Exploring barriers and enablers to implementing a digital mental health crisis risk mitigation pathway in acute paediatric care: A multi-site,exploratory mixed-methods study

Abstract

Objective

Children and young people (CYP) presenting in mental health crisis to acute paediatric settings represent a growing clinical and system-level challenge. These environments, primarily designed for physical healthcare, frequently lack tailored, evidence-based digital tools to support risk mitigation and clinical decision-making in safety-critical situations. In response, we co-developed a prototype digital risk mitigation pathway, designed as a clinical decision support system, to enhance safety and care quality for CYP in crisis. This study examined the feasibility of implementing this pathway across diverse general hospital contexts.

Methods

We conducted a multi-site, exploratory mixed-methods study using a multiple case study design across three acute paediatric hospitals in England. Data were collected between October 2022 and March 2023 through organisational surveys, documentary analysis, semi-structured interviews and focus groups. Qualitative data were analysed inductively, with within-case analysis followed by cross-case synthesis to identify patterns of barriers and enablers influencing implementation feasibility.

Results

Three organisational surveys were completed, 13 organisational documents analysed, and 30 healthcare professionals participated in interviews and focus groups. Five overarching themes were identified as key determinants of implementation: digital infrastructure; information and communications technology training and support; communication; information governance; and healthcare professional attributes. Marked variation in digital maturity was observed across sites. Feasibility was strongly shaped by the alignment of digital readiness with clinical safety requirements, device availability, workflow integration, governance processes and workforce support in time-pressured crisis care.

Conclusion

This study provides novel, contextually grounded insights into the organisational and workforce determinants shaping the feasibility of implementing digital decision support in acute paediatric care. Our findings highlight the central importance of aligning digital readiness with clinical safety priorities and addressing multi-level implementation challenges. These insights offer actionable evidence to inform the design, deployment and scaling of contextually responsive digital health interventions for CYP admitted in mental health crisis.

Keywords

Digital health clinical decision support implementation paediatrics mental health crisis risk mitigation healthcare innovation

Introduction

Globally, 10–20% of children and young people (CYP) experience mental health conditions.¹ In the United Kingdom (UK) recent figures have shown that 16% of CYPs have a mental health disorder, with more than 50% of older adolescents with a disorder having self-harm or attempted suicide.² This trend represents a significant and escalating challenge for healthcare systems, both clinically and economically.³

These presentations increasingly occur in environments primarily designed for physical healthcare,⁴ often resulting in sub-optimal, costly, and non-evidence-based approaches to managing risks such as suicide, self-harm, absconding, or aggression.⁵ In acute paediatric settings, care is typically delivered by paediatricians and Registered CYP nurses who may lack specialist mental health training and skills. This gap highlights the urgent need for tailored, evidence-informed digital tools that can support clinical decision-making and enhance safety for CYP in crisis. To address this need, we co-designed and co-created a prototype digital risk mitigation pathway, for implementation as a clinical decision support system (CDSS). CDSS technologies offer potential to improve patient safety, clinical efficiency and administrative processes by providing timely, context-specific information to healthcare professionals (HCPs).^6,7

While CDSS interventions are increasingly recognised for utility in clinical care, successful deployment depends on robust implementation strategies that account for contextual readiness and sustainability.⁸ Despite the promise of digital solutions, barriers to adoption, including organisational culture, digital literacy, infrastructure, and governance, persist across healthcare settings.⁶ Therefore, understanding feasibility of implementing a digital risk mitigation pathway for CYP in mental health crisis requires a comprehensive exploration of these factors across diverse clinical environments. In this study, we aimed to assess the readiness of three acute paediatric hospital sites in England to implement and adopt the newly developed CDSS.

Methods

We conducted a multi-centre, exploratory mixed-methods study using a multiple case study design approach.⁹ Each case represented a distinct acute hospital site in England (UK) selected to reflect variation in geography, organisational structure and population served. This design enabled in-depth exploration of contextual factors influencing implementation feasibility and enhanced transferability of findings. Moreover, the combination of organisational surveys, documentary analysis and qualitative interviews facilitated systematic triangulation across data sources, which enabled the identification of areas of convergence, divergence and explanatory extension within the dataset. This integrative analytic strategy yielded a more robust and contextually grounded understanding of site-level readiness than could have been achieved through reliance on a single methodological approach. A detailed protocol for this study has been published elsewhere.¹⁰ This mixed-methods study adheres to the Good Reporting of A Mixed Methods Study (GRAMMS) criteria, with the completed checklist available in Supplemental File 1.

Ethical approval

The study received favourable ethical opinions from the South Central – Hampshire A Research Ethics Committee (REC reference: 22/SC/0237) and the West Midlands – Black Country Research Ethics Committee (REC reference: 22/WM/0167). All participants provided written and/or verbal informed consent before data collection.

Study sites and participants

The study was conducted across three tertiary acute hospitals located in the East Midlands, West Midlands, and Northwest regions of England. Sites were purposively selected to capture diversity in digital maturity and service configuration. Participants included HCPs and digital experts with direct experience of caring for CYP in mental health crisis or involvement in digital implementation, demonstrating public participatory strategy of the study. Eligibility criteria are detailed in Table 1.

Table 1.

Participants eligibility criteria.

Participants
Healthcare professionals (HCPs)		Healthcare digital experts
Inclusion criteria	Exclusion criteria	Inclusion criteria	Exclusion criteria
Having a leadership/management role in a healthcare setting providing services to CYP experiencing mental health conditions/crisis. Experience of providing care to CYP in mental health crisis. Experience in using existing technologies.	HCPs who are not qualified to work with CYP. HCPs who are working in non-clinical settings. HCPs who do not have experience in providing care to CYP with mental health needs.	Those who liaise between the information system team and nursing or medical departments to meet the needs in clinical practice. Working in each of the three aforementioned hospital sites. Experience in implementing other technologies.	Digital experts having no experience implementing similar technologies. Digital experts who work in hospital settings other than the aforementioned sites.

Recruitment and sample size

A purposive sampling approach¹¹ was used, targeting ten participants per site. Recruitment was facilitated by site Principal Investigators using chain referral methods. Invitations were distributed via email, accompanied by participant information sheets. Written or verbal consent was obtained before participation.

