Table 5 Normalisation Process Theory mechanisms underlying each theme and subthemes

Patient engagement

- The patients’ understanding of the benefits of early intervention was an important for individuals to engage with the model.

- The active outreach and engagement work were valued by clinicians and were seen as important for patient coherence.

- Outreach, the engagement call, and emphasising the importance of early intervention enrols patients in FREED work.

- Engagement calls were easy to integrate but depends on the relation/interaction with patient and/or referrer.

- Rota system used in some teams to distribute engagement calls.

- Individual clinicians were engaged in appraisal work regarding the impact of FREED on motivation and engagement.

Patient complexity and comorbidities

- Difficulties determining suitability for FREED.

- Individual and collective work (i.e., thorough evaluation and team discussions) to determine and develop confidence in suitability.

Clinician

Hope and enthusiasm: Making sense of early intervention and FREED

- There was a high degree of individual and collective understanding of FREED and its value in FREED teams.

- The potential benefits of FREED to patients were core to how clinicians made sense of FREED.

- There was a high degree of personal alignment and internalisation of the objectives of FREED amongst clinicians.

- Assessing the evidence-base was a key mechanism in how clinicians attribute value to FREED.

- Comparison of FREED against standard illness prioritisation procedures built coherence towards the model.

- Key enthusiastic individuals drive FREED forward using a range of activities to create and maintain ‘buy-in’.

- Clinician and senior staff supporting the adoption of FREED was central to implementation and the distribution of resources.

- Appraisal of the evidence-base and the observed impact on patients and the team was used to evaluate the worth of FREED.

Conflicting feelings: Eligibility and concerns about non-FREED patients

- Individual and collective concerns regarding the impact on waiting lists and non-FREED patients were key barriers.

- Wider team did not always value all aspects of FREED (i.e., perceived as ‘privileged’ and ‘light’ work).

- Most clinicians perceived FREED as beneficial for all ages. Equally, the age eligibility criterion was understood as pragmatic and enabled tailoring to developmental stage.

- The value of FREED was perceived to extend beyond FREED patients.

- Some services adapted the eligibility criteria to align with their service and beliefs.

- Difficulties determining duration of an untreated eating disorder due to confidence/skills, and clarity of information from patient.

- Ongoing clinician appraisal of the broader impact of the model (i.e., impact on non-FREEDs, wider service).

- Clinicians re-configured the eligibility criteria and formally (data) and informally (personal experience) appraised the change.

Self-efficacy: Experience, stress, and resilience

- Greater experience in EDs increases the internalisation of FREED as important and needed.

- Individual skills and belief about skills and capacity to implement FREED impacted the implementation.

- Continued investment and engagement with FREED builds skills and confidence around the model over time.

- Individuals with pre-existing caseloads and many years in EDs are required to do more work to integrate FREED into their existing practice.

- Active support to manage stress/anxiety provides individuals with the resources to engage in FREED work.

- Ongoing appraisal regarding oneself and other’s ability to understand and use the model.

The Service Model

Flexibility and structure

- Structure enables clear understanding of the specific tasks and steps needed to implement FREED.

- An understanding of how FREED compares to standard practice was needed to adapt it to the local context.

- The flexibility around the model was valued.

- There was individual and collective work taking place to adapt FREED to ‘fit’ the local context (e.g., sharing the Champion responsibilities, ‘whole team’ approach to implementing FREED) – largely undertaken by senior staff and FREED Champion.

Champion as invaluable

- Champion as designated individual that drives FREED forward, creates, and maintains engagement, and enrols others in FREED work.

- Champion distributes and manages the work and resources needed to implement FREED.

- Champion supports ongoing training and skill development to enable clinicians to implement FREED (also relevant to the Practice and ongoing training subtheme).

- Insufficient capacity for Champion to complete all tasks. Sharing and delegating Champion tasks and responsibilities is often needed.

Meeting people where they are at: Care package and resources

- Tailoring treatment perceived as beneficial and valued.

- Some difficulties understanding how and when to integrate care package adaptations into standard treatment.

- Some unawareness of care package components (typically at outset and in wider team).

- Tailoring treatment and having resources available online engages clinicians and patients into FREED work.

- Work was required to adapt standard treatment to accommodate FREED adaptations.

