Implementation of individual placement and support (IPS) into community forensic mental health settings: Lessons learned

Abstract

Introduction

Assessment of the effectiveness of individual placement and support in forensic mental health settings is a relatively new field of research despite evidence demonstrating its effectiveness in generic mental health settings.

Method

IPS was implemented into a community forensic mental health setting within a large National Health Service trust in the United Kingdom over 6 months. Using the Consolidated Framework for Implementation Research this paper describes the lessons learned from implementing individual placement and support into such settings.

Results

Our findings suggest that implementation of individual placement and support in forensic mental health settings is complex and requires robust planning and collaboration with internal and external agencies. Barriers to implementation included staff attitudes, difficulty engaging employers and lack of employment related performance indicators, and facilitators included the support of service managers and outside groups. Adaptations to the IPS model were made to address challenges encountered, including difficulty starting rapid job searches, concerns about stigma, lack of confidence, uncertainty around employment opportunities, offence restrictions and lack of interest from potential employers.

Conclusion

This paper adds to the limited literature in the field. Findings are relevant to practitioners and service providers who wish to implement individual placement and support services for people with mental disorder and offending histories.

Keywords

Individual placement and support implementation employment offenders forensic mental health reoffending

Introduction

Literature view

Mental disorder is highly prevalent in the general population, and 1 in 5 people who are of working age in the United Kingdom (UK) have a mental health problem (Department for Work and Pensions, 2016). Evidence exists for higher rates of mental disorder and unemployment among offenders than in the general population (Centre for Mental Health, 2010; Singleton et al., 1999) and nearly 60% of people released from prison re-offend within 3 years of their release (Pager, 2003). Employment is widely recognised as a tool to aid mental health recovery and has also been shown to reduce the likelihood of reoffending (Ministry of Justice, 2013). Individual placement and support (IPS) is a well-established form of supported employment which has proved effective in helping people with severe mental disorders find employment (Kinoshita et al., 2013; Marshall et al., 2014). Despite our knowledge about its positive impact on those with mental disorders and our understanding of how employment can reduce levels of reoffending, very little research has considered how effective IPS may be for individuals with severe mental disorder and offending histories (Sneed et al., 2006).

A fundamental prerequisite to IPS research is appropriate implementation (Khalifa et al., 2016). This entails embedding the IPS model in the services in which IPS is provided by bringing employment specialists into clinical teams, raising awareness about IPS within the organisation and developing links with employers. Fidelity reviews are conducted to assess the extent to which the service follows the eight principles of IPS and how well the employment specialist functions within the service (Bond et al., 2012). These principles include, for instance, small caseloads for employment specialists, rapid job search and prioritising client job preferences. Evidence suggests that high-fidelity programmes have greater effectiveness than low fidelity programmes with regard to employment outcomes (Lockett et al., 2016), indicating that the importance of robust IPS implementation is paramount.

Implementation science has a lot to offer mental health services and can help translate research findings into practice (Fixsen et al., 2005). It has been used as a broad framework to guide the implementation of IPS into mental health services (Rinaldi et al., 2010). Evaluations of IPS often use the 25 domain IPS Fidelity Scale (Becker et al., 2008), or descriptive, case study like approaches using observational monitoring and interviews to evaluate the barriers and facilitators to IPS and supported employment implementation (e.g. Fioritti et al., 2014; Giesen et al., 2007; Schneider and Akhtar, 2012; Van Veggel et al., 2015). A notable exception is a study by Bergmarka et al. (2016) which described the barriers and facilitators to implementation, according to constructs described in the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009). Descriptive evaluations lack a framework driven approach, limiting the reproducibility and comparisons that can be made across studies. Whilst papers using the fidelity criteria provide a framework from which comparisons across studies can be made far more easily by providing scores demonstrating high or low fidelity, the nature of the IPS fidelity scale means that adaptations to the model, which in complex public health settings are often needed (Samele et al., 2018), are viewed negatively and discouraged by some authors (e.g. Perez et al., 2016).