Data collection

Data were collected from October 2022 to March 2023 using three complementary methods: organisational surveys, documentary analysis and qualitative interviews and focus groups (Figure 1).

Figure 1.

Data collection and analytical process.

Survey: A structured survey was developed based on the Healthcare Information and Management Systems Society (HIMSS) framework.¹² It included 36 statements across six domains: digital strategic alignment, leadership and management, stakeholder engagement, information governance, partnerships, and resourcing and skills. Responses were recorded on a five-point Likert scale, with free-text fields to capture contextual insights.¹²

Documents: We sought relevant organisational documents from each site to contextualise digital readiness and governance processes, including policies, guidelines and strategic plans related to digital implementation, information governance and equality, diversity and inclusion. Documents were requested via a defined process facilitated by each site Principal Investigator. Where documents were provided, these were reviewed to identify organisational processes and contextual factors that could influence implementation feasibility and readiness for digital innovation. Owing to governance/permission constraints, no organisational documents could be shared by case study 3 despite repeated requests; consequently, documentary analysis was undertaken for Case Studies 1 and 2 only.

Interviews and focus groups: Semi-structured interviews and focus groups were conducted using a standardised topic guide (see Supplemental Table 1). Discussions explored perceptions of organisational readiness, anticipated barriers and enablers, and views on the feasibility of implementing the digital pathway. Interviews lasted 15–30 min and focus groups 40–60 min.

Data analysis

We used a sequential exploratory mixed-methods approach within a multiple case study design. Documentary review and the organisational survey were first used to characterise each site's context and digital readiness and to inform interview/focus group prompts and scheduling. Qualitative interviews and focus groups were subsequently analysed inductively, and findings were synthesised through within-case analysis followed by cross-case comparison (Figure 1).⁹

Qualitative data (interviews, focus groups, documentary data where available, and free-text survey responses) were initially analysed within each case. Interviews and focus groups were transcribed verbatim, anonymised, and imported into NVivo (Version 12).¹³ A codebook was developed iteratively by ZA and TM, with refinement through team discussion (ZA, JCM, TM, TC, and JC). Codes were grouped into themes^14,15 and mapped across structural levels (individual, ward/team, organisational, national). Documentary analysis followed a reflective and iterative approach, involving repeated reading and thematic synthesis^16,17,18 to identify relevant organisational processes and contextual determinants.

Organisational survey data were analysed using descriptive statistics in Microsoft Excel. Integration of the mixed-methods strands was undertaken through narrative comparison during case-level interpretation and cross-case synthesis,⁹ using the case summary tables (Tables 3 to 5) and the cross-case summary table (Table 6) as joint displays of barriers and enablers across cases, themes and data sources. We did not apply formal convergence coding; rather, we compared patterns across data sources to identify corroboration and contextual divergence and used these comparisons to support interpretation of implementation feasibility.

The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.¹⁹

Rigour and reflexivity

Prior to identifying data being sought, all documents obtained for documentary analysis were assessed for authenticity, credibility, representativeness, and meaning.¹⁶ The use of documentary analysis enhanced data triangulation through comparison of findings with findings from both questionnaires and interviews to provide a comprehensive perspective, strengthening the credibility and validity of the study. For interview data, dependability was ensured through a standardised interview guide, while credibility was maintained using audio recordings, interview notes, verbatim transcripts and systematic coding.

Results

Thirty participants were recruited across the three case study sites. Participants were predominantly Registered nurses (93%, n = 28), with two medical practitioners. The majority were female (70%), with a mean age of 36 years (range 23–60 years). Participants had an average of 9.8 years of clinical experience caring for CYP (range 2 months–33 years). Detailed demographic data are presented in Table 2.

Table 2.

Characteristics of study participants.

Demographics	HCPs (n = 30)	Site 1 (n = 10)	Site 2 (n = 11)	Site 3 (n = 9)
Gender	70% Female 30% Male	80% Female 20% Male	54% Female 55% Male	80% Female 20% Male
Mean age (Range) in years	36 (23–60)	40 (23–60)	34 (25–46)	29 (23–36)
Profession (n)	Paediatric Nurses 27 Learning Disability Nurse 1 Doctors 2	Paediatric Nurses 9 Doctor 1	Paediatric Nurses 10 Doctor 1	Paediatric Nurses 8 Learning Disability Nurse 1
Ethnicity (n)	White British 29 Asian 1	White British 9 Asian 1	White British 11	White British 9
Mean years of experience (Range)	9.8 years (2 months–33 years)	14 years (2 months–32 years)	6.7 years (1–20 years)	4.8 years (1.5– 12 years)
Data collection	Individual interviews 20 Focus groups 3 Organisational Survey 3	Individual interviews 10 Focus groups 0 Organisational Survey 1	Individual interviews 1 Focus groups 3 Organisational Survey 1	Individual interviews 9 Focus groups 0 Organisational Survey 1

Data description

As outlined in Table 2, data collection included three organisational surveys, 20 individual interviews and three focus groups. In total, over 10 h of audio recordings were transcribed, resulting in approximately 100 pages of qualitative data. Documentary analysis included 10 documents from case study 1, and 3 from case study 2. No documents were available for case study 3 despite repeated requests via the site Principal Investigator. In this manuscript, ‘data items’ refer to coded excerpts (units of meaning) identified across qualitative interviews/focus groups, free-text survey responses and organisational documents where available. Data items were coded inductively within each case and then grouped into themes. Each item was additionally characterised as representing a barrier or an enabler and mapped to a structural level (individual, ward/team, organisational, and where applicable national and/or digital system level). Counts of data items are provided to describe the relative distribution of coded content across themes and levels within each case. These counts should be interpreted as descriptive indicators of emphasis within the dataset rather than as measures of prevalence in the wider workforce.

Organisational survey

The organisational survey, aligned to HIMSS framework, was completed by senior HCPs with digital technology roles.¹² Across the 36 statements, 66.7% were positively endorsed (agreed or strongly agreed) by all respondents. A further 27% were endorsed by two respondents, and 6% by one respondent. Findings corroborated qualitative data from interviews and documents, reinforcing the identification of barriers and enablers to digital implementation across sites (see Supplemental Table 2).

