational being (Joshi, 2020; Korsgaard, 1996), which led to the development of morality and moral obligation. This development is differently explored and theorised (see Hamlin et al., 2007; Kohlberg, 1969; Piaget, 1965; Smetana, 1981), thus showing that the development of a person in the Kantian sense “is a gradual process that differs from one child to another” (Attard et al., 2022, p. 3). Based on these philosophical assumptions, many practices in child and adolescent mental health care actively involve parents, whilst the young person is only passively consulted (Franck & Callery, 2001; Frauenholtz & Mendenhall, 2020).

The Study

Aims & Objectives

The aim of this research study was to explore the current practices of within a child and adolescent mental health in-patient unit and identify person-centred moments and their impact on the care provided and experienced. Person-centred moments are “particular times in practice when everything seems to come together and the outcome feels satisfying” (McCormack et al., 2011, p. 1). Even though they may be brief, such moments can lead to feelings of empowerment, positiveness, and worthiness to those involved, be it healthcare professionals, young persons, or main caregivers The identification of person-centred moments informed pathways for the potential development of person-centred practices.

Research Questions

By following this research protocol, the researcher investigated the following research questions:

• How are current care practices perceived by the young person’s receiving care, their main caregivers, and the multidisciplinary team (MDT)?

• What are the person-centred moments experienced by young persons, their main caregivers, and the MDT?

• How did these moments influence the experience of young persons, caregivers, and MDT?

• How can person-centred moments be further developed into person-centred practices?

Theoretical Framework

This study follows a philosophical inquiry approach, enabling an analysis and critique of current practices which may lead to a new understanding and development of the practices based on the identified needs (Grace & Perry, 2013). The philosophical inquiry is based upon the SECI model, developed by the Japanese organisational theorist Ikujiro Nonaka. This theoretical framework was described as a ‘knowledge creation model’ (Nonaka, 1994), and was intended for use in facilitating business and organisational expansion. Over time it was also adapted for healthcare systems, as it emphasises the collaborative involvement of all the persons in the systems and focuses on the sharing of personal knowledge. Thus, this process does not only result in the creation of organisational knowledge, it can also lead to personal ‘self-renewal’ (Attard et al., 2022), as the sharing of knowledge often results in new explicit and tacit knowledge through the formation of new experiences.

This framework represents the process by which an individual’s knowledge is evaluated, augmented, and connected to organisational knowledge with the aim of creating new knowledge (Nonaka et al., 2006). Through this theory Nonaka showed that knowledge is a personal “justified true belief,” and knowledge gives the person the capability to act according to any situation presented (Nonaka et al., 2006, p. 1181). Further, Nonaka explained that there are two types of knowledge: tacit and explicit knowledge. Tacit knowledge is the knowledge that is acquired through personal values, beliefs, emotions, and experiences, while explicit knowledge can be written, stored, and articulated (Brix, 2017). By the development of the SECI model, Nonaka suggested that the interaction and conversion between the two types of knowledge within an organisation can lead to the creation of new knowledge (Nonaka et al., 2014), which in turn will lead to improvements in service delivery. This model (Figure 1) describes that there are four modes of knowledge conversion which will ultimately lead to knowledge creation: Socialisation, Externalisation, Combination, and Internalisation (Nonaka & Takeuchi, 1995).

Figure 1.

The seci mode.

This process is represented as a spiral. The SECI spiral conceptualises how organisational knowledge practice is facilitated, sustained, and expanded (Nonaka & Takeuchi, 2019). Knowledge creation is a continuous process that involves both the interaction of knowledge at an individual level as well as at an organisational level. This will ultimately result in more knowledge being created and put into practice, with more people involved, thus enlarging the ‘knowledge creating/practising community’ (Nonaka & Takeuchi, 2019).

Upon the creation of the SECI model, Nonaka argued that a physical context or ‘place’ is required for knowledge creation to take place. Thus, the concept of Ba was incorporated with the SECI model. The concept of Ba was initially proposed by Kitaro Nishida and Shimizu, and later adapted by Nonaka as part of the knowledge creation process (Nonaka & Konno, 1998). The literal translation of ‘Ba’ is place, thus Ba refers to a space in different forms where knowledge can be shared, and new knowledge created. Ba is considered to be an essential part of knowledge creation, because it is through the creation of Ba that experiences are shared and reflected upon. When Ba is not present, these experiences become static information rather than dynamic knowledge. Information can be viewed on different media therefore it is tangible; in contrast, “knowledge is embedded in Ba” and is intangible (Nonaka & Konno, 1998, p. 40). The formation of Ba requires the formation of inter-individual relationships that allow the sharing of values, cultures, and practices in a safe non-formal space (Fayard, 2003).