However, other authors (e.g. Bopp et al., 2013; Durlak and DuPre, 2008) have acknowledged the complimentary roles of implementation and adaptation in health promotion programmes. For instance, Bopp et al. (2013) conceptualised tensions between fidelity to the original plan and adaptation for the setting and population within a “program life cycle” framework that included nonlinear but complimentary stages: development, adoption, implementation, maintenance, sustainability or termination, and dissemination or diffusion. Further, a systematic review by Durlak and DuPre (2008) that assessed the impact of implementation on programme outcomes underscored the importance of adaptation and offered further evidence that expecting perfect or near-perfect implementation is unrealistic.

In this study, we use the CFIR approach to describe the process of IPS implementation and barriers and facilitators to IPS implementation in community forensic mental health settings. The CFIR is comprised of five major domains: characteristics of the intervention, inner setting, outer setting, individuals involved and implementation process (also see Table 2). The rationale for using the CFIR is twofold. First, it has unified and consolidated common constructs found in published implementation research, enabling researchers to evaluate the implementation of interventions in a consistent and standardised way (Damschroder et al., 2009). Second, it enables researchers to examine implementation factors beyond IPS fidelity since IPS fidelity, whilst important, explains only part of the variance in programme outcomes (Lockett et al., 2016).

Study aims

Many papers using the CFIR in their evaluation of implementation have used it to drive interviews or analyse outcome data (Breimaier et al., 2015; Varsi et al., 2015). The current paper, however, aims to use it to guide a description of IPS implementation based on observations, spanning 6 months in community forensic mental health settings. Additionally, it aims to provide a comprehensive description of the lessons learned, including barriers, facilitators and potential adaptions to IPS implementation. The key research question this study aimed to address is ‘What are the lessons learned from IPS implementation in community forensic mental health settings?’

Method

Study design

The current study was conducted as part of a wider study which aimed to assess the feasibility of conducting a full trial to evaluate the efficacy of IPS in improving employment rates and psychosocial outcomes for patients with offending histories (Khalifa et al., 2016) using three major strands as follows.

A: Implementation of IPS in community forensic services. The specific objective of this strand was to embed the IPS model in the community forensic services by bringing an employment specialist into clinical teams, raising awareness about IPS within the organisation and forming links with local IPS services, developing links with employers, as well as IPS fidelity reviews

B: Feasibility cluster randomised controlled trial (RCT): The specific objectives of this strand were to estimate the parameters required to design a full RCT in order to benchmark potential effect sizes and enable sample size calculations. Clusters were defined according to clinical services in the community forensic services of Nottinghamshire Healthcare National Health Service (NHS) Foundation Trust as follows:

Cluster 1: Nottingham City Community Forensic Service.

Cluster 2: Nottinghamshire County Community Forensic Service.

Cluster 3: The Personality Disorder Service in Nottingham.

Cluster 4: The Personality Disorder Service in Mansfield.

Clusters 1 and 4 were assigned to the intervention (IPS + treatment as usual), and clusters 2 and 3 to the control group (treatment as usual). At the start of the study in 2014, of the 250 patients who were on the caseloads of the Nottinghamshire Community forensic services, 200 (80%) were unemployed, indicating that there was a stock of people who could potentially be enabled to fulfil their employment aspirations as a part of their recovery. Adults (females and males) aged 18 years or over who were on the caseload of the community forensic services were eligible to participate. Those who were unable to provide informed consent, not eligible to work in the UK, currently in open employment or who did not wish to work were excluded.

The primary outcome was the proportion of people in open employment at 12 month follow-up. Open employment is defined as having a job paying at least the minimum wage in a mainstream setting. The secondary outcomes were employment and educational activities, e.g. hours in paid work or education; Brief Psychiatric Rating Scale (Overall and Gorham, 1998); Rosenberg's Self Esteem Scale (Rosenberg, 1965); Client Service Receipt Inventory (Beecham and Knapp, 2001); health related quality of life using SF-12v2 (Ware et al., 2002) and EQ-5D-3L (EuroQol Group, 1990); Social Functioning Questionnaire (Tyrer et al., 2005); and re-offending.

