The stress of the COVID-19 pandemic is placing health care workers (HCWs) at increased risk of poor mental health [1], with posttraumatic stress disorder (PTSD) being a major concern [2-5]. Mental health treatments can lower the risk of HCWs developing mental ill-health [1], yet few appropriate services are available at the necessary scale for all specializations of HCWs. The Australian health care workforce is currently estimated at 800,000 [6]. This figure will likely continue to grow alongside population growth, indicating that large-scale solutions are required. Early in the COVID-19 pandemic, researchers called for evidence-based, self-guided mental health services for HCWs, citing reluctance to seek help, coupled with the challenges of delivering quality support to thousands of time-poor consumers [7]. Blended care services that integrate digital (websites and apps) and person-to-person (including telehealth) services [8] can rapidly scale, while offering a personalized choice of evidence-based care options [9]. In this manner, blended care is a promising means of providing large-scale mental health services to HCWs during the ongoing COVID-19 pandemic.

Over and above scalability, mental health services must be sensitive to the specialized needs of HCWs. As HCWs battle the pandemic, they face numerous sources of stress, such as fear of infection [10], unsupportive workplaces [11], and even watching colleagues die [12]. HCWs also vary in how they manage these stressors across time [13]. Therefore, HCWs need adaptable mental health services that can help with a range of concerns, from situational distress to moral injury [14] to PTSD [2,3]. Yet, even services tailored to HCWs have seen little uptake despite high reported demand [15]. One likely explanation is the lack of psychological safety many HCWs experience when accessing mental health care. Concerns about stigma [1,16], confidentiality, and discrimination from colleagues or employers [17,18] keep many HCWs from using the available services. Blended care can address some of these concerns through digital services (eg, anonymous chat-based therapies, accessing tailored resources without registration), while still providing the flexibility for HCWs who prefer person-to-person care to access these services.

To fully leverage the potential of blended care to support HCWs during the COVID-19 pandemic and beyond, services must be implemented in a way that ensures HCWs feel psychologically safe to use them. Thus far, little is known about implementing these services is a way that builds trust and increases uptake of available services. The few studies within the COVID era describe institution-specific implementation practices without data on the effectiveness of implementation strategies [19]. Studies implementing HCW-specific mental health services from previous pandemics are largely of poor quality and evaluate the effects of an intervention rather than implementation strategies to facilitate uptake and engagement [20]. These challenges exemplify implementation science in digital health, which is yet to produce a unified implementation framework to guide not only the reporting of strategies but also the evaluation of certain approaches [21,22]. Understanding how to effectively implement HCW-specific mental health services could boost the uptake of available care and inform the development of new services as the pandemic continues to unfold.

The Essential Network (TEN) was funded by the Australian Government Department of Health as part of its national COVID-19 response strategy. TEN follows a sequential blended care approach [9] using an integrated service model that spans 4 care phases: (1) well-being promotion, (2) early detection and preventative interventions, (3) low-to-moderate-intensity services for HCWs experiencing preclinical distress, and (4) person-to-person clinical services for HCWs’ mental health difficulties or clinical distress. In this sequential blended care approach, users engage with digital resources and treatment options, as required, and progress to person-to-person clinical services, where necessary. This selection of treatment options is made possible by a “digital ecosystem” that brought together a network of existing and new services from partner organizations with interest in the mental health of HCWs. Services are made available through a single web-based digital hub (Figure 1) accessible across desktop, laptop, and mobile web browsers. Digital services comprise an online mental health assessment, mental health resources and advice for assisting individuals and their colleagues, and links to other relevant resources and organizations (eg, psychiatrists who treat HCWs, peer support organizations). Person-to-person services comprise up to 5 individual clinical consultations with either a clinical psychologist or a psychiatrist delivered either via telehealth or in person at our clinic in Sydney, New South Wales (NSW), Australia. Users can select and explore the digital or person-to-person options that they believe best match their needs.

This study will examine the implementation of TEN, a blended mental health service for Australian HCWs established during COVID-19, funded by the Australian Federal Government. The Consolidated Framework for Implementation Research (CFIR) framework will be used to guide this examination as the constructs within the CFIR span both implementation and effectiveness within a health service context [23]. However, some adaptation of the CFIR will be required. The CFIR assumes that an intervention will be implemented in a single organization or industry, unlike TEN, which spans many organizational structures and professions. Similarly, the frameworks consolidated within the CFIR are largely aimed at implementing singular, intervention-based face-to-face services, rather than multichannel digital services like TEN. Previous attempts to consolidate implementation strategies for digital mental health have focused on delivering specific digital programs as an alternative to traditional mental health services, rather than linking users to a range of care options in the way TEN does [21]. Work is underway to consolidate optimal digital health implementation strategies [22]; however, no such framework exists yet. For these reasons, in our study, the CFIR subconstruct definitions described by Damschroder et al [23] will be adapted to the digital and multiorganizational nature of TEN, guided by the digital-specific implementation strategies suggested by Graham et al [21] (see Table 1).

