University students' access to mental health services: A qualitative study of the experiences of health service professionals through the lens of candidacy in England.

OBJECTIVES: In order to develop a better understanding of students' access to mental health services, we explored the experiences of health care professionals interacting with university students with mental health problems. METHODS: We interviewed 23 professionals working across university advice and counselling services, NHS general practice, crisis, and psychological services in North and East London between June 2022 and January 2023. Our approach drew on reflexive thematic analysis and the principles of abductive analysis. The notion of candidacy - that is, how different needs are deemed deserving of health service attention - was particularly helpful to our understanding of the ongoing phenomenon of interest in the data. RESULTS: Each student's access to mental health support was highly contingent on the student's dynamic social context and the pressures and organisation of the local health system. Professionals described how different students viewed different needs as deserving of health service attention. Which students reached the professional's service depended on the resources and relationships a student could draw upon, and the service's relative permeability. Once there, what action professionals took was strongly influenced by the professional's service expertise, resource constraints, the relationships the professional's service had with other organisations, the students' wishes, and whether students regarded treatment offers as acceptable. CONCLUSIONS: Candidacy offers a useful lens to view university students' access to mental health support. Access appears to be an increasingly intricate task for students, given the fragmented service landscape, surging demand for mental health care and challenges of emerging adulthood. Our findings suggest that policy goals to increase use of mental health services are unlikely to improve outcomes for students without policy makers and health systems giving holistic consideration of inter-service relationships and available resources.

Adolescent help-seeking: an exploration of associations with perceived cause of emotional distress.

Background: Help-seeking is intrinsic to efforts to manage the onset, maintenance, or escalation of mental health difficulties during adolescence. However, our understanding of adolescent help-seeking remains somewhat nebulous. A greater comprehension of help-seeking behavior from the perspective of adolescents is needed. It is also prudent to explore help-seeking behavior in the context of perceived cause for emotional distress, particularly as causal beliefs have been found to influence help-seeking behavior in adults. Objectives: The present study sought to categorize adolescents' experiences of help-seeking, and to examine the extent to which these categories (or "types") of help-seeking behavior are associated with their perceptions of causal factors for emotional distress. Methods: The data for this study were drawn from interviews conducted as part of the HeadStart Learning Programme. The sample comprised of 32 young people aged 11-12 years. Ideal-type analysis, a qualitative form of person-centered analysis, was used to construct a typology of adolescent help-seeking. Participants' help-seeking "type" was then compared with their perceived cause for emotional distress "type." Findings: We developed four distinct categories of help-seeking: (1) guided by others who have taken notice; (2) skeptical with unmet needs; (3) motivated and solution focused; and (4) preference for self-regulation. Simultaneously, we identified principal associations between perceived cause of emotional distress-(1) perceived lack of control; (2) unfair treatment; (3) others: their actions and judgements as the catalyst; (4) concern for self and others; and (5) self as cause-and help-seeking approaches. "Perceived lack of control" was most likely to be associated with "others who have taken notice"; "Unfair treatment" with "skeptical with unmet needs"; "others: their actions and judgements as the catalyst" with "motivated and solution focused"; "concern for self and others' with 'guided by others who have taken notice"; finally, "self as cause" was most likely to be associated with "preference for self-regulation." Conclusions: This study demonstrates meaningful and distinct categories of adolescent help-seeking and offers empirical evidence to support the assertion that perceived cause for emotional distress may influence the help-seeking approaches of adolescents.

Promoting mental health and well-being in schools: examining mindfulness, relaxation and strategies for safety and well-being in English primary and secondary schools-study protocol for a multi-school, cluster randomised controlled trial (INSPIRE).

There are increasing rates of internalising difficulties, particularly anxiety and depression, being reported in children and young people in England. School-based universal prevention programmes are thought to be one way of helping tackle such difficulties. This paper describes an update to a four-arm cluster randomised controlled trial ( http://www.isrctn.com/ISRCTN16386254 ), investigating the effectiveness of three different interventions when compared to usual provision, in English primary and secondary pupils. Due to the COVID-19 pandemic, the trial was put on hold and subsequently prolonged. Data collection will now run until 2024. The key changes to the trial outlined here include clarification of the inclusion and exclusion criteria, an amended timeline reflecting changes to the recruitment period of the trial due to the COVID-19 pandemic and clarification of the data that will be included in the statistical analysis, since the second wave of the trial was disrupted due to COVID-19.Trial registration ISRCTN Registry ISRCTN16386254. Registered on 30 August 2018.