C: Process evaluation: This strand involved conducting qualitative interviews with staff and patients to assess their general views of IPS, benefits from participating, disadvantages from or dislikes about participating and barriers and facilitators to implementation.

Sample and settings

The current study reports findings from the first strand – IPS implementation. It aims to describe the process of implementation in clusters 1 and 4 as well as the barriers and facilitators to IPS implementation.

Project team and procedure

No specialist employment support was available to patients in the services prior to this project commencing. The project team responsible for implementation included the Principal Investigator, Research Assistant, IPS Worker, IPS Supervisor and Service Manager, as well as an external facilitator who was an expert in IPS. The project team introduced the two forensic services to the IPS service, guided by IPS fidelity reviews conducted at the start and end of the implementation period. The IPS team produced a number of documents for staff throughout implementation (including IPS information leaflets for both employers and patients) in order to give them information about the study. The IPS team completed a pilot trial, where the IPS service was offered to five patients prior to full service roll out and research recruitment. An IPS Steering group, comprising of the project team, service managers, representatives from the service user reference group and a representative from the Department for Work and Pensions (DWP), was established to oversee the implementation process including actions plans arising from the fidelity reviews.

Data collection and analytic strategy

The CFIR (see Table 2) was used as an overarching framework to guide implementation, utilising data from observations recorded over the 6 month implementation period and IPS fidelity reviews.

Observations were recorded systematically using a data recording log, based on the constructs found in the CFIR. Information relating to activities attended, IPS service referral pathways, identification of study participants and organisational and individual level barriers and facilitators to implementation was recorded. The observations were discussed regularly at the IPS steering group meetings and, where applicable, action plans were developed to ensure a timely implementation of the IPS service.

IPS fidelity reviews, conducted using the UK version of the IPS fidelity scale (Becker et al., 2008), were completed following the start and end of the implementation period to assess how closely the IPS service adhered to the principles of IPS. The scale is divided into three sections; staffing, organisation and services. Each item is rated on a five-point scale (1 = no implementation, 5 = full implementation) with intermediate numbers representing progressively greater degrees of implementation: 115–125 = exemplary fidelity; 100–114 = good fidelity; 74–99 = fair fidelity; 73 and below = not supported employment.

Findings from the IPS fidelity reviews were used to inform the implementation process by devising dedicated action plans to address the key recommendations. The observational data were analysed using a directed approach to content analysis (Hsieh and Shannon, 2005) based on implementation constructs found in the CFIR. Initially, data were analysed to identify key variables as coding categories. Then the operational definitions for each category were defined using the CFIR.

Research ethics

The study was approved for conduct by a local research ethics committee and the Research and Innovations Department of the NHS trust. Written informed consent was obtained from all research participants. The ethical challenges of research involving patients with offending histories include those associated with obtaining consent, attrition at follow up and a reputational risk linked to a participant committing an offence in the work place. Appropriate governance arrangements were in place to ensure that the rights of the participants were fully considered and protected.

Results

IPS fidelity

Table 1 summarises scores on the IPS fidelity scale at baseline (total = 61) and at the end of the implementation period (total = 85). At the start of the study, the total IPS fidelity score was below the threshold of what would constitute supported employment. A fair level of fidelity was attained at the end of the implementation period. It is notable that several items could not be scored due to lack of a sufficient number of referrals at that stage.

Table 1.

Individual placement and support (IPS) Fidelity Scale scores.