Current-state workflow and workforce

Across all sites, clinical decision-making for CYP presenting in mental health crisis is currently supported primarily through separate mental health assessment documentation (typically paper proformas) and existing clinical documentation systems, rather than through a fully embedded digital CDSS. Figure 2 summarises the current-state workflow spanning either emergency department presentation or direct admission and subsequent acute paediatric ward care. The workflow involves multiple professional groups, including Registered Children's nurses (bedside nurses and shift coordinators), acute paediatric medical staff, CAMHS/liaison psychiatry teams, safeguarding services, security/site management and bed management/patient flow teams. Our participant sample was predominantly Registered Children's nurses, reflecting their central operational role in implementing observation, escalation and safety measures on acute paediatric wards and their position as primary end users of documentation and decision-support artefacts during crisis admissions.

Figure 2.

Current-state workflow and decision-support touchpoints for CYP in mental health crisis.

Case study findings

Qualitative data were analysed inductively within each case study, with findings categorised as enablers or barriers and mapped across four structural levels: individual, ward/team, organisational and national. Eighteen codes were generated across all data sources, which were synthesised into five overarching themes: digital infrastructure, information and communication technology (ICT) training and support, communication, information governance and HCP attributes.

Tables 3 to 5 present within-case ‘joint displays’ summarising barriers and enablers to implementing new digital technology across data sources (interviews/focus groups, survey and organisational documents where available). Within each case, entries are organised by structural level (individual, ward/team, organisational; and where relevant national or digital system level). Each entry represents a coded data item (unit of meaning) and is summarised as a brief descriptor with illustrative contextual detail. Case study 3 did not provide organisational documents for analysis; therefore, organisational-level context for that case is derived from interview/focus group accounts and survey responses.

Case study 1

Forty-two relevant data items were identified. Over half (57%) were classified as enablers, with the remainder as barriers. Data items were distributed across all five themes, with communication and ICT training/support frequently represented as both enabling factors and sources of friction depending on how they were operationalised (Table 3). At organisational and digital-system levels, participants described challenges arising from multiple systems, service pressures and legacy infrastructure alongside governance processes shaping access and information sharing (Table 3). Staff accounts emphasised that accessibility and ease of integration into practice were critical, noting that if a tool is difficult to access, ‘you’ve got to get lots of pushback straightaway’ (Digital Infrastructure, Quote 2). At organisational level, structured processes for requesting and building digital functionality were described, for example: ‘we have the ASR process … an Additional Service Request, and then … it then gets filtered to the relevant people to build’ (Digital Infrastructure, Quote 3). At individual and ward/team levels, clinical pressures constrained time for email communication and release for training, and participants described variability in digital literacy requiring more targeted support (Table 3).

Table 3.

Barriers and enablers of implementing digital technology for case study 1.

Data source	Level
Data source	Individual	Ward/team level	Organisation/Trust	Digital system
Documents	Clinical commitments (Clinical pressure/ lack of reporting)		Communications/ sharing information (Requirements and agreements from multiple teams before sharing)	Utilising digital system (Unique credentials to login/ set of skills or literacy level)
	IT support (Need approved credentials to gain access)		Record management (Guidelines from different resources Trust has to follow)
	Communications or sharing information (Anonymous data can be shared uncontrolled)	Monitoring (Audits to improve sharing practice)	Communication (measures to protect sharing process/ lawful and legislative)	Entries are traceable (System can inform who and when access the system)
	IT Support (can document under different credentials after permission)	Monitoring (Audits to improve sharing practice)	Training (Duty to facilitate training/ information governance training is compulsory)
Interviews/ focus groups	Behavioural (inattention to online training / resistant to change/ feel bombarded with requirements)	Clinical commitments (clinical pressure behind lack of time to read emails/ difficult to release for training)	Communication (huge amount of information to be shared/ loads of filled/jammed posters)
	Communications (Difficult accessing emails/ unappealing posters)	Communication (lack of time/events to share new digital tools during handovers/ management team may not be the right staff to feedback on systems)	IT Support (multiple systems/ huge pressure on the system leading to freeze or service down/ no CNIO/ old devices)
	Infrastructure (Clinical educators are not leading digital training/ cannot access test environment/ lack of devices)		Training (some are not targeted to a set of practitioners/ no digital literacy assessment or education to use digital tools)
	Training (Newly qualified/ low digital literacy staff need more support and time)
	Communications (Posters in the right place such as rest rooms/ brief bulletin points in emails)	Communications (reinforcing the message through handovers is effective)	Communication (Using a mixture of approaches to share information; emails, poster etc…/ point of call for feedback/ hospital newspaper)
	Engagement (users’ involvement during development/ senior engagement/ younger generation engage quicker)	Engagement (clinical champions/ leading clinician can influence others to use digital technology/ physical presence)	Infrastructure (Importance of having CNIO/ making reports out of new digital tools for publication)
		Infrastructure/ IT Support (Extra devices for temporary agency staff to use)	Planning ahead for engagement (develop existing systems/ rolling out plans and leaders/ a focused development digitalisation strategy)
			Awareness training (sharing the benefit of digital tools/ hands on training sessions/ links to refreshing videos)
Survey		Having enough devices (no definitive plan getting extra devices for newly recruited staff)	Engagement (partnering with academic institution/ involving patients or service users in the engagement process)
			Strategy (not specific on a clinical problem to be resolved digitally/ lack for a sense of urgency of deploying digital solution)
	Communications (capture and respond to service user feedback)	Training (presence of a dedicated clinical and technical team to support the implementation process)	Communication (using social media for announcement/ using screen savers/ preserving communication channels between different teams/ using visual media)
	Engagement (involving clinicians in the early stage of implementation/ recruit clinical champions to lead implementation)	Engagement (recruit dedicated project manager to liaise with the clinical team)	Digital strategy (Have an agreed partnership or procurement model with the project supplier/ Making proactive engagement with external bodies such as (ICO)/ defined digital strategy)
	Training (invest in personnel and ability to aid implementation)		Engagement (dedicated and experienced team to transform paper pathways into digital pathways/ have a clear strategic framework)
			Information governance (open and transparent with patients and public groups/Extra and precautions when collaborating with industry partners/ processes in place to scrutinise and evaluate investment in digital technology)