Self-management, self-care, and self-help in adolescents with emotional problems: a scoping review.

This study aimed to review the existing published and grey literature describing the concepts of self-management, self-care, and self-help, and to capture strategies or techniques related to these concepts, for adolescents with emotional problems. Emotional problems are rising amongst adolescents, yet timely access to specialist mental health treatment is limited to those with greater severity of mental health difficulties. Self-management, self-care, and self-help strategies may be used by adolescents with emotional problems both in terms of those waiting for treatment and to prevent relapse. Given the overlap in existing definitions and the lack of clarity around these concepts in an adolescent mental health context, a scoping review of the literature is warranted to provide clarity. Eligible studies were those involving adolescents aged 10 to 19 years with symptoms of emotional problems. Studies referenced self-management, self-care, or self-help, not involving a professional, in this population. Quantitative, qualitative, economic, and mixed methods studies, as well as systematic, scoping, and literature reviews, from 2000 onwards and in the English language, were eligible for inclusion. A systematic search was conducted of both published and grey literature. Databases searched included PsycINFO, Medline, Embase, Web of Science, and CINAHL Plus. Mednar was also searched for unpublished studies and grey literature. Tables  of themes, terms, and associated strategies are presented alongside a thematic analysis of the results. 62 articles were included. These were 20 quantitative studies, 14 systematic reviews, 10 qualitative studies, five review papers, four book chapters, four mixed methods studies, two dissertations, two meta-analyses and one scoping review and systematic review. Most of the included articles referenced self-help (n = 51), followed by self-management (n = 17) and self-care (n = 6). A total of 12 themes were identified from a reflexive thematic analysis of descriptions (and associated strategies) of self-management, self-help, or self-care in included texts. This scoping review provides clarity on the similarities and differences between how these concepts are discussed, and the strategies which are associated with each of these concepts in the relevant literature. Implications for policy and intervention development for adolescents' self-management, self-help, and self-care of their mental health are discussed. There is considerable overlap in both the ways in which these concepts are described, and the strategies or approaches proposed in relation to them, supporting previous research suggesting these strategies should be grouped under a single term, such as "self or community approaches." More research is needed for self-management, self-help, and self-care amongst marginalized groups as these adolescents may have the highest unmet need for mental health support.

A Qualitative Study of How Adolescents' Use of Coping Strategies and Support Varies in Line With Their Experiences of Adversity.

Background: Adolescence is associated with a rise in the incidence of mental health issues. Thus, the factors, processes, and contexts that protect and promote positive mental health in adolescence are of key interest to policymakers. Objective: Our aim was twofold: First, to explore the coping strategies and sources of support that adolescents identify as protective (or not) in the face of difficulty over a three-year period; second, to examine how and why this may vary in line with the levels of adversity that they report experiencing in life. Methods: Participants were attending schools in England implementing a mental health prevention programme called HeadStart. 93 semi-structured interviews were conducted with 31 adolescents (age 11-12 at the outset of the study; 58% female) once per year over three years. The interviews were analysed using thematic analysis. Results: Six coping strategy themes (e.g., 'Disengaging from problems') and five support themes (e.g., 'Parents as a source of comfort and advice') were derived from the interviews. The types, quality, and consistency of reported coping strategies and support varied in line with whether adolescents were experiencing higher or lower levels of adversity in life over time, and according to the resources that they had available within their physical and social contexts. Conclusions: Our findings underscore the importance for mental health prevention programmes of bolstering both individual-level coping strategies and the resources available within adolescents' environments to help them to manage adversity.

'Shall We Send a Panda?' A Practical Guide to Engaging Schools in Research: Learning from Large-Scale Mental Health Intervention Trials.

The substantial time that children and young people spend in schools makes them important sites to trial and embed prevention and early intervention programmes. However, schools are complex settings, and it can be difficult to maintain school engagement in research trials; many projects experience high levels of attrition. This commentary presents learning from two large-scale, mixed-methods mental health intervention trials in English schools. The paper explores the barriers and challenges to engaging schools in promotion or early intervention research and offers detailed recommendations for other researchers.