	Element	Baseline Fidelity Review score	Second Fidelity Review score	Change in score
Staffing
1	Number on caseload	5	5	0
2	Employment Services staff	5	5	0
3	Vocational generalists	5	5	0
Organisation
4	Integration with CMHT through team assignment	5	5	0
5	Integration with CMHT through frequent contact	4	5	+1
6	Collaboration between employment specialists and Job Centre Plus	2	5	+3
7	Vocational unit	5	5	0
8	Role of employment supervisor	4	4	0
9	Zero exclusion criteria	3	3	0
10	Mental Health Agency focus on competitive employment	4	4	0
11	Executive team support	4	4	0
Services
12	Work incentives planning	5	5	0
13	Disclosure	5	5	0
14	Ongoing, work-based vocational assessment	5	5	0
15	Rapid search for competitive job	0	4	+4
16	Individualised job search	0	4	+4
17	Job development – frequent employer contact	0	5	+5
18	Job development – quality of employer contacts	0	4	+4
19	Diversity of job types	0	0	0*
20	Diversity of employers	0	0	0*
21	Competitive jobs	0	0	0*
22	Individualised follow-along supports	0	0	0*
23	Time-unlimited follow-along supports	0	0	0*
24	Community-based services	0	0	0*
25	Assertive engagement and outreach by integrated team	0	3	+3
	Total score	61	85	+24
	Maximum IPS score	125

CMHT: Community Mental Health Team *Not assessed due to lack of sufficient referrals at that stage.

Table 2.

Consolidated Framework for Implementation Research (CFIR) implementation framework (Damschroder et al., 2009).

Domains	Items	Key findings
Characteristics of the intervention	• Intervention source • Evidence strength and quality • Relative advantage • Adaptability • Triability • Complexity • Design quality • Cost	The IPS service was internally developed and introduced. IPS implementation has proven feasible in the UK, but UK studies have shown less favourable employment outcomes than those conducted in USA. Challenges of implementing IPS into forensic services included: Changing staff culture takes time; differences in service function across clusters impeded efforts to embed IPS worker; managing job expectations of patients with limited work experience, rapid job search adversely affected by lack of work experience; concerns about stigma discouraged patients from disclosure of information about their mental health/forensic history to potential employers. Distributing high quality publicity materials aided implementation. Staff received motivational interviewing training, this can often be critical in engaging individuals with offending histories. Costs included costs of posts, service support, treatment, fidelity reviews, patient and public involvement and others.
Inner setting	• Structural characteristics • Networks and communication • Culture • Implementation climate	Implementation required collaboration between several organisations. Several fora were used during implementation to bring professionals together and increase the support available to the project. IPS worker secured links with the existing IPS service within the trust. It took time for staff to embrace IPS and ‘research’ can have daunting connotations for NHS staff. Some clinicians perceived IPS as clinically inferior to other interventions though team managers continued to support the project which was crucial to embedding IPS.
Outer setting	• Patient needs and resources • Cosmopolitanism • Peer pressure • External policies and incentives	Lack of funding for additional patient employment support costs, such as DBS checks, CSCS cards, uniforms and travel to interviews acted as barriers to employment. The project made key links with several external organisations such as DWP, the Probation Service and employers. Networking challenges: often hard to engage employers, vacancies for larger business are often listed online, limiting opportunity to establish a good relationship with employers, preventing a discussion about mental health and offending and the suitability of the patient. Supported employment is enshrined in government initiatives, but lack of performance related indicators attached to supported employment meant there was no incentive for senior staff to promote employment. Nonetheless, the project was embraced enthusiastically by professionals who particularly valued the role of employment.
Individuals involved	• Knowledge and beliefs about the intervention • Self-efficacy • Individual stage of change • Individual identification with the organisation • Other personal attributes	Lack of clarity among staff as to what value a dedicated IPS service would bring. Concerns that IPS would add a layer of complexity to therapeutic interventions. Staff felt they lacked capacity or skills to prioritise employment. Barriers facing patients with offending histories included: lack of relevant experience, skills and qualifications, or confidence; uncertainty around employment opportunities; offence restrictions and stigma; discrimination; and lack of interest from potential employers.
Implementation process	• Planning • Engaging • Executing • Reflecting and evaluating	A significant amount of advance preparation and planning went into implementing IPS, in terms of engaging senior managers, clinicians and patient groups, distributing publicity material materials, networking and establishing links with employers. It was not possible to co-locate the IPS worker within one cluster (therapy only service) due to lack of a permanent base. Feasibility of IPS service was tested using a pilot group of 5 patients. Service managers played an active role in engaging staff members. The project benefitted from the expertise of an IPS expert whose guidance was invaluable. Fidelity reviews were conducted at the start and end of implementation period. RMG, SURG and IPS Steering Group provided oversight to IPS implementation. The project team and staff felt that implementation was successful and success stories of recruited patients were shared during weekly team meetings.