Shared values, beliefs and emotions are the basis of the relationships formed in Ba, and this is congruent to the basis of the relationships formed in person-centred practices and research (Attard et al., 2022). For example, the use of the SECI model requires the formation of mutual relationships and mutual participation; it also values ‘the embodiment of direct, personal experiences’ (Attard et al., 2022) thus acknowledging the importance of involving all persons irrelevant of their cognitive and rational abilities. Furthermore, one of the main principles of the development of person-centred research, is the sense of connectivity where the researcher will need to become ‘more nomadic’ (Jacobs et al., 2017) in the way they think, and thus be more open to different possibilities and perspectives. This also requires a continuous reflexive approach where the researcher needs to be constantly be aware of positionality whilst ensuring mutual involvement.

Sampling & Recruitment

Sample

This research included three groups of key stakeholders in the care process and the child and adolescent mental health in-patient unit.

• Young People: Between the ages of 13–18 years, and who were admitted to the Young People’s Unit for at least 24 hours, following the unit’s admissions policy.

• Main caregivers: The person who carries out the primary care duties of the young person. Generally, the young person resides with and depends on the caregiver who may or may not be the legal guardian of the young person. One main caregiver of each young person who was admitted to the YPU for at least 24 hours was invited to participate.

• Multi-disciplinary team: Care at the in-patient unit is coordinated between different members of the multidisciplinary team to ensure holistic care. The team consisted of nurses (including registered mental health and registered general nurses), nursing aides, psychologists, psychiatric specialists, occupational therapist and an educator. Other professionals who worked on the unit on an occasional basis, were not included in the study.

Recruitment

Recruitment took place at the Young People’s Unit, over a period of 5 months. Purposive sampling based on the criteria named above, was used. Young people and their main caregivers were invited to take part in the study initially by one of two intermediaries (practice development psychiatric nurses), independent from the research, yet who held in-depth knowledge of the research context yet were not working on the unit. Through this intermediary, a formal introduction was made between prospective participants and the researcher. One of the benefits of the use of an intermediary is that it may foster an ‘aura of trust’ to assure the researcher’s good intentions and credibility (Petkov & Kaoullas, 2016). If potential participants showed interest in participating, an information meeting was held with the researcher, where written information about the study and their participation was given and discussed. Informed written consent was obtained from all participants, also including the consent from the legal guardians of all young persons involved and assent from young persons. All members of the multidisciplinary team were also invited to participate. Written information letters were distributed and discussed and informed written consent was obtained.

All participants from the first stage of the study (i.e. the socialisation stage outlined in the SECI model) were invited to participate in the externalisation and combination phases of the applied model. Two young people, two main caregivers and two members of the MDT were involved in the last two phases; they were chosen upon a ‘first come’ basis.

Although it may be challenging to determine a priori sample size for a qualitative study on account of contributing factors such as methodological considerations (Sim et al., 2018), an estimated sample size of 15 young persons and main caregivers was calculated for this research. This estimate was generated by looking at the monthly average number of admissions at the unit from the previous two years. Since all members of the MDT were invited to participate, the recruitment number of healthcare professionals was 24 and included all the professionals working within the unit at the time of the study design.

Data Collection & Analysis following the SECI Model

This research study follows the SECI model, therefore is divided into 3 stages: socialisation, externalisation, and combination (Table 1). The final step of the SECI model, internalisation, was not incorporated within this study as it required the implementation of person-centred practices.

Table 1.

Data Collection and Analysis Following the SECI Model.

SECI Stage	Corresponding Study Stage	Participants Involved
Socialisation	Data collection using the following methods: 1. Draw, Write & Tell 2. Semi-structured Interviews 3. WCCAT-R & World Café Method	1. Young persons admitted at the YPU (N = 15) 2. Main caregivers of the young persons admitted at YPU (N = 15) 3. MDT at the YPU (N = 24)
Externalisation	Collaborative data analysis	2 young persons, 2 main caregivers & 2 MDT members who participated in the Socialisation Stage.
Combination	Formulation of new pathways to develop person-centred practices.	Same participants who will be involved in the Externalisation phase.