Case study 2

Thirty-six data items were identified, with 24 classified as enablers and 12 as barriers. This case included national-level context within the dataset, reflecting stronger strategic digital oversight and mature digital governance structures (Table 4). Communication was prominent across levels, including the perceived need for clear routes for reporting problems and providing feedback, as well as concerns that static communication formats may not support timely troubleshooting (Table 4). Participants emphasised that usability and contextual fit were important: ‘you also need buy-in from the people who are using it… if they don’t think that the tool's useful then they’re not going to use it and you need a consistent message’ (Communication, Quote 6). Enabling features included practical, low-burden training approaches and ease of access to training provision, for example using QR-linked micro-learning: ‘I scan it, it's a two-minute video… and that works every time’ (Training and support, Quote 4), and ‘there's lots of training opportunities… face to face… MS Teams… lots of time slots’ (Training and support, Quote 5). Survey responses for this case also indicated stronger agreement across several domains, including device availability planning and digital strategy alignment.

Table 4.

Barriers and facilitators of implementing new digital technology: case study 2.

Data source	Level
Data source	Individual	Ward/team level	Organisation/Trust	National level	Digital system
Documents	Strategic Guidance. Digital Oversight Collaborative (DOC) review and advise the Trust on performance against agreed milestone delivery plans of Digital and Data Futures Strategy Programme.
Interviews/ focus groups	Behaviour of certain staff groups (Junior doctors will not use the tool unless seniors request it, people resistance to change with new intervention, staff avoid using personal devices and avoid new technology).	Clinical commitments (clinical pressure behind lack of time to read emails/ difficult to release for training)	ICT Support (multiple systems/ huge pressure on the system leading to freeze or service down/ difficult to capture data if staff using their own devices/ third party calls handler don’t understand ICT problems).		User-hostile (If digital tool is difficult to be used it will not be accepted).
	Communications (no standardised way of giving feedback, don’t know how to report broken device)	Communication (lack of time/events to share new digital tools during handovers/ clinical educators cannot capture all staff for feedback and training)	Communication (Recorded video or poster do not allow for feedback or troubleshoot and can be outdated with any updates for the digital tool)		Contextually irrelevant (digital tools developers are not HCP and not aware of clinical pressure
	Training (Newly qualified/ low digital literacy staff need more support and time by superusers in Trust)		Engagement (cannot use generic login due to lack of accountability, uncommon digital pathway can be forgotten, instructing without explaining why to use the digital pathway)
	Infrastructure (Digital literacy varies among staff and need different level or approaches of training)	Training (Clinical champion, clinical educating in every ward to facilitate implementation live online meetings are best way to give feedback and ask)	Training (Doctors are usually targeted by clinical educators, use gamification for educating doesn’t work for all specialities)
	Communications (The availability of staff liaison team can be helpful to tell you where you want to go)	Communications (a mixture of approaches to communicate, board in staff room to get feedback, big-laminated infographic posters)	Communication (Using a mixture of approaches to share information; emails, poster, weekly meetings such as Ground round, using a snappy word to communicate)
	Engagement (Agency staff can get their login details on first shift, scanning QR codes to learn or get quick training video, incentives can help with engagement)	Engagement (Ongoing evaluation of the implementation process, sharing success with other areas to improve engagement)	Infrastructure (Trust is paperless, experienced digital team, CNIO to drive changes, robust processes in place, strong ICT support)
		Infrastructure/ IT Support (Doing peer to peer training, Having computers on wheels, handheld devices, soft bleeps devices, availability of super users)	Engagement (Big piece of comms, digital projects have members clinical experience, rolling out in summer is better than winter)
			Awareness training (Training for any new digital tool, clinical educators to communicate new digital technology)
Survey	Communications (capture and respond to service user feedback)	Training (presence of a dedicated clinical and technical team to support the implementation process)	Communication (Create a sense of urgency for implementation among seniors/ using social media for announcement/ using screen savers/ preserving communication channels between different teams/ using visual media)	Global exemplar (Alder Hey is a Global Digital Exemplar site and achieved HIMSS Stage 7 status)
	Engagement (involving clinicians in the early stage of implementation/ Comprehensive patient engagement in the implementation process)	Engagement (recruit dedicated project manager to liaise with the clinical team, be specific about a clinical problem)	Digital strategy (Making proactive engagement with external bodies such as (ICO)/ defined digital strategy/ established steering group of key stakeholders)	External collaboration (Making proactive engagement with external bodies such as Information Commissioner's Office, National Data Guardian)
	Training (invest in personnel and ability to aid implementation)	Infrastructure (Have enough devices or plans to secure and fund tablets devices for all clinical areas)	Engagement (To embed the project in the digital ecosystem of the NHS organisation/ senior attendance to routine clinical meetings/ choosing a universal system to be adopted)	External review (Partner with academic institutions to perform independent evaluation).
			Information governance (open and transparent with patients and public groups/Extra and precautions when collaborating with industry partners/ processes in place to scrutinise and evaluate investment in digital technology)

Case study 3

Twenty-four data items were identified, with 16 classified as enablers and eight as barriers. Communication and engagement were frequently represented, including the perceived need for multi-channel messaging and involving staff in decision-making (Table 5). Participants described device availability and network reliability as practical constraints affecting feasibility, particularly where decision-support documentation is required at pace in crisis care: ‘is there enough computers on wheels that everybody can use to do the assessment? Electronic devices would be a challenge if there is not enough devices’ (Digital Infrastructure, Quote 1). Consistent with this, survey responses in case study 3 included disagreement with statements relating to digital strategy alignment, and disagreement with having enough devices or plans to secure and fund devices for clinical areas. Interview accounts also described governance involvement as time consuming during implementation processes (Table 5). As no organisational documents were available for this case, organisational-level context is based on interviews/focus groups and survey responses.

Table 5.

Barriers and facilitators of implementing new digital technology: case study 3.