IPS: Individual placement and support; CSCS: Construction Skills Certification Scheme: DBS: Disclosure and Barring Scheme; DWP: Department of Work and Pensions; RMG: Research Management Group; SURG: Service User Reference Group.

Observational data

Table 2 summarises findings from the observational data, based on the CFIR implementation framework. In this section, we present the findings under two main headings in accordance with the aims of the study.

IPS implementation process

The IPS service was internally developed within the NHS trust and introduced by stakeholders well known to the community forensic services. The project involved collaboration between the trust and several other organisations including three universities (Nottingham, Leicester, Southampton), the probation service and an Expert by Experience Advisory Panel (EEAP), as well as an external facilitator who was an expert in IPS. This collaborative approach brought together diverse though complimentary experiences that acted as a major facilitator to IPS implementation.

Prior to the commencement of the study, there was no specific provision for supported employment within the community forensic services. A significant amount of advance preparation and planning went into developing and implementing IPS. A study protocol detailing the background of the project, aims and objectives, methods and design and study management along with accompanying study documents were drawn up. These were essential for supporting and guiding the research team throughout implementation. An IPS steering group was established to oversee the implementation process and to ensure that IPS was kept on the clinical agenda and that key stakeholders were informed of new practice. Discussions throughout implementation ensured the research team had real time feedback to ensure the services were being provided in an effective manner.

The IPS worker was collocated within the city community forensic service, enabling her to attend regular clinical meetings and share patient information with clinical staff, including information about risk. It was not possible to collocate the IPS worker within the county Personality Disorder (PD) service or attend as many staff meetings there due to lack of a permanent base, and this impeded effective communication between the IPS worker and clinicians there.

A large proportion of implementation was also spent putting together the correct tools for implementing the service and understanding the patient groups, which meant less time could be allocated to engaging staff fully, making links with employers and accepting pilot participants. Several fora were used during implementation to bring professionals together and increase the support available to the project.

Detailed recruitment flowcharts were adapted throughout implementation from feedback received from clinicians, patients and service managers. Additionally, the IPS team produced information leaflets for staff, employers and patients to give them information about the study, its goals and what participation entailed. To further promote the service, advertisements were made in the trust's magazine and forensic staff bulletins to announce the start of the study and successes during the trial. Posters and leaflets were also distributed to staff. A minimum of two working days per week was allocated to employer engagement; establishing relationships, networking, identifying those businesses willing to hire individuals with mental illness and offending histories and searching for current vacancies.

A financial reward was available to the forensic services as payment for screening participants prior to trial recruitment starting. This money was subsequently used to pay for a motivational interviewing training course, recommended by the IPS expert during the second fidelity review.

In order to test the intervention on a small scale, a pilot group of five patients received the IPS service. The pilot work enabled the IPS worker to familiarise herself with her role and begin contacting employers and gave clinicians the opportunity to use the referral process.

Barriers and facilitators to IPS implementation

Time constraint was a major barrier to IPS implementation. Initially the proposed duration of implementation was 12 months. However, this was reduced to 6 months following the advice of the study funders, due to concerns that this was disproportionality long. As such, the time allocated to implementation was significantly shorter than needed, and this proved challenging since changing staff culture takes time. Staff must feel knowledgeable, invested and at ease with procedures set out during implementation and as with any new treatment intervention, it can take a while for people to embrace the concept of the intervention.