Socialisation

The first stage involved data collection, the gathering of the tacit knowledge. The experiences, including those of the care practices and possible person-centered moments, of the young persons admitted to the in-patient unit, main caregivers and the multidisciplinary team were explored. The methods of data collection varied between the three participant groups to ensure that the methods were age appropriate and minimised participation burden.

The Draw, Write and Tell Method (DWT)

This method was adopted and used with the young people to ensure the inclusivity of different ages and abilities. This is a participatory qualitative method where young persons were asked to write or draw about their experiences, and then discussed with the researcher to develop an accurate interpretation. The DWT is a creative method which results in ‘high’ data quality, as often young people participate in an authentic way (R. J. Angell & Angell, 2013). The use of creative methods allows research to be done ‘with’ children rather than ‘on’ children, as it provides time to think and build responses in stages without the pressure to provide an immediate response (Gauntlett & Holzwarth, 2006). A ‘happy side effect’ for participants who feel their contribution is valued is the experience of empowerment (Gauntlett & Holzwarth, 2006).

This sense of comfort and ease to share their experiences may also have a negative impact (Backett-Milburn & McKie, 1999) as it may lead to the sharing of information which the participants do not necessarily wish to share. Thus, the ‘tell’ component of the DWT method offers the young people control over the data that is gathered about them and the way it is interpreted (Angell et al., 2015). This is often done by means of an interview that focused on the drawing and/or writings that were presented by the young person.

During this research, after consenting to participate, the young person was given a tablet to write and/or draw about the way they were experiencing their admission. While they were admitted, the young person had full control over their content, and they could add, delete, and edit freely. Furthermore, the tablet was password protected, known only to the young person and the researcher, to ensure confidentiality. This allowed all young persons to express their thoughts and emotions freely, while process consent was continuously obtained. Process consent is an approach especially used with persons who are not able to provide legal consent to provide an opportunity “to participate in meaningful ways to the level of their capacity and other abilities” (Dewing, 2008, p. 60). Once the young person was discharged from the in-patient unit, the tablet was returned to the researcher whereby the data was stored and then deleted from the tablet. The writing and/or drawing presented was discussed in a one-to-one interview with the researcher. During this time the young person was still able to amend and delete any information they did not wish to share. The interview was held at a place agreed between the researcher and the young person, and was audio-recorded for the purpose of an accurate transcription.

By using this method, Ba was created through the use of the tablet as well, as the tablet served as a medium for the young persons to share their experiences, thoughts and emotions. In addition during the interview. Ba was created by using, an empathic and non-judgmental approach, this approach is also congruent with the principles used in person-centred research. Dignity and autonomy were supported by being attentive, compassionate and respectful, all of which are important principles of person-centred research (McCormack et al., 2017).

Semi-Structured Interviews

This method was used with the main caregivers participating in the study. Semi-structured interviews require a prepared interview guide whilst encouraging ‘depth and vitality’ to extend the conversation (Adeoye-Olatunde & Olenik, 2021; Dearnley, 2013). The interview questions (Appendix 1) focused on the main objectives of the research and were based on the Person-centred Practice Theoretical Framework (McCormack & McCance, 2017).

The interviews lasted approximately 40–60 minutes and took place in the participants’ preferred language, either Maltese or English. Facilitated either face-to-face or online, upon participant’s preference, the interviews aimed to create a relationship of mutual respect and trust which was an essential part in the formation of Ba and person-centred research. The interview was audio-recorded and transcribed; those completed in Maltese were translated and reviewed in English by the researcher.

Workplace Culture Critical Analysis Tool Revised

The Workplace Culture Critical Analysis Tool Revised (WCCAT-R) (Wilson, Dewing, Cardiff, Mekki, Oye, et al., 2020) informed observations at the YPU, which were then brought into discussion with all the MDT members using the World Café Method. This observational tool supports the development of insight about the practice culture of a particular environment, such as the child and adolescent in-patient unit. The tool was developed ‘to link explicitly’ with the person-centred practice framework and therefore is to be specifically used in person-centred research and practice (Wilson et al., 2020). The use of this tool required the researcher to carry out observations on the in-patient unit in four domains identified by the WCCAT-R based upon the person-centred practice framework (Wilson, Dewing, Cardiff, Mekki, Oye, et al., 2020). At times pre-determined by the charge nurse and the researcher, the researcher kept field notes with all the observations of daily routines and practices on the unit by ‘seeing, hearing and perceiving what is going on’ (Wilson et al., 2020). A tool such as the WCCAT-R was useful as the observer could recognise practices that were ‘embedded in the organisational culture’ that could not be challenged by persons who were directly involved (Pope & Allen, 2020). Thus, the observations were not focused on an individual’s performance but rather on practices, routine and norms of the care setting (McCormack et al., 2007). The observations took place during the same period of recruitment.