Data source	Level
Data source	Individual	Ward/team level	Organisation/Trust
Interviews/ focus groups	Behaviour of certain staff groups (people resistance to change with new intervention)	Clinical commitments (clinical pressure behind lack of time to read emails/ difficult to release for training)	ICT Support (Data synchronising is a tricky part as always need ICT support). Network is an issue /not enough devices or computers in clinical areas)
		Communication (lack of devices and computers to keep up to date with all new changes in UHCW).	Engagement (experienced seniors still have different perspectives/ personalities due to new significant changes digitally/ governance team is involved in every step and this is time consuming)
		Training
	Communications (Emails can be check on personal devices if you are given access/ Posters and board messages is helpful to get messages/ Staff will love digital tools when they realise it will make their life easier)	Communications	Communication
	Engagement (Staff want to be in the decision-making process)	Engagement (Ongoing evaluation of the implementation process, sharing success with other areas to improve engagement)	Infrastructure
			Engagement
			Awareness training
Survey		Infrastructure/ IC T Support (Not enough devices or computers on wheels, handheld devices in clinical areas)	Digital strategy (is not making proactive engagement with external bodies such as (ICO)/ digital strategy is still underdevelopment/)
			Engagement (Digital strategy is under development and not yet implemented/ has not started any independent digital service evaluation)
	Communications (capture and respond to service user feedback)	Training (presence of a dedicated clinical and technical team to support the implementation process)	Communication (Create a sense of urgency for implementation among seniors/ using social media for announcement/ using screen savers/ preserving communication channels between different teams/ using visual media)
	Engagement (involving clinicians in the early stage of implementation/ Comprehensive patient engagement in the implementation process)	Engagement (recruit dedicated project manager to liaise with the clinical team, be specific about a clinical problem)	Digital strategy (established steering group of key stakeholders/ giving priority for health care related technology)
	Training (invest in personnel and ability to aid implementation)	Infrastructure (Have enough devices or plans to secure and fund tablets devices for all clinical areas)	Engagement (To embed the project in the digital ecosystem of the NHS organisation/ senior attendance to routine clinical meetings/ choosing a universal system to be adopted)
			Information governance (open and transparent with patients and public groups/Extra and precautions when collaborating with industry partners/ processes in place to scrutinise and evaluate investment in digital technology)

Themes

Digital infrastructure

Across cases, digital infrastructure was described as a foundational condition for implementation feasibility in the acute paediatric context, where CYP mental health crisis admissions require timely access to assessment, escalation and safety documentation. Data items related to infrastructure included availability of devices in clinical areas, network reliability and the operational consequences of legacy equipment or system instability (Tables 3 to 5). Participants described device constraints directly affecting assessment completion: ‘is there enough computers on wheels that everybody can use to do the assessment? Electronic devices would be a challenge if there is not enough devices’ (Table 5, Quote 1). Accessibility and ease of integration into routine practice were repeatedly emphasised: ‘it's got to be something that is easy and embeds very easily into practice… if staff are finding it too hard to access it, is it going to be accessed?’ (Table 5, Quote 2). In addition to hardware and connectivity, infrastructure was also framed as organisational capability to manage and route digital build requests and workflow integration, for example through a structured service request process (Table 5, Quote 3). Survey responses indicated variation across sites in perceived digital strategy alignment and in planning for device availability, with two cases disagreeing with having enough devices or plans to secure and fund devices for clinical areas.

ICT training and support

ICT training and support featured prominently across cases and levels, reflecting the need to sustain safe use of decision-support artefacts during time-pressured crisis care. Data items included staff release constraints for training due to clinical commitments, perceived variability in digital literacy and the importance of accessible support during implementation and routine use (Tables 3 to 5). Participants provided examples of low-burden refresher training embedded in clinical areas, such as QR-linked microlearning: ‘I scan it, it's a two-minute video… and that works every time’ (Quote 4). Others emphasised the value of multiple training modalities and flexible scheduling, including face-to-face and virtual formats: ‘it can be face to face, it can be MS Teams, there's lots of time slots’ (Table 5, Quote 5). At ward/team level, the presence of superusers, clinical educators and dedicated clinical/technical teams was described as enabling, whereas barriers included difficulty releasing staff during clinical pressure and the perceived mismatch between training approaches and differing levels of digital confidence (Tables 3 to 5).

Communication

Communication was consistently represented across cases as both an enabler and a barrier, with salience in CYP mental health crisis care where rapid changes in risk status and escalation plans necessitate timely, comprehensible information sharing. Data items reflected the volume and format of organisational communications, limited time during shifts to access messages, and challenges identifying appropriate routes for feedback and reporting problems (Tables 3 to 5). Participants highlighted the importance of consistent messaging and perceived usefulness to secure end-user buy-in, ‘you also need buy-in from the people who are using it… if they don’t think that the tool's useful then they’re not going to use it and you need a consistent message’ (Table 5, Quote 6). Others described embedded digital communication mechanisms as a means of disseminating guidance: ‘information is shared by pop-up screens… relevant or new guidance’ (Table 5, Quote 7). Survey responses across sites also emphasised multi-channel engagement strategies (e.g. screensavers, intranet and visual media), alongside the importance of capturing and responding to user feedback in a timely manner.

Information governance

Information governance was described as a necessary condition for implementing decision-support approaches in a context involving minors, safeguarding considerations and sensitive mental health information. Data items included access controls, accountability and traceability, and the requirement for approvals and agreements across teams before information sharing (Tables 3 to 5). Participants described governance as a structured pathway preceding implementation, including ratification, dissemination and training mobilisation, ‘if there is a new digital process… it would go through the governance structure and be ratified… then that would then go out to the wards… there would be a big teaching package… screensavers, emails… engagement with the clinical educating teams’ (Table 5, Quote 8). Access processes were also described as practically consequential for workforce readiness, with delays in obtaining system access for new or temporary staff (Table 5, Quote 9). Survey responses further indicated agreement that additional governance and precautions are required when collaborating with industry partners and that organisations should be open and transparent with patients and public groups regarding data processing and security.