The word ‘research’ can sometimes have daunting connotations for NHS staff. Whilst there was provision for social inclusion within the community forensic services, some clinicians were unclear as to what added value (or relative advantage) a dedicated IPS service would have, and raised concerns that this would add a layer of complexity to therapeutic interventions, thereby distracting attention away from the core clinical business. Some clinicians in the PD service cluster also felt that therapy should take priority over IPS services, to help keep patients focused on recovery, ignoring that employment is a key component of recovery (Van Stolk, 2014). Further, as there were no performance related indicators attached to supported employment within the trust, there was no incentive for senior managers to promote supported employment among staff and patient groups. Nevertheless, the project was embraced enthusiastically by the service managers and those professional groups who valued employment.

During implementation, it was clear that staff often perceived a divide between ‘researchers’ and front line staff delivering services. It was important that the research team were transparent with staff about what support would be needed from them. Whilst most clinicians recognised the role that employment could play in improving patient outcomes, they raised concerns that given the current economic climate where the NHS is facing serious challenges with financial cuts and staff were spread thinly, they often had no capacity or skills to prioritise employment. Some clinicians perceived IPS as clinically inferior to other interventions e.g. pharmacological and psychological approaches. In response to these concerns, all clinicians were given core information about IPS, details of its success in mental health settings and the goals of the current project. The commitment and involvement of the service managers enabled concerns to be highlighted and responded to appropriately.

The study team adhered to the eight core IPS principles since making full adaptations to the IPS model itself was beyond the scope of this study. They were mindful however that implementing IPS in a community forensic setting could be challenging and as such some adaptations were made as follows.

By virtue of the study being exclusively for patients with offending histories, a number of patients in the PD network, who did not have offending histories, were excluded.

Finding competitive employment for patients was always the primary goal for the IPS worker. However, it soon became apparent that volunteering and educational opportunities must be considered, at least initially, for some patients due to their lack of recent work experience and work skills. On many occasions the IPS worker had to manage the job expectations of patients who had aspirations of obtaining professional jobs for which they lacked work experience or suitable qualifications. Given this population's lack of ICT (information and communications technology), numeracy and literacy skills and often, lack of any employment related skills, the rapid job search principle was affected by the need to spend more time on pre-employment actions such as volunteering and educational activities.

Most patients also lacked the confidence that they could gain employment. Based on patients' perception that many employers attribute stigma to offending behaviour and mental health problems, all the pilot patients chose to withhold information about their mental health/forensic history to potential employers. This prevented the IPS worker from offering support to employers and meant that she was unable to aid in the discussion of in-work support or reasonable adjustments.

Some of the challenges related to differences in service function across clusters: the city community forensic service provided case management to patients whilst the county PD service provided therapy only. The latter cluster presented a complex challenge for the research team. For instance, contact between patients and staff only occurred during group therapy and staff felt this wouldn't be an appropriate time to promote IPS, as only eligible patients could be approached and this may create in-group tensions. PD service patients were not allocated a care co-ordinator and as such did not have someone who took responsibility for organising and monitoring their care. As such, considerations were given to establishing support for the IPS worker in the event of any patient crisis or difficulties, for the safety of the patient and the IPS worker, particularly as the IPS worker had no experience with PD patients.

From the outset of implementation, the research team were aware of the barriers facing patients with offending histories. These included a lack of relevant experience, skills and qualifications, lack of confidence, uncertainty around employment aspirations and opportunities, offence restrictions and stigma, discrimination and lack of interest from the community and potential employers. To overcome these barriers, the IPS worker dedicated a significant amount of time to employer engagement, priority was given to face-to-face meetings but phone communication and leaflets that promoted IPS were also used.

However, employer engagement was fraught with difficulties. Firstly, it was often hard to engage employers, especially if the IPS worker did not have a specific patient to promote. Even when successfully engaged, an employer's motivation to hire an individual dwindled when the IPS worker was unable to offer anyone who was suitable or who had that job as a preference. Secondly, vacancies for larger business were often listed online, thereby limiting the IPS worker's opportunity to establish a good face-to-face relationship with employers and preventing a discussion about mental health and offending and the suitability of the patient. Lack of funding for additional patient employment support costs, such as Disclosure and Barring Service (DBS) checks, Construction Skills Certification Scheme (CSCS) cards, uniforms and travel to interviews acted as additional barriers.

