Table 2.

Summary table of multi-level positive and negative influences on the implementation of the SDM tool based on qualitative data along with strategies to promote the use of SDM at each level

Level	Positive influences on potential implementation	Negative influences on potential implementation	Strategies to promote the use of SDM tool within services
Macro level (structural)		Mental Health Act	Introduce additional accountability mechanisms related to the quality of SDM and associated outcomes
		Protocol driven practice	Introduce quality targets associated with the quality of SDM and use of the tool and promote within services
		Resource limitations	Seek and act on the feedback from of a range of stakeholders (service users, carers and professionals) about the tool and wider SDM within services and how this might be improved
		Culture
		IT systems
Meso level (healthcare)	Community setting	Culture (risk focussed, paternalism)	Provide holistic care
	AOT approach	Access to professionals	Provide recovery focussed care
	Information provision	Lack of medication choice	Provide information about the tool, how it works, available options and what users are entitled to
	Activity provision	Lack of information sharing	Provide wider engagement activities within the Trust
	Holistic approach		Provide, promote and utilise mechanisms for service users and carers to feedback about the quality of the tool, SDM and associated outcomes
Micro level influences
Service user/carer	Insight	Lack of insight
	New to services	Behaviour (delusions, paranoia)
	Role of carer	Crisis/lack of capacity
		Perception of services
		Institutionalisation
Professional	Behaviour (compassion, conviction)	Focus on psychosis	Actively involve carers in the use of the tool
	Relationships	Limited contact	Consider carer involvement in situations (acute illness) where service user involvement is not possible
	Communication	Offering choice looking like uncertainty	Make explicit the purpose and boundaries of SDM within a given situation when using the tool
		Authority and power	Highlight varieties and boundaries of SDM possible within different contexts when using the tool (e.g. choice of medication for those detained under the Mental Health Act)
			Treat the use of the tool as an on-going process which is revisited continually