Individual attributes

Variation in digital literacy needs was recognised as a major barrier in the delivery plan of digital technology if left unaddressed. Workforce generation differences were perceived as a barrier in circumstances where an organisation has a low-profile workforce or a workforce who are less confident attitudes to technology (see Table 5, quote 10). Digital readiness, described as positive attitude and digital experience, was vital (Tables 6 and 7).

Table 6.

Qualitative thematic analysis codes, cross-case analysis and themes.

Code	Category by case study			Theme
Code	Case study 1	Case study 2	Case study 3	Theme
Digital tools (equipment)	Enabler	Enabler	Barrier	Digital infrastructure
Digital strategy	Enabler	Enabler	Enabler
Infrastructure	Barrier	Enabler	Barrier
Planning ahead	Enabler	Enabler	Enabler
Digital maturity	Enabler	Enabler	Barrier
Information governance	Enabler	Enabler	Barrier	Information governance
Auditing	Enabler	Enabler	Barrier
Monitoring	Enabler	Enabler	Barrier
Records management	Enabler	Enabler	Enabler
Training	Enabler	Enabler	Barrier	Training and support
Digital literacy	Barrier	Enabler	Barrier
Visibility of digital workforce	Enabler	Enabler	Barrier
ICT support	Barrier	Barrier	Barrier
Communication	Enabler	Enabler	Enabler	Communication
Engagement	Enabler	Enabler	Barrier
Technology benefits	Enabler	Enable	Enabler
Behaviour/ Attitude	Enabler	Enabler	Barrier	Individual attributes
Clinical Commitment	Enabler	Barrier	Barrier	Individual attributes

Table 7.

Participant quotes.

Theme	Reference	Quote
Digital Infrastructure	1	‘Yeah, accessibility for example is there enough computers on wheels that everybody can use to do the assessment? Electronic devices would be a challenge if there is not enough devices’.
	2	‘It's got to be something that is easy and embeds very easily into practice, because I feel that could be the very, very first hurdle if staff are finding it too hard to access it, is it going to be accessed? And staff will try very, very hard to do it because they know that's what they should be doing, but if it's too hard to access you’ve got to get lots of pushback straightaway’.
	3	‘I think within [Case Study 1] we already have a very focused pathway to do things, so we have the ASR process that we would go down, so that's an Additional Service Request, and then depending what it would be it then gets filtered to the relevant people to build’.
Training and support	4	‘And our ID team have managed to get a two minute video from the supplier which is dead basic but tells you what you need to do of start with this, do this, do this, do that. And it's on a QR code on the drawer where the gripper needles are, so as a member of staff you think oh I just want a quick refresher, I scan it, it's a two-minute video and you go ‘yeah, fine’. And that works every time’.
Training and support	5	‘There's lots of training opportunities, they make it very easy, it can be face to face, it can be MS Teams, there's lots of time slots, so yeah, I think the Trust are really good at that’.
Communication	6	‘You also need buy-in from the people who are using it. They need to think of the tool as being useful, because if they don’t think that the tool's useful then they’re not going to use it and you need a consistent message’.
Communication	7	‘Information is shared by pop-up screens, so digital information that's very relevant or new guidance if you want to ensure that that wider group have picked up specific information’.
Information governance	8	‘And so firstly, if there is a new digital process that's coming out, it would go through the governance structure and be ratified at all levels. So there should be information from there to say at a high level exactly what the project hopes to achieve, how it's going to do this, what technology is going to be involved and all of the costings and everything. And from there, once it's been ratified and it's been okayed then that would then go out to the wards and there would be a big teaching package that would go with it, so there would be advertising, there would be things on screensavers, emails, etc., but there’d also be engagement with the clinical educating teams on each of the wards to do that’.
Information governance	9	‘I think they often end up applying for a Meditech log-in but it is a long process when they do their first shift at [place 2] to get up and running. Once you’ve done one and you’ve got that log-in, I don’t think it times out and stuff that much’.
Individual attributes	10	‘So you would have Nurse A who is very up to date with technology and is quite comfortable and confident using it and probably would have read that email and felt like they could interpret what the message was and not feel scared off by it. Whereas you’d have Nurse B who was completely a technophobe, you know, it's pen and paper for eternity, which is fine and I can understand those perspectives’.

Box 1.

Worked example (triangulation across data sources). To illustrate how evidence from multiple sources informed theme development, the theme ‘Digital infrastructure’ provides a clear example.

Survey responses demonstrated cross-site variation in planning for device availability, with only one case strongly agreeing that the organisation has ‘enough devices or plans to secure and fund tablets devices for all clinical areas for inputting patient data’, while two cases disagreed. Participant accounts aligned with this emphasis on access and availability, describing the practical implications for completing assessments in crisis contexts: ‘is there enough computers on wheels that everybody can use to do the assessment? Electronic devices would be a challenge if there is not enough devices’ (Quote 1). Participants also emphasised that accessibility and ease of embedding into routine practice are likely to be early adoption determinants: ‘it's got to be something that is easy and embeds very easily into practice… if staff are finding it too hard to access it, is it going to be accessed?’ (Quote 2). In case study 1, organisational processes for initiating digital build and routing requests were described through a structured additional service request mechanism (Quote 3), which was coded as an enabling condition for translating pathway requirements into implementable digital functionality. These convergent data items were coded within cases, mapped by structural level, and synthesised into the overarching ‘Digital infrastructure’ theme.

Cross case analysis

Cross-case synthesis demonstrated variation in digital readiness across sites. Survey responses indicated that Case Studies 1 and 2 strongly agreed that the organisation has a clearly defined digital strategy aligned to clinical and corporate objectives, whereas case study 3 disagreed. Similarly, responses suggested divergence in planning for device availability across sites. Consistent with this, Case Studies 1 and 2 contained more organisational and system-level enabling conditions in the qualitative dataset (e.g. stronger ICT support structures, clearer digital oversight and leadership), whereas case study 3 included proportionally more data items indicating infrastructure constraints and reliance on ICT support for routine functionality, including network reliability and synchronisation issues (Tables 3 to 5). Across all cases, communication and ICT training/support were frequently represented, reflecting shared operational challenges related to staff release for training, feedback routes and the burden of implementation messaging under clinical pressure. Organisational-level triangulation was limited in case study 3 because no organisational documents were available for analysis; consequently, comparisons for this case draw on interview/focus group accounts and survey responses.