The observation data was presented to the MDT members for feedback and critical dialogue. To ensure that most team members were able to participate, the ‘World Café’ Method was used. This was a one-time event where all members of the MDT were invited to participate. A world café enabled discussion in an informal setting; the participants were divided into groups of five and each group gathered at round tables, café style. Each table had allocated critical questions to each observation area as indicated in the WCCAT-R. Each group had an allocated time frame (20 minutes) at each table, after which they shifted to the next table. Each group was asked to nominate a person to share the main discussed points with the facilitators of the other groups as well as to record the discussions. By doing so, all groups discussed all the critical questions related to all areas of observations. This method ensured an open discussion in an informal, safe and comfortable environment (Banfield et al., 2022). For optimum adaptation of the SECI model, ideally there was at least one representative of each profession of the MDT in the discussions. This was further important to the development of person-centred practices and environments but following research ethics and procedures potential participants were free to refuse participation at any time. During this process Ba was created as all participants were welcomed to share their emotions, values and beliefs.

Externalisation

During this stage, the tacit knowledge (data) that was gathered in the socialisation stage was analysed and converted into explicit knowledge. Following the SECI model (Attard et al., 2022), a smaller group of participants were involved in this stage. The data was analysed collaboratively with two young people, two main caregivers and two members of the MDT who previously participated in the Socialisation stage. The aim of participant involvement in the process of data analysis was to support the researcher to investigate different aspects of the data that may have otherwise been missed. This resulted in “improvement in research accessibility and quality” (Stocker et al., 2021, p. 1350). The Externalisation phase enabled a sample of participants to become research collaborators engendering them with an active role in the potential development of person-centred practices.

An inductive thematic analysis was used to analyse the data and develop codes and themes. All anonymised interview transcripts and tablet-based (young person) data were used in the analysis. Thematic analysis can be a flexible process (Braun & Clarke, 2006), and within this study this was an advantage given the six additional collaborators involved in the analysis. However, the researcher was mindful about their position and responsibility to facilitate the process in order to retain focus of the aim and objectives of the study.

Collaborative Data Analysis

There are several methods of collaborative data analysis (CDA) intended for projects with variable time and financial realities and the number of stakeholders involved. For the purpose of this study, the approach that Jennings et al. (2018) described as ‘Development’ was followed. In the initial meeting, as guided by the process discussed by Jennings et al. (2018) basic information about the open coding process was shared. The aims, objectives and research questions of the study were also shared with the participants. The full transcripts in Maltese or English (depending on the participants used language) were developed by the researcher, and all transcripts were anonymised before they were shared. A sample of the transcripts and content from the tablets were shared with the collaborators during the focus group in their preferred language (Maltese or English) This sample was chosen randomly by allocating a number to each transcript, and a random number was chosen by all the group members involved in the analysis. The chosen transcripts were then analysed and codes were developed without any priori framework. Each person initially read the presented transcripts individually with encouragement to highlight what stood out to them. These data excerpts were then discussed with the whole group until a collective agreement of the main codes was agreed. The developed codes were then applied by the researcher to the rest of the transcripts; when needed, more codes were added. A second focus group was held with all collaborators to discuss all the analysed data and emerging codes. Each code was explained and quotes from transcripts were also presented, offering the group opportunity to challenge and endorse the codes developed by the researcher. Upon agreement on the codes, themes were then developed collaboratively. These themes were either specific for one of the group of participants (young persons, main caregivers or healthcare professionals) or were common for two or three of the groups.

Since the collaborators were only involved in the data analysis, and they themselves participated in sharing their experiences within the data generation phase, it was more likely that they maintained their ‘outsider’ view (Garfield et al., 2016), as being a more integral part of the whole research may have compromise the authenticity in their involvement. Furthermore, all participants came from different backgrounds (young persons, main caregivers and healthcare professionals) which brought multiple perspectives and considerations to the generated data. Using such an approach highlights the importance of empowering all stakeholders to work together towards the improvement of the services, as this is an essential part in carrying out person-centred research (McCormack et al., 2017).

The software program NViVo was used for data management.