Barriers and Facilitators to Sustaining School-Based Mental Health and Wellbeing Interventions: A Systematic Review.

Despite an increasing focus on schools to deliver support and education around mental health and wellbeing, interventions are often not sustained beyond initial funding and research. In this review, the barriers and facilitators to sustaining mental health and wellbeing interventions in schools are explored. A systematic review was conducted using keywords based on the terms: 'sustainability', 'school', 'intervention', 'mental health', and 'emotional wellbeing'. Six online databases (PsycINFO, Embase, MEDLINE, British Education Index, ERIC, and Web of Science) and relevant websites were searched resulting in 6160 unique references. After screening, 10 articles were included in the review and extracted data were qualitatively synthesized using thematic analysis. Data synthesis led to the identification of four sustainability factors at the school level (school leadership, staff engagement, intervention characteristics, and resources) and one at the wider system level (external support). These factors were separated into 15 themes and discussed as barriers and facilitators to sustainability (for example, school culture and staff turnover). Most articles included no definition of sustainability, and nearly all barriers and facilitators were discussed at the school level. The findings suggest that more longitudinal and theory-driven research is required to develop a clearer picture of the sustainability process.

A qualitative investigation of LGBTQ+ young people's experiences and perceptions of self-managing their mental health.

There is evidence that young people generally self-manage their mental health using self-care strategies, coping methods and other self-management techniques, which may better meet their needs or be preferable to attending specialist mental health services. LGBTQ+ young people are more likely than their peers to experience a mental health difficulty and may be less likely to draw on specialist support due to fears of discrimination. However, little is known about LGBTQ+ young people's experiences and perceptions of self-managing their mental health. Using a multimodal qualitative design, 20 LGBTQ+ young people participated in a telephone interview or an online focus group. A semi-structured schedule was employed to address the research questions, which focussed on LGBTQ+ young people's experiences and perceptions of self-managing their mental health, what they perceived to stop or help them to self-manage and any perceived challenges to self-management specifically relating to being LGBTQ+ . Reflexive thematic analysis yielded three key themes: (1) self-management strategies and process, (2) barriers to self-management and (3) facilitators to self-management. Participants' most frequently mentioned self-management strategy was 'speaking to or meeting up with friends or a partner'. Both barriers and facilitators to self-management were identified which participants perceived to relate to LGBTQ+ identity. Social support, LGBTQ+ youth groups and community support were identified as key facilitators to participants' self-management of their mental health, which merits further investigation in future research. These findings also have important implications for policy and intervention development concerning LGBTQ+ young people's mental health.

A Scoping Review of the Factors That Influence Families' Ability or Capacity to Provide Young People With Emotional Support Over the Transition to Adulthood.

The transition to adulthood is typically marked by changes in relationships with family members, peers, and romantic partners. Despite this, the family often maintains a prominent role in young adults' lives. A scoping review was conducted to identify the factors that influence families' ability or capacity to provide young people with emotional support during the transition to adulthood, and to understand the gaps in this research area. Title and abstract searches were conducted from January 2007 to February 2021 in multiple databases, including PsycINFO, MEDLINE, and Sociological Abstracts. Fifteen semi-structured interviews were also conducted with stakeholders (professionals from relevant sectors/working within this field). In total, 277 articles were eligible for inclusion in the review. Following data extraction, 19 factors were identified. Factors with the most research (more than 20 articles) included: family proximity or co-residence; mental health; sex or gender differences; and family communication. Factors with less research included: societal context; young person's sexual orientation or gender identity; social networks; and adverse life events. Gaps in the research area were also identified, including methodological issues (e.g., lack of mixed methods and longitudinal study designs), a disproportionate focus on the parent-child relationship, and a lack of contextually situated research. Our findings indicate that future research in this area could benefit from taking an intersectional, multi-method approach, with a focus on the whole family and diverse samples.

Adaptation of a school-based mental health literacy curriculum: from Canadian to English classrooms.