Discussion

This study provides a novel and contextually rich exploration of the feasibility of implementing a digital risk mitigation pathway for CYP admitted in mental health crisis to acute paediatric care. Through a multi-site case study design, we identified key determinants of implementation across individual, ward, organisational and national levels. The integration of digital readiness with clinical safety emerged as a critical conceptual factor influencing feasibility, underscoring the need for tailored strategies that reflect the complexity of healthcare ecosystems. Our findings align with existing literature on digital health implementation, which emphasises the importance of stakeholder engagement, infrastructure and governance.^20–22 This study extends current understanding by mapping these determinants across structural levels and highlighting the interplay between digital maturity and clinical context (see Table 8). However, interpretation of organisational-level determinants across sites should be considered in light of differences in available data sources. Specifically, documentary analysis was not possible for Case Study 3 due to governance/permission constraints, and organisational context for that site was therefore derived from interview/focus group accounts and the organisational survey without corroborating internal documentary evidence. As organisational documents can provide important evidence of strategy, governance and readiness, the absence of documentary data for Case Study 3 may have limited organisational-level triangulation and reduces the strength of direct organisational-level comparisons across cases.

Table 8.

Study highlights summary.

1. Inductive thematic analysis enabled the study to capture nuanced perspectives from stakeholders, revealing both commonalities and site-specific challenges.

2. Multiple case study approach strengthened rigour of study analysis by facilitating cross-case synthesis and triangulation of data sources.

3. This design also enabled the identification of patterns and divergences in implementation readiness, enhancing the transferability of findings.

4. The inclusion of diverse hospital sites, including a Global Digital Exemplar, provided a valuable lens through which to examine national-level influences and digital transformation trajectories.

The conclusions of this study also differed in several important respects from evidence reported in adult mental health and adult acute care settings. Although core implementation determinants such as digital infrastructure, governance processes and workforce training were broadly comparable, the context of CYP mental health crisis admissions introduced additional constraints not typically observed in adult services. Caring for ‘minors’ required stricter safeguards around consent, confidentiality and parental involvement, and digital pathways had to align with statutory safeguarding processes and multi-agency decision-making. Paediatric teams also had more variable exposure to crisis mental health care than adult acute or specialist mental health staff, which increased reliance on clear, role-specific decision-support and simplified user interfaces. As a result, implementation feasibility in acute paediatrics depended not only on organisational digital maturity but also on the availability of workforce-appropriate training and the fit of the pathway with family-centred models of care. These contextual features suggested that although general implementation principles were transferable from adult environments, the operationalisation of digital risk mitigation tools for CYP required additional tailoring to the legal, relational and workflow characteristics of paediatric crisis care.

Study findings are further supported by previous literature which emphasise early pipeline engagement of stakeholders.⁸ Co-design, co-development and co-production of healthcare services with stakeholders is crucial to successful implementation, with stakeholder interrelationships allowing for more effective and accurate resource prioritisation.²³ A fundamental factor in dealing with these processes is the active contribution of clinicians and healthcare leaders who can identify obstacles and bring stakeholders together to facilitate the process.⁸ To achieve this, clinicians and health care leaders should involve end users in the design and testing phases of digital technology to ensure that the system meets the contextual needs and is aligned to existing workflows.⁶ Frontline HCPs have shown preferences for CDSS that streamline their workflows and could seamlessly integrate with other systems already in use.^8,21 There are various functions and advantages of CDSS of which patient safety is a mandatory requirement no matter the primary purpose for their implementation.^6,7 The digital risk mitigation pathway technology has the potential to enhance patient safety in terms of clinical decision-making and management. Such a CDSS will have a set of standardised interventions pertaining to clinical management of CYP admitted with mental health crisis and provides administrative functions through integration with other systems for clinicians to have relevant up-to-date patient records.

Engaging all stakeholders early also serves as a mechanism for transparency in the development and assurance of system governance of the CDSS. Overall, levels of engagement with end users across the workforce are influenced by attitudes towards the CDSS and perceptions surrounding individual and safety benefits.²⁴

Digital technologies must be readily available and easily accessible, for example, the availability of necessary devices, and ease of use to facilitate favourable implementation and adoption. The more complex the CDSS or its user interface, the more unlikely it is for end-user adoption. This is closely linked to the availability of interactive assistance/support and training.²³ Effective technical assistance includes centralised ICT staff to maintain the digital technology, help desk support, and, where possible, visibility of a member of ICT staff in the clinical area.^25,26 Providing ongoing/mandatory training and education as part of the digital implementation strategy can address perceptual and psychological aspects of the new CDSS acceptance, facilitating effectiveness of use or system implementation.²⁴ Training includes: HCP skills fairs, workshops and annual clinical personnel training.²⁷

In interpreting the findings, we drew on the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework²⁸ and the Consolidated Framework for Implementation Research (CFIR).²⁹ The NASSS framework highlights the complexity of digital health interventions and the need to consider technological, organisational and contextual factors. Our study reflects this complexity, particularly in the variation of digital infrastructure and governance processes across sites. Similarly, CFIR's emphasis on inner and outer settings, individual characteristics and implementation processes is mirrored in our thematic structure and cross-level mapping. Adapting and tailoring CDSS infrastructure implementation strategies to different healthcare service contexts is key to addressing organisational-level factors related to workflow integrations and ensuring that the proposed digital technology is compatible with the current processes and infrastructure.²¹ From the authors’ clinical experiences lack of interoperability among current technological platforms across healthcare organisations provides a typical example of potential challenges within the current innovation landscape. Interoperability is vital for any digital solution working beyond a single organisation for the following reasons: compatibility of systems makes it easier to share patient records,³⁰ improvements in patient safety and cost-effectiveness.²⁶

Strengths and limitations

This study recruited primary stakeholders who would be responsible for, or directly affected by, implementation of the proposed digital pathway. We achieved the planned recruitment target across three large teaching hospital sites with differing organisational characteristics and geographies, supporting cross-case comparison and transferability of implementation-relevant insights.