Combination

The same collaborators involved in the Externalisation stage were invited to participate in the final stage of the study - the Combination phase of the SECI model. Initially, basic information about the person-centred practice framework (McCormack & McCance, 2017) was discussed with the collaborators. The themes and data previously analysed were discussed in view of this framework to identify ways on how person-centred practices may be developed. These discussions were then integrated to propose initial pathways which may be used in the development of person-centred practices for the YPU, these pathways were then further developed by the researcher. These developed pathways were then re- discussed and evaluated with the collaborators involved in this stage. They will also be shared with the unit’s management with the hope of implementation, which will lead to the final stage of the SECI model.

Ethical Considerations

The study received approval by the Queen Margaret University, University of Malta, and the Maltese Health Department ethics Committees. It followed all guidelines outlined in the Maltese Mental Health Act and it was not anticipated that the participants would be at any risk of harm through their involvement in this research. Informed consent, and where needed assent, was sought from all participants including the young people. All participants had the right to withdraw from the study at any point and unless data was not yet published they could ask for their data to be deleted and excluded from the study. They also had the right to ask for copies of their own data. Pseudonyms were used throughout the study to ensure confidentiality. During any of the phases of the study, if participants expressed any kind of distress, the data collection process was terminated, with the possibility of postponing if the participant agreed too. Refusal or withdrawal of participation did not result in any prejudice or consequence in the care provided.

Rigour

Several strategies were applied in this research study to ensure rigour. The research questions were stimulated by real-life observation and events of the researcher through professional experience as a psychiatric nurse within the YPU, though not during the time of the study. This led to a detailed literature review to formulate the study’s objectives and research questions. The research methods and sampling strategies are described in detail to ensure transferability and dependability of the study (Johnson et al., 2020). Purposive sampling was used to ensure that participants offer insight into answering the set research questions, furthermore the inclusion of the different stakeholders resulted in having a more accurate perspective, as the development of person-centred practices involves the inclusion of all persons involved in the service. The use of an observational method may have created bias as it is the researcher who determined what was observed (Johnson et al., 2020); this was mitigated by working with the WCCAT-R tool and through discussion with the MDT in the world café. The use of the tablet with the young persons ensured that those involved felt safe in sharing their experiences, as they had the flexibility and autonomy to share their thoughts and experience whenever they felt comfortable using the means of their preference. Furthermore, their writings/drawings were not seen by the researcher until the point of their discharge. Although the semi-structured interviews may have limited the information as the participant may not have shared all the information about their experiences and the thoughts and emotions related to it.(Karatsareas, 2022), they enabled the participant to discuss their experience in a private and safe setting. All interviews were carried out by the same interviewer who had experience in good communication skills (Mitchell, 2015). Data triangulation also minimised research bias and improves validity and reliability as data is collected from multiple sources (Valencia, 2022).

Conclusion

This study followed an Eastern theoretical framework coupled with principles from person-centred research, to gather and analyse data from all stakeholders involved in the service provision at a child and adolescent mental health in-patient unit. It explains how the SECI model can be adapted in person -centred research in the health sector and the several strategies used towards the formation of Ba were discussed. The importance of involving all persons within the service was also highlighted. To do this, three different methods were used to gather data, the draw, write and tell method, semi-structured interviews and use of the WCCAT and the world café method. The externalisation and combination stages were done collaboratively with two young persons, two main caregivers and two healthcare professionals. This ensured that multiple perspectives were taken into consideration, this gave a more dynamic approach towards the data analysis as all collaborators involved could also see the perspectives of persons with a different role within the service. This research was the first step in evaluating the need for and the perspectives related to person-centred practices within the child and adolescent mental health services in Malta. The developed pathways will hopefully be adopted within the unit, to further enhance the care provided as experienced by the young persons, main caregivers and also the healthcare professionals who are responsible for the provision of care. The development of this study aided in starting the conversation and showed the benefits of getting all persons involved to discuss and develop further the care practices.

Supplemental Material

Supplemental Material - Exploring the Potential for Developing Person-Centred Practices in a Child and Adolescent Mental Health Inpatient Unit: A Qualitative Research Protocol

Supplemental Material for Exploring the Potential for Developing Person-Centred Practices in a Child and Adolescent Mental Health Inpatient Unit: A Qualitative Research Protocol by Christie Attard, Michelle L. Elliot, and Paulann Grech in International Journal of Qualitative Methods

Footnotes

Acknowledgements

Prof. Brendan McCormack., University of Sydney

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

ORCID iDs

Christie Attard

Michelle L. Elliot

Supplemental Material

Supplemental material for this article is available online.

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