The primary objective of this study is to work with HCW researchers, industry partners, and active TEN users to design and test an implementation strategy for TEN. The secondary objectives are to examine the acceptability of TEN, to measure any changes in psychosocial well-being associated with the use of TEN, and to determine whether TEN reduces mental health stigma among HCWs.

This study will follow an implementation-effectiveness hybrid design [24]. The protocol has 3 components (Figure 2). The consultation study component (Study 1) is a series of semistructured qualitative interviews conducted with stakeholders to explore the needs of Australian HCWs and develop an implementation strategy for TEN. The observational study component (Study 2) is a pre-/postobservational study with Australian HCWs evaluating the acceptability TEN, providing feedback on the implementation strategy, and examining any changes in mental health outcomes that are associated with use of the service. The implementation study (Study 3) component will be a pre-/postaudit of TEN users both before and after the implementation strategy is implemented [25].

There is no specific study site. Semistructured interviews carried out as part of the consultations will be conducted online via videocalls (eg, Zoom, Microsoft Teams). As a digital mental health hub, participants in the observational study will be able to participate in the study and access the TEN service from any location in Australia. If applicable, face-to-face consultations through the TEN Clinic may be conducted at the Black Dog Institute, Randwick, NSW 2031, or via telehealth.

Blended digital and person-to-person care has significant potential to support mental health of HCWs through service flexibility and widespread availability. To date, however, the potential of blended care has been hampered by a lack of knowledge around the optimal implementation of such services. The CFIR framework provides a structured approach to implementation that will guide the development and application of implementation strategies for TEN. Using a implementation-effectiveness hybrid study, this implementation study will span 3 separate components. Through a series of consultations, an implementation strategy tailored to HCWs will be developed. Feedback on this strategy will be provided by HCWs participating in an observational study of TEN, from which data on the effectiveness of TEN will be acquired. Finally, the implementation strategy will be implemented and compared against the previous engagement strategies. The knowledge created by this project will inform the development and delivery of blended mental health services for HCWs, including how such services can be rapidly launched and implemented during times of crisis.

Although the implementation strategy has not yet been designed, the wide availability of TEN makes it difficult to examine site- or specialization-specific implementation strategies or service upgrades. Although the goal of TEN is to provide a blended care service for all Australian HCWs, this lack of specificity may hamper implementation within specific HCW specializations. The future of blended health is platforms that can be easily customized to different contexts, allowing for tailored implementation strategies and service upgrades. Similarly, the broad aims of the implementation of TEN may not be easily generalizable to other, more specific, contexts.

This implementation study and observational study will also be carried out during the ongoing COVID-19 pandemic. TEN itself was designed to support the mental health of HCWs during the pandemic. As such, changes in the COVID-19 context in Australia, such as outbreaks, restrictions, and the vaccination rollout, are likely to affect both uptake of the service and mental health outcomes. Such wider events will be considered when interpreting the results of both the implementation strategy and the observational study.

The observational study is also limited by a lack of an appropriate control arm and use of randomization. Common mental health outcomes, such as distress, anxiety, and depression, have the potential to improve over time without intervention. Although subgroup analyses examining usage of the service may shed some light on improvement without the use of the TEN service, the fact remains that a randomized controlled trial design with a suitable control would provide more robust data on efficacy.

Due to common concerns around mandatory reporting among HCWs [34], the TEN website was designed to be accessed anonymously (ie, without registration). Although this is a strength of the service itself, it poses problems for measuring participant engagement with the TEN website during a prospective study. The method used in the observational study—providing users with a unique website link—is error prone. Although participants are asked to bookmark the link and will be provided with the link via email, it remains that participants may simply access the TEN website without using their unique link. During data analysis, participant website analytics will be compared against self-reported usage to understand the extent of such errors.

By using a blended care approach, TEN can overcome common barriers to HCWs engaging with mental health services—primarily by allowing HCWs to anonymously access digital resources. Nonetheless, it remains that many HCWs will still choose not to engage with person-to-person services due to concerns around mandatory reporting. Further, although the lack of registration to access TEN ameliorates concerns around digital privacy, it requires computer skills that some HCWs may be lacking. Although these are issues beyond the scope of this evaluation, they need to be considered and addressed when designing and implementing mental health services for HCWs.