Several limitations should be noted. Recruitment targets (approximately 10 participants per site) were pre-specified pragmatically and we did not use formal data saturation as a stopping criterion; therefore, the completeness of captured perspectives cannot be assessed using saturation criteria. In addition, we did not undertake participant transcript review or member checking of findings, which may have reduced opportunities to validate interpretations.

Documentary analysis was undertaken inconsistently across sites because organisational documents could not be shared by case study 3 due to governance/permission constraints despite repeated requests via the site PI. As organisational documents can provide important evidence of strategy, governance and readiness, this absence may have limited organisational-level contextualisation and triangulation for case study 3 and therefore weakens the strength of direct organisational-level comparisons across cases.

Finally, the sample may not be representative of the wider healthcare organisation workforce. Participants were recruited using purposive and chain-referral methods, which are appropriate for implementation-focused enquiry but may over-represent engaged or well-networked staff. Participant ethnicity was predominantly White British which may limit transferability to settings with different workforce profiles and experiences.

Implications to practice

Our findings suggest that implementation planning for digital decision-support in acute paediatric settings managing CYP mental health crises should distinguish between: (1) onboarding training; (2) just-in-time support during live clinical use; and (3) continuous optimisation after go-live. Firstly, onboarding should be role- and context-specific, acknowledging variability in digital literacy and the realities of clinical pressure that limit protected time for training. Secondly, responsive support mechanisms are needed to avoid disruption to workflow in safety-critical situations, including standardised routes for reporting faults, obtaining rapid troubleshooting, and providing feedback. This aligns with survey items emphasising timely response to user feedback and the value of dedicated clinical and technical teams to support implementation and ongoing support. Third, ongoing optimisation should be resourced through structured feedback loops, with visible clinical leadership and ward-based champions or superusers supporting sustained use, and with communication methods that remain current and allow for interactive troubleshooting rather than static dissemination alone.

Although our study does not quantify staffing ratios for digital teams, it does support specification of required support functions during implementation, including ward-facing support during deployment, timely helpdesk/technical response capability and clinical informatics leadership to ensure that decision-support remains usable, accountable and aligned with safeguarding and information governance requirements for minors and sensitive mental health information.

Conclusion

This multi-site case study identifies a set of generalisable determinants that shape feasibility of implementing digital decision-support approaches in acute hospital settings, including digital infrastructure, ICT training and support, communication processes, information governance arrangements and HCP attributes. In the context of CYP mental health crisis care in acute paediatrics, these determinants are amplified by the safety-critical and time-pressured nature of crisis admissions, the need for multi-professional coordination (including liaison psychiatry, safeguarding, security and patient flow), and the sensitivity of information governance for minors and mental health presentations. Collectively, our findings indicate that successful implementation requires alignment of digital readiness with clinical safety priorities, underpinned by sufficient devices and reliable connectivity, accessible and role-sensitive training and support, and clear feedback and governance pathways. These insights provide evidence to inform internal policy development, workforce preparation and resourcing strategies for integrating digital decision-support more seamlessly into acute paediatric pathways managing CYP in mental health crisis.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076261431890 - Supplemental material for Exploring barriers and enablers to implementing a digital mental health crisis risk mitigation pathway in acute paediatric care: A multi-site, exploratory mixed-methods study

Supplemental material, sj-docx-1-dhj-10.1177_20552076261431890 for Exploring barriers and enablers to implementing a digital mental health crisis risk mitigation pathway in acute paediatric care: A multi-site, exploratory mixed-methods study by Takawira C Marufu, Jane Coad, Zaki Albelbisi, Tim Carter, Sarah Bolton, Philip Breedon, Michael P Craven, Kate Frost, Anthony Harbottle, Julian Patel, Laura Rad, Peter White, Damian Wood, Aikaterina Kaltsa, Callum Stevenson, Pavan Landa and Joseph C Manning in DIGITAL HEALTH

Supplemental Material

sj-docx-2-dhj-10.1177_20552076261431890 - Supplemental material for Exploring barriers and enablers to implementing a digital mental health crisis risk mitigation pathway in acute paediatric care: A multi-site, exploratory mixed-methods study

Supplemental material, sj-docx-2-dhj-10.1177_20552076261431890 for Exploring barriers and enablers to implementing a digital mental health crisis risk mitigation pathway in acute paediatric care: A multi-site, exploratory mixed-methods study by Takawira C Marufu, Jane Coad, Zaki Albelbisi, Tim Carter, Sarah Bolton, Philip Breedon, Michael P Craven, Kate Frost, Anthony Harbottle, Julian Patel, Laura Rad, Peter White, Damian Wood, Aikaterina Kaltsa, Callum Stevenson, Pavan Landa and Joseph C Manning in DIGITAL HEALTH

Footnotes

ORCID iDs

Sarah Bolton

Michael P Craven

Joseph C Manning

Ethical approval

The study was reviewed and given a favourable opinion from the South Central – Hampshire A Research Ethics Committee (REC number: 22/SC/0237) and the West Midlands – Black Country Research Ethics Committee (REC number: 22/WM/0167).

Consent to participate

All participants provided written and/or verbal consent before taking part in the study.

Author contributions

Study conceptualisation and design: All authors; Development and drafting of the protocol: All authors; Gaining ethical approval: JCM, AK, ZA; Investigation: All authors; Formal analysis: JCM, ZA, TM, TC, JC; writing – original draft: TM, JCM; writing – review, editing and approval of the final version of the manuscript: All authors; Supervision: All authors; Project administration: JCM.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The ‘SAPhE Pathway’ Study: Co-creating a prototype digital risk mitigation pathway for Children and Young People admitted with mental health crisis to acute paediatric NHS care is funded by the NIHR [NIHR203880]. JCM is the Chief Investigator.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MPC is funded by NIHR MindTech MedTech Co-operative (Insititute of Mental Health, University of Nottingham). The views expressed are those of the authors and not necessarily those of the NHS, the National Institute of Health and Care Research (NIHR) or the Department of Health and Social Care, United Kingdom.

Guarantor

JCM

Supplemental material

Supplemental material for this article is available online.

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