BACKGROUND: School-based mental health literacy (MHL) interventions are increasingly trialled outside of the country in which they were developed. However, there is a lack of published studies that qualitatively explore their cultural adaptation. This study investigated the reasons for adaptations made and suggested to a Canadian MHL curriculum (The Guide) within the English school context. METHOD: Semi-structured interviews were conducted with 11 school staff responsible for the planning and/or implementation of The Guide across three schools in the South East of England, as part of the Education for Wellbeing (EfW) feasibility study. Transcripts were analysed using a hybrid, deductive-inductive thematic analysis. RESULTS: Adaptations made and suggested included dropping and emphasising content, and adapting language, examples and references. Most adaptations were proactive and related to The Guide's implementation methods, including developing more interactive and student-led approaches. Staff Capacity and Expertise, Timetabling, and Accessibility of Resources were identified as logistical reasons for adaptations. Philosophical reasons included Consistency of Messages, Student Characteristics, Reducing Stigma and Empowering Students, National and Local Context, and Appropriate Pedagogic Practices. CONCLUSION: Overall, recommendations were for immediately implementable lesson plans informed by teachers' knowledge about best pedagogic practices in England. Adequate training, attended by both senior leadership and those implementing, was also emphasised. While ensuring that the core components are clear, MHL interventions should be developed with a necessary level of flexibility to accommodate contextual characteristics. Future research should ensure that adaptations are captured through process and implementation evaluations conducted alongside efficacy trials.

Self-management, self-care, and self-help in adolescents with emotional problems: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to clarify the ways in which the concepts of self-management, self-care, and self-help are defined in the literature in the context of adolescents with emotional problems, as well as to identify the strategies or techniques that have been proposed to facilitate self-management, self-care, and self-help for this group. INTRODUCTION: There is evidence that emotional problems are rising amongst adolescents, yet timely access to specialist mental health treatment is limited to adolescents with greater severity of mental health difficulties. Nonetheless, self-management, self-care, and self-help strategies may be used by adolescents. Given the overlap in existing definitions and the lack of clarity around these concepts in a youth mental health context, a scoping review of the literature is warranted. INCLUSION CRITERIA: The review will consider studies that involve adolescents aged 10 to 19 years with symptoms of emotional problems. These problems do not require a formal diagnosis and may be based on self-reporting. Studies that reference self-management, self-care, or self-help in this population, in any setting, will be included. Strategies may be provided by a mental health professional or discovered by the adolescent on their own. Quantitative, qualitative, economic, and mixed methods studies, as well as systematic, scoping, and literature reviews, are eligible for inclusion. METHODS: MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, Google Scholar, and MedNar will be searched for English-language texts from the year 2000 onward. A map or typology of definitions will be presented alongside a narrative summary of the results.

Adolescents' Understanding of What Causes Emotional Distress: A Qualitative Exploration in a Non-clinical Sample Using Ideal-Type Analysis.

Background: There is increased interest in early intervention and prevention of mental health difficulties during adolescence; thus, we are seeing increased efforts to optimize well-being during this epoch. Positive emotional experiences are a central component of overall well-being. However, research exploring what adolescents perceive to be the cause(s) of their emotional difficulties is lacking. Improving understanding of this issue within non-clinical adolescent groups may provide useful insight into how to develop strategies to support young people as they navigate emotional difficulties. Objectives: The aim of this research was to explore if meaningful categories of perceived cause(s) for emotional distress exist for non-clinical adolescent groups. Methods: The data for this study were drawn from interviews across 6 sites in England conducted as part of the 5-year national evaluation of the HeadStart Learning Programme. The sample comprised of 32 young people aged 11-12 years from the first annual wave of qualitative data collection in 2017. Ideal type analysis-a qualitative form of person-centered analysis-was used to construct a typology of adolescents perceived cause(s) for emotional distress. Findings: We identified five distinct categories of perceived cause: (1) perceived lack of control; (2) unfair treatment; (3) others, their actions and judgements as the catalyst; (4) concerns for self and others; and, (5) self as cause. Conclusions: Our findings illustrate that distinct categories for perceived cause of emotional distress exist among adolescents considered to be "at risk" of developing mental health difficulties, which provides a foundation for future necessary work seeking to investigate the possible link between perceived cause for emotional distress and help-seeking behavior among sub-clinical groups.

Perspectives of paediatric hospital staff on factors influencing the sustainability and spread of a safety quality improvement programme.