- FREED-related materials (e.g., tracker template), prompts, reminders, and using different communication methods made FREED easier to integrate into work.

- The interaction between the patient’s life stage and adaptations can make the adaptations easy (e.g., relevance) and difficult (e.g., family involvement for students) to use.

Implementation Strategy

Practical and ongoing training

- Training and its continuation as key to developing individual and collective understanding of FREED and its benefits.

- Training supports initiation and legitimisation of FREED.

- Sufficient training was undertaken to develop the skills to implement FREED, but more and ongoing training was desired. FREED Champion was key for ongoing training and skill development in teams.

Being part of something bigger: The FREED Network

- Network enabled teams to work together to make sense of FREED and its implementation.

- Wider investment and interest lead to greater internalisation of the importance of FREED.

- Conferences as key medium to share information and “take FREED off the pedestal”.

- Network and data feedback create a broad community of practice that legitimises and maintains engagement.

- Implementation supervision and ongoing evaluation contribute towards accountability and confidence in using the model.

- Data collection work shared with/delegated to assistant psychologists, support workers, and administrators.

- Formal and informal appraisal during implementation supervision and data feedback to evaluate whether FREED and its components are working and worthwhile.

Service

Capacity and competing demands

- Concerns regarding capacity at the outset and over time can impact value attributed to FREED.

- Champion, mini team, and Network identified as important for maintaining momentum and engagement amongst competing demands.

- Insufficient resources allocated to implement FREED in some but not all teams.

- Individually and collectively adapting mental and material resources to address capacity issues.

- Ongoing individual and communal appraisal around capacity and the re-configuration of FREED and treatment as usual as capacity fluctuates.

Compatibility and integration

- Developing an understanding of how FREED differs from standard practice was done to allow for integration work.

- At the outset, FREED was sometimes perceived as “special” and very different from standard practice, which was a barrier, but this changed over time as it became integrated.

- Integration and protected time supported the enrolment, legitimisation, and sustainability of FREED.

- Compatibility with the existing service and clinician values and practice was a facilitator.

- Relational and contextual integration through integrating into service processes and procedures, culture, and resources (e.g., protected Champion time and meetings).

- Limited integration with wider team can disrupt working relations and FREED.

- Carefully balancing and integrating FREED and non-FREED work was important.

- Dedicated FREED huddles and integrating FREED into discussion in general meetings was used to appraise FREED work.

- Clinicians appraised and re-configured to overcome integrational barriers.

An open dialogue: Sharing and involvement

- Involvement and an open dialogue allowed teams to work together to develop a shared understanding of the model, its benefits, and to address concerns.

- Active involvement and creating an open dialogue initiate and enrol clinicians in FREED work.

- Mini team enables ongoing engagement and maintenance of the model.

- Subtheme included the interactional work people do around FREED to develop accountability and confidence in the model.

- Allocated time in meetings to enable interactional work to take place.

- FREED work distributed amongst the entire team or mini team.

- FREED can disrupt working relations/create a divide in the service.

- Communal appraisal of the functioning, and problems around FREED was an important facilitator.

- Re-configuring the structure of FREED, i.e., mini vs. whole team approach, following appraisal and then appraising the value of this re-configuration.

Wider System

Broader system care

- A wider shared understanding (e.g., public, healthcare services) of EDs and FREED is needed for early identification but was not always present.

- Understanding of outreach work as a core responsibility in early intervention and a valued part of FREED.

- Identification and enrolment of referrers at the outset is needed to ensure successful implementation.

- Funding/resources needs to be obtained quickly from the broader system (e.g., commissioners) to enable implementation.

- Relational work with educational institutions and referrers was taking place to ensure early identification and appropriate referrals.

- Clinicians engaged in appraisal work regarding the referral pathways and processes into the service to ensure the earliest identification.

Coronavirus diseases 2019 (COVID-19)

- FREED still perceived as important; however, less important relative to pressing COVID-19 demands.

- COVID-19 disrupted interactional and relational work. Clinicians and patients required to re-establish relations and implement FREED in the context of COVID-19.

- Clinicians worked to re-operationalise and maintain FREED in altered circumstances (e.g., virtual appointments).

- Clinicians were routinely engaged in informal appraisal of the positive and negative impacts of virtual working.