The aim of the present study was to gain in-depth insight into an organizational and a financial implementation strategy for IPS by exploring the perceived facilitators and barriers among participating practitioners and decision makers in mental health care and vocational rehabilitation. Using a theoretical framework [24, 25], several perceived facilitators and barriers related to IPS, the implementation strategies and the socio-political context were identified. Important perceived facilitators were the key principles of the IPS model, regular meetings of stakeholders in mental health care and vocational rehabilitation, stakeholders’ experienced ownership of IPS and collaboration, the mandate and influence of the decision makers involved and secured IPS funding. Important perceived barriers included the experienced rigidity of the IPS model fidelity scale and lack of independent fidelity reviewers, the temporary and fragmented character of the secured funding, lack of communication between decision makers and practitioners and negative attitudes and beliefs among mental health clinicians. Changes in legislation were experienced as a facilitator as well as a barrier.
Comparison with other studies
In the literature on multifaceted implementation strategies, financial and organizational implementation activities are underrepresented [29]. Grimshaw et al. showed that most strategies focused on professionals involved [30]. An important reason for that may be that professional-directed implementation strategies are easier to realise in the study practice than financial or organizational strategies [29]. There is, however, some literature on facilitators and barriers to the implementation and sustainment of supported employment [10, 20, 31], and to components of multifaceted implementation strategies for supported employment [32, 33]. For example, two studies evaluating implementation [10] and sustainment [20] of supported employment found that important facilitators to IPS implementation and sustainment were strong personal commitments by program leaders [10] and leadership [20], in line with the facilitators found in the present study. Unlike the present study, these studies [10, 20] focused only on the experiences of MHA and IPS stakeholders and did not include stakeholders from different organizations.
Regular meetings of professionals comparable to the meetings in this implementation study were also found to be important in the study by Holwerda et al. [34]. Using questionnaires to assess the collaboration between professionals in mental health care and vocational rehabilitation to support employment of individuals with mental disorders, they also found that collaborating in a structural way was essential for developing an effective collaboration between the organizations involved [34].
Although the secured IPS funding (including pay for performance) as a strategy was experienced as a facilitator, it was not perceived as adequate, as the funding itself was still rather fragmented, and the agreements about the funding were only temporary. Previous studies also identified inadequate funding as an important barrier to IPS implementation and sustainment [10, 19, 20, 31]. Noel et al. concluded that, within the context of an active learning community, secured funding was an important facilitator to IPS sustainment [20]. This learning community promotes dissemination, implementation, sustainment and expansion of IPS [19, 20].
The finding of limited consensus about the added value of pay for performance in the present study was also reported by McGrew et al. [32], who found that although some participating professionals where satisfied with the funding, others raised concerns about increased financial risks, pressure to achieve job placements and possible pressures for adverse client selection.
Strengths and limitations
A strength of this study is that it is one of the first studies to assess the experiences with a multifaceted implementation strategy for IPS among stakeholders. Another strength is that all decision makers and practitioners involved in the first year of the collaboration between the different organizations were interviewed. This helped to achieve an accurate and complete understanding of perceived facilitators and barriers among these different stakeholders. Furthermore, the participants provided feedback on their interview summary, which improves the credibility and validity of the data. The credibility of the analysis is also increased by coding five interviews independently and developing the coding scheme by two researchers, and discussing the results in research team meetings with all authors.
The use of a theoretical framework [24, 25] to develop a topic list and guide the interviews and their analysis, is both a strength and a limitation of this study. It is a strength because using a framework based on prior research enables a structured analysis and might improve the validity of the data; it is also a limitation because the framework [24, 25] focuses on innovations within health care organizations. The innovation in this study, however, consisted of a multifaceted implementation strategy, mainly focusing on improving the IPS implementation by collaboration between different types of organizations and secured IPS funding.
A limitation of this study is the limited generalizability of the findings due to the small number of participants within this qualitative study focusing on the Dutch social security context. However, similar facilitators and barriers to the implementation of IPS have been reported in other countries with a different social security system [19, 20, 31, 35].
Implications for practice and research
Important barriers were the ignorance of decision makers regarding obstacles for MHA practitioners, and a lack of formal written information about the responsibilities and the roles of the different practitioners involved. These findings suggest that communication between decision makers and practitioners, and information transfer with regard to the innovation, can be improved and therefore need more attention in future implementation strategies in order to make IPS a success in practice.
The perceived barriers related to the IPS funding suggest that there is a need for one, sustainable funding for all clients based on proven cost-effectiveness of IPS. Consequently, future research should focus on evaluating the cost-effectiveness of IPS. In addition, the.
experienced rigidity of the IPS model fidelity scale and lack of independent fidelity reviewers were perceived as barriers to providing IPS services and may need further evaluation in the European context, considering the dependence of IPS funding on the IPS fidelity score. However, it appears to be important to continue IPS fidelity monitoring, since ongoing fidelity monitoring may promote long-term sustainability of IPS [15, 19, 31].
An important barrier was the lack of support experienced within the MHA, based on negative attitudes and beliefs among mental health clinicians. Fortunately, these negative attitudes and beliefs of clinicians are likely to change over time, as they come to better understand the relevance of employment on health for everyone [36]. This process may be accelerated by increasing clinicians’ involvement in the IPS trajectories and by presenting frequently examples of successful IPS candidates to them. However, not only were negative attitudes and beliefs among clinicians experienced as challenging for IPS implementation in the MHA by several MHA participants, the ongoing changes in laws and regulations regarding IPS funding and participation of people with SMI also seemed to complicate this process. It is therefore important to ensure ongoing support and continuity within all organizations involved, and to continue facilitating IPS specialists.