Background Countries around the world have committed in policy to transforming their mental health services towards a recovery orientation. How has mental health recovery been implemented into services for adults, and what factors influence the implementation of recovery-oriented services? Methods This systematic mixed studies review followed a convergent qualitative synthesis design and used the best-fit framework synthesis method. Librarians ran searches in Ovid- MEDLINE, Ovid-EMBASE, Ovid-PsycInfo, EBSCO-CINAHL Plus with Full Text, ProQuest Dissertations and Theses, Cochrane Library, and Scopus. Two reviewers independently screened studies for inclusion or exclusion using DistillerSR. Qualitative, quantitative, and mixed methods peer-reviewed studies published since 1998 were included if they reported a new effort to transform adult mental health services towards a recovery orientation, and reported findings related to implementation experience, process, or factors. Data was extracted in NVivo12 to the 38 constructs of the Consolidated Framework for Implementation Research (CFIR). The synthesis included a within-case and a cross-case thematic analysis of data coded to each CFIR construct. Cases were types of recovery-oriented innovations. Results Seventy studies met our inclusion criteria. These were grouped into seven types of recovery-oriented innovations (cases) for within-case and cross-case synthesis. Themes illustrating common implementation factors across innovations are presented by CFIR domain: Intervention Characteristics (flexibility, relationship building, lived experience); Inner Setting (traditional biomedical vs. recovery-oriented approach, the importance of organizational and policy commitment to recovery-transformation, staff turnover, lack of resources to support personal recovery goals, information gaps about new roles and procedures, interpersonal relationships), Characteristics of Individuals (variability in knowledge about recovery, characteristics of recovery-oriented service providers); Process (the importance of planning, early and continuous engagement with stakeholders). Very little data from included studies was extracted to the outer setting domain, and therefore, we present only some initial observations and note that further research on outer setting implementation factors is needed. Conclusion The CFIR required some adaptation for use as an implementation framework in this review. The common implementation factors presented are an important starting point for stakeholders to consider when implementing recovery-oriented services.

Background Seven housing and health services organizations were guided through a process of translating Chapter Six of the Canadian Guidelines for Recovery-Oriented Practice into a recovery-oriented innovation and plan for its implementation. At the time of the COVID-19 outbreak and lockdown measures, six of the seven organizations had begun implementing their chosen innovation (peer workers, wellness recovery action planning facilitator training, staff training and a family support group). This mid-implementation study used the Consolidated Framework for Implementation Research (CFIR) to identify contextual factors that influenced organizations to continue or postpone implementation of recovery-oriented innovations in the early months of the COVID-19 pandemic. Methods Twenty-seven semi-structured 45-min interviews were conducted between May and June 2020 (21 implementation team members and six providers of the innovation (trainers, facilitators, peer workers). Interview guides and analysis were based on the CFIR. Content analysis combined deductive and inductive approaches. Summaries of coded data were given ratings based on strength and valence of the construct’s impact on implementation. Ratings were visualized by mid-implementation outcome and recovery innovation to identify constructs which appear to distinguish between sites with a more or less favorable mid-implementation outcomes. Results Four mid-implementation outcomes were observed at this snapshot in time (from most to least positive): continued implementation with adaptation (one site), postponement with adaptation and estimated relaunch date (four sites), indefinite postponement with no decision on relaunch date (one site), and no implementation of innovation yet (one site). Two constructs had either a negative influence (external policies and incentives—renamed COVID-19-related external policy for this study) or a positive influence (leadership engagement), regardless of implementation outcome. Four factors appeared to distinguish between more or less positive mid-implementation outcome: adaptability, implementation climate and relative priority, available resources, and formally appointed internal implementation leaders (renamed “engaging implementation teams during the COVID-19 pandemic” for this study). Conclusions The COVID-19 pandemic is an unprecedented outer setting factor. Studies that use the CFIR at the mid-implementation stage are rare, as are studies focusing on the outer setting. Through robust qualitative analysis, we identify the key factors that shaped the course of implementation of recovery innovations over this turbulent time.

IntroductionRecovery is integral to mental health planning in G-8 countries including Canada. A recovery-oriented approach to care aims to promote personal empowerment, illness self-management and a life beyond services for people with serious mental illness (SMI), while reducing the financial burden associated with mental illness. Although there is a growing body of literature on recovery, no synthesis of research on the implementation of recovery into mental health services exists.ObjectivesThe objective is to conduct a mixed studies systematic review on the operationalisation of recovery into mental health services for adults with SMI. It will inform the transformation of Canadian services to a recovery orientation, but may be applicable to other countries.Methods and analysisSeven databases including PubMed, Ovid Medline, Ovid Embase, Ovid PsycInfo, CINAHL, the Cochrane Library and Scopus will be searched for peer-reviewed empirical studies published from 1998 to December 2016. Systematic reviews and studies using quantitative, qualitative and mixed methodologies will be included. Secondary searches will be conducted in reference lists of all selected full text articles. Handsearches will also be performed in the tables of contents of three recovery-focused journals for the last 5 years. International experts in the field will be contacted for comments and advice. Data extraction will include identification and methodological synthesis of each study; definition of recovery; information on recovery implementation; facilitators and barriers and study outcomes. A quality assessment will be conducted on each study. The data will be synthesised and a stepwise thematic analysis performed.Ethics and disseminationEthics approval is not required for this knowledge synthesis. Findings will be disseminated through knowledge translation activities including: (1) a 1-day symposium; (2) presentations in national and international conferences and to local stakeholders; (3) publications in peer-reviewed journals; (4) posts on the organisational websites.

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