Discussion

While IPS implementation has proven feasible in the UK, including the NHS trust in which the current study was conducted (e.g. Schneider et al., 2016), studies conducted in the UK have shown less favourable outcomes compared with those conducted in the USA (Heffernan and Pilkington, 2011; Marshall et al., 2014). This disparity in outcomes has been attributed to differences in economic climates and health and welfare systems between the two continents (Burns et al., 2007; Van Veggel et al., 2015). It has also been attributed to the scale of IPS implementation which is often small when IPS is implemented as part of a clinical trial (Van Veggel et al., 2015) such as this study.

Implementation research aims to understand what works in the real world, seeking to discover what factors may influence implementation and has identified a number of key resources essential to successful implementation including, decision making guided by knowledge and informing key stakeholders about the intervention (Eccles and Mittman, 2006; Peters et al., 2013). A number of studies have used the CFIR as a tool to evaluative implementation, serving as guidance to gather information about barriers and facilitators to implementation and facilitate cross cluster comparisons (Breimaier et al., 2015; Damschroder and Lowery, 2013; Varsi et al., 2015). Our study provides further insights into the process of IPS implementation in community forensic mental health settings, using the CFIR as a tool on which to base a descriptive analysis of IPS implementation.

The implementation process is a major domain within the CFIR. Our findings suggest that implementing IPS in forensic mental health settings is complex and requires robust planning and preparation as well as effective collaborations involving internal and external agencies. The strength of these collaborations acts as a major facilitator to IPS implementation. While there is limited evidence from which to compare the implementation of IPS within forensic mental health services in the UK, the facilitators and barriers to IPS implementation that our study identified are not unique to forensic settings. In the mental health literature, common barriers include staff attitudes and an embedded culture of low expectations about the employment goals of patients and common facilitators include the support of outside groups, the provision of clear guidance and information about IPS to staff and service champions, (Rinaldi et al., 2010; Schneider and Akhtar, 2012).

The development of IPS specifically for individuals with offending histories is an adaptation suggested by some authors (e.g. Bond et al., 2015). Our findings underscore the complimentary roles of implementation and adaptation (Bopp et al., 2013; Durlak and DuPre, 2008). Adaptations to the IPS model need to take into consideration some of the challenges encountered in this study, including difficulty starting rapid job searches due to lack of work experience; concerns about stigma which discouraged patients from disclosure of information about their mental health/forensic history to employers, lack of confidence, uncertainty around employment opportunities, offence restrictions and lack of interest from potential employers. Additionally, lack of funding for additional patient employment support costs, such as DBS checks, CSCS cards, uniforms and travel to interviews is worthy of consideration.

Research in the USA (e.g. Bond et al., 2015) suggests that implementation of IPS for those who have mental illness and involvement with the criminal justice system produces modest outcomes but that with adjustments, including the use of motivational interviewing, it could produce similar employment outcomes to those reported within the mental health literature. Another UK-based project recently undertook a three-year pilot with the aim being to develop an IPS programme for offenders with mental health problems (Samele et al., 2018). Difficulties implementing this service meant that the team introduced a more flexible service which they named ‘Employment and Social Inclusion’. A number of similarities can be found between this study and our own. Samele et al. (2018) also suggest the key to implementing a supported employment programme within forensic services is flexibility, a willingness to consider alternative focuses such as volunteering and education as opposed to a sole focus on competitive employment and a well organised programme which gives staff clearly defined roles. Lack of funding for additional employment support costs, such as DBS checks, CSCS cards, uniforms and travel to interviews acted as barriers to employment.

Within the inner and outer domains of the CFIR, our findings underscore the importance of enlisting the support of senior managers. While supported employment is enshrined in government initiatives (e.g. Joint Commissioning Panel for Mental Health, 2013 Mental Health Taskforce, 2016; NHS England, 2016a, 2016b), lack of performance related indicators attached to supported employment meant there was no incentive for staff to promote employment. Therefore, the importance of engaging senior managers is paramount. Further, establishing links with other organisations such as the DWP, the probation service and patient groups proved invaluable. However, it was often hard to engage employers and vacancies for larger business were often listed online, limiting opportunity to establish a good relationship with employers, preventing a discussion about mental health and offending and the suitability of the patient.