OBJECTIVE: Situation Awareness For Everyone (SAFE) is a quality improvement programme aiming to improve situation awareness in paediatric clinical teams. The aim of our study was to examine hospital staff perceptions of the facilitators and barriers/challenges to the sustaining and subsequent spread of the huddle, the key intervention of the SAFE programme. SETTING: Interviews were held on two wards in two children hospitals and on two children wards in two district general hospitals. METHOD: Semistructured interviews were conducted with 23 staff members from four National Health Service paediatric wards. A deductive thematic analysis was conducted, drawing on an existing framework, which groups the factors influencing programme sustainability into four categories: innovation, leadership, process and context. PARTICIPANTS: 23 staff in two children's hospitals and two children's wards across four UK hospitals, comprising of nurses and doctors, administration or housekeeping staff, ward managers and matrons, and allied professionals. PRIMARY OUTCOMES: Understanding factors contributing to the sustaining and spread of a quality improvement intervention. RESULTS: Perceptions of the benefits, purpose and fit of the huddle, team commitment, sharing learning, adaptation of the method and senior leadership were identified as facilitators. High staff turnover, large multiple specialty medical staff teams, lack of senior leadership and dislike of change were identified as barriers/challenges. CONCLUSIONS: Sustaining and spreading quality improvement interventions in a complex clinical setting requires understanding of the interplay between the actual innovation and existing leadership, process and contextual factors. These must be considered at the planning stage of an innovation to maximise the potential for sustainability and spread to other settings.

Counseling for Young People and Families Affected by Child Sexual Exploitation and Abuse: A Qualitative Investigation of the Perspective of Young People, Parents, and Professionals.

Despite growing awareness of the negative impact of child sexual exploitation on young people's psychological, emotional and relational lives, little is known about how counseling can support young people and their families. The aim of this study was to explore the experience of counseling for young people and parents affected by child sexual exploitation and abuse, with a view to examining what facilitates progress, from the perspective of young people, parents and professionals. In-depth semi-structured interviews were conducted with 10 young people, 8 parents and 7 professionals and were analyzed using thematic analysis. Findings suggest that through counseling, young people experienced affective and relational improvements that were attributed to the process. Characteristics of the counseling relationship that facilitated progress included being able to talk openly in a caring, non-judgmental and unpressurized environment, as well as receiving advice, techniques or solutions within a holistic approach. Facets of service delivery were also highlighted, including the provision of confidentiality, flexibility and consistency, along with a multi-agency approach that promoted engagement. Perceived obstacles to progress included resistance at the outset and service location issues.

Children and young people's experiences of completing mental health and wellbeing measures for research: learning from two school-based pilot projects.

BACKGROUND: In recent years there has been growing interest in child and adolescent mental health and wellbeing, alongside increasing emphasis on schools as a crucial site for research and intervention. This has coincided with an increased use of self-report mental health and wellbeing measures in research with this population, including in school-based research projects. We set out to explore the way that children and young people perceive and experience completing mental health and wellbeing measures, with a specific focus on completion in a school context, in order to inform future measure and research design. METHODS: We conducted semi-structured interviews and focus groups with 133 participants aged 8-16 years following their completion of mental health and wellbeing measures as part of school-based research programmes, using thematic analysis to identify patterns of experience. FINDINGS: We identified six themes: Reflecting on emotions during completion; the importance of anonymity; understanding what is going to happen; ease of responding to items; level of demand; and interacting with the measure format. CONCLUSIONS: Our findings offer greater insight into children and young people's perceptions and experiences in reporting on their mental health and wellbeing. Such understanding can be used to support more ethical and robust data collection procedures in child and adolescent mental health research, both for data quality and ethical purposes. We offer several practical recommendations for researchers, including facilitating this in a school context.

Promoting mental health and wellbeing in schools: examining Mindfulness, Relaxation and Strategies for Safety and Wellbeing in English primary and secondary schools: study protocol for a multi-school, cluster randomised controlled trial (INSPIRE).

BACKGROUND: There are increasing rates of internalising difficulties, particularly anxiety and depression, being reported in children and young people in England. School-based, universal prevention programmes are thought to be one way of helping tackle such difficulties. This protocol describes a four-arm cluster randomised controlled trial, investigating the effectiveness of three different interventions when compared to usual provision, in English primary and secondary pupils. The primary outcome for Mindfulness and Relaxation interventions is a measure of internalising difficulties, while Strategies for Safety and Wellbeing will be examined in relation to intended help-seeking. In addition to the effectiveness analysis, a process and implementation evaluation and a cost-effectiveness evaluation will be undertaken. METHODS AND ANALYSIS: Overall, 160 primary schools and 64 secondary schools will be recruited across England. This corresponds to 17,600 participants. Measures will be collected online at baseline, 3-6 months later, and 9-12 months after the commencement of the intervention. An economic evaluation will assess the cost-effectiveness of the interventions. Moreover, a process and implementation evaluation (including a qualitative research component) will explore several aspects of implementation (fidelity, quality, dosage, reach, participant responsiveness, adaptations), social validity (acceptability, appropriateness and feasibility), and their moderating effects on the outcomes of interest, and perceived impact. DISCUSSION: This trial aims to address important questions about whether schools' practices around the promotion of mental wellbeing and the prevention of mental health problems can: (1) be formalised into feasible and effective models of school-based support and (2) whether these practices and their effects can be sustained over time. Given the focus of these interventions on mirroring popular practice in schools and on prioritising approaches that present low-burden, high-acceptability to schools, if proved effective, and cost-effective, the findings will indicate models that are not only empirically tested but also offer high potential for widespread use and, therefore, potentially widespread benefits beyond the life of the trial. TRIAL REGISTRATION: ISRCTN16386254. Registered on 30 August 2018.

School-based intervention study examining approaches for well-being and mental health literacy of pupils in Year 9 in England: study protocol for a multischool, parallel group cluster randomised controlled trial (AWARE).

INTRODUCTION: The prevalence of emotional difficulties in young people is increasing. This upward trend is largely accounted for by escalating symptoms of anxiety and depression. As part of a public health response, there is increasing emphasis on universal prevention programmes delivered in school settings. This protocol describes a three-arm, parallel group cluster randomised controlled trial, investigating the effectiveness and cost-effectiveness of two interventions, alongside a process and implementation evaluation, to improve mental health and well-being of Year 9 pupils in English secondary schools. METHOD: A three-arm, parallel group cluster randomised controlled trial comparing two different interventions, the Youth Aware of Mental Health (YAM) or the Mental Health and High School Curriculum Guide (The Guide), to Usual Provision. Overall, 144 secondary schools in England will be recruited, involving 8600 Year 9 pupils. The primary outcome for YAM is depressive symptoms, and for The Guide it is intended help-seeking. These will be measured at baseline, 3-6 months and 9-12 months after the intervention commenced. Secondary outcomes measured concurrently include changes to: positive well-being, behavioural difficulties, support from school staff, stigma-related knowledge, attitudes and behaviours, and mental health first aid. An economic evaluation will assess the cost-effectiveness of the interventions, and a process and implementation evaluation (including a qualitative research component) will explore several aspects of implementation (fidelity, quality, dosage, reach, participant responsiveness, adaptations), social validity (acceptability, feasibility, utility), and their moderating effects on the outcomes of interest, and perceived impact. ETHICS AND DISSEMINATION: This trial has been approved by the University College London Research Ethics Committee. Findings will be published in a report to the Department for Education, in peer-reviewed journals and at conferences. TRIAL REGISTRATION NUMBER: ISRCTN17631228. PROTOCOL: V1 3 January 2019. Substantial changes to the protocol will be communicated to the trials manager to relevant parties (eg, ISRCTN).

Assessing risks to paediatric patients: conversation analysis of situation awareness in huddle meetings in England.