There are a number of key points readers should take from this paper:

Consideration should be given to allocating time building collaboration with internal and external agencies.

Preparation and planning is essential but more time is needed to implement IPS into forensic services, particularly to allow for IPS and employment goals to become embedded in staff and patient culture.

IPS principles may need to be adapted and made more flexible for a forensic client group. Whilst IPS principles should be used as a guide, with competitive employment always the end goal, alternative focuses, such as education and volunteering may be more feasible and more time may have to be allocated to pre-employment actions for some individuals.

Support from individuals such as team leaders and managers with a formal influence on the organisation and staff are essential for driving the intervention through.

IPS is inherently difficult to implement in some therapy based services and the process of implementation very different from that in traditional case management services.

Publicity materials provide staff with knowledge of IPS and give encouragement and guidance during implementation and beyond but these materials must be distributed periodically and supported by face to face discussions.

Motivational interview training should be considered prior to implementation as techniques like this can often be critical in engaging individuals with offending histories.

Lack of funding for additional patient employment support costs can prove challenging. Future studies should consider including additional costs when applying for funding to allow for such support to be given if needed.

Conclusion

This paper describes the lessons learned from the implementation of IPS within community forensic mental health settings over a period of 6 month, prior to a feasibility RCT. It is hoped that this paper will provide commissioners, professionals groups and other interested parties with an understanding of how IPS could be implemented and potentially adapted to forensic mental health settings elsewhere. It provides insights into the potential barriers and facilitators to implementing IPS with a forensic mental health services. The findings of this study are particularly of relevance to a key recommendation by the College of Occupational Therapists' practice guideline which stipulates that ‘occupational therapists consider supported employment or prevocational training as part of occupation-based intervention opportunities for patients' (College of Occupational Therapists, 2012). Our findings also highlight the importance of including employment or return to work within health services' performance indicators. The Organisation for Economic Co-operation and Development (OECD) policy document Fit Mind, Fit Job: From Evidence to Practice in Mental Health and Work (OECD, 2015), provides the impetus for introducing such indicators, for instance, through the provision of integrated employment and mental health services such as IPS.

Study limitations are numerous including that IPS was implemented on a small scale as part of a clinical trial. The implementation period was relatively short and some of the challenges described above meant that only a fair degree of fidelity was attained.

Future studies should consider implementing IPS on a larger scale using multiple forensic mental health sites to form a better understanding of the barriers and facilitators that are specific to implementing IPS in these settings. They should also give due consideration to the fact that in addition to facing widespread stigma and discrimination among employers and members of the public, patients with offending histories face other personal and social barriers, including substance misuse and lack of relevant skills and qualifications

(Baron et al., 2013; Centre for Mental Health, 2010) making it difficult for them to secure employment.

Key findings

It takes time to change staff culture and imbed IPS into forensic mental health services.

IPS is inherently difficult to implement into forensic settings.

IPS core principles may need to be adapted to suit forensic populations

What the study has added

This paper provides a detailed explanation of the barriers and facilitators to implementing IPS into forensic mental health setting and the adaptations that may be needed to do this successfully.

Footnotes

Acknowledgements

The authors thank Erick Wodke for his expert advice in relation to IPS implementation; Peter Bates (Patient and Public Involvement lead) and members of the Expert by Experience Advisory Panel, Julie, Andrew, Alan and John for their invaluable advice; and Dr Louise Thompson for her expert advice. The views expressed are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research or the Department of Health.

Research ethics

The study was approved for conduct by a local research ethics committee (Reference: 15/EM/0253 – 1 July 2015) and the Research and Innovations Department of Nottinghamshire Healthcare NHS Foundation Trust. All research participants provided written informed consent.

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.

Funding

This work was supported by the National Institute for Health Research under its Research for Patient Benefit (RfPB) Programme (grant number PB-PG-1013-32093).

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