OBJECTIVES: To analyse the language and conversation used in huddles to gain a deeper understanding of exactly how huddles proceed in practice and to examine the methods by which staff members identify at-risk patients. SETTING: Paediatric wards in four English hospitals, which were part of a 12-hospital cohort participating in the Situation Awareness for Everyone programme. Wards varied by geographical region and type of hospital. PARTICIPANTS: Paediatric staff on wards in four English hospitals. DESIGN: Ethnomethodology and conversation analysis of recorded safety huddles. METHODS: This study represents the first analysis of huddle interaction. All huddle meetings taking place on four wards across four different hospitals were audio recorded and transcribed. The research question examined was: how are staff identifying at-risk patients in huddles? The ethnomethodological conversation analytic approach was used to analyse the transcripts. RESULTS: Huddlers made use of categories that allowed them to efficiently identify patients for each other as needing increased attention. Lexicon included the use of 'no concerns', 'the one to watch', 'watcher' and 'acute concerns'. Huddlers used the meetings to go beyond standardised indicators of risk to identify relative risk and movement in patients towards deterioration, relative to the last huddle meeting and to their usual practices. An implicit category, termed here 'pre-concerns', was used by staff to identify such in-between states. Sequential analysis also highlighted the conversational rights that were held implicitly by staff in different clinical roles. CONCLUSION: Practical implications and recommendations for huddlers are considered. These included that for increased situation awareness, it is recommended that all staff are active in the huddle conversation and not only the most senior team members.

Facing Shadows: working with young people to coproduce a short film about depression.

BACKGROUND: IMPACT (Improving Mood with Psychoanalytic and Cognitive Therapies) is a multi-centre randomised controlled trial of three therapeutic interventions for the treatment of depression in young people. IMPACT- My Experience (IMPACT-ME), a qualitative research study, followed up a sub-sample of families involved in IMPACT to explore young people's experiences of therapy and depression. Members of the IMPACT-ME steering group, who brought their own experiences of depression and engaging with mental health services, were keen to find ways to provide information about depression and help-seeking beyond traditional academic audiences, specifically to other young people experiencing depression and wondering where to turn: their chosen medium was film. Here we describe and reflect on the four-day coproduction workshops in which researchers, young people and film-makers coproduced 'Facing Shadows', a short animation about depression and therapy (https://www.youtube.com/watch?v=LdmRPKUhNEY). MAIN BODY: We outline the process, focusing on the four-day creative, collaborative workshop in which young people shared their experiences, decided on the tone, tenor and message of the film, identified their primary audience and produced the bulk of the audio and visual material. The adults acted as facilitators: developing a creative, collaborative learning environment in which trusting relationships could flourish, as well as offering guidance, instruction, advice and support. To date the film has been viewed around 12,000 times on YouTube. The young people learned new skills, felt listened to and enjoyed the process. They produced a film which sends a hopeful message to other young people, '… that they are not alone'. CONCLUSION: We reflect on the creative participatory workshop approach which transformed the project from dissemination to an insightful learning experience for young people and researchers alike.

Development of the Huddle Observation Tool for structured case management discussions to improve situation awareness on inpatient clinical wards.

BACKGROUND: 'Situation Awareness For Everyone' (SAFE) was a 3-year project which aimed to improve situation awareness in clinical teams in order to detect potential deterioration and other potential risks to children on hospital wards. The key intervention was the 'huddle', a structured case management discussion which is central to facilitating situation awareness. This study aimed to develop an observational assessment tool to assess the team processes occurring during huddles, including the effectiveness of the huddle. METHODS: A cross-sectional observational design was used to psychometrically develop the 'Huddle Observation Tool' (HOT) over three phases using standardised psychometric methodology. Huddles were observed across four NHS paediatric wards participating in SAFE by five researchers; two wards within specialist children hospitals and two within district general hospitals, with location, number of beds and length of stay considered to make the sample as heterogeneous as possible. Inter-rater reliability was calculated using the weighted kappa and intraclass correlation coefficient. RESULTS: Inter-rater reliability was acceptable for the collaborative culture (weighted kappa=0.32, 95% CI 0.17 to 0.42), environment items (weighted kappa=0.78, 95% CI 0.52 to 1) and total score (intraclass correlation coefficient=0.87, 95% CI 0.68 to 0.95). It was lower for the structure and risk management items, suggesting that these were more variable in how observers rated them. However, agreement on the global score for huddles was acceptable. CONCLUSION: We developed an observational assessment tool to assess the team processes occurring during huddles, including the effectiveness of the huddle. Future research should examine whether observational evaluations of huddles are associated with other indicators of safety on clinical wards (eg, safety climate and incidents of patient harm), and whether scores on the HOT are associated with improved situation awareness and reductions in deterioration and adverse events in clinical settings, such as inpatient wards.