The postnatal period is high-risk time for the first onset and recurrence of maternal mental health disorders. Untreated maternal mental illness can have significant adverse impacts on a woman, her baby, and the wider family unit. For women with mental illnesses that cannot be managed in the community, psychiatric inpatient mother-baby units are the gold standard treatment whereby mothers are co-admitted with their infant for specialist perinatal and infant mental health assessment and treatment. The study explores the model of care and examines the philosophies of care that are used within a psychiatric mother-baby unit. Purposive sampling was used to conduct semi-structured focus group and individual interviews with multidisciplinary staff members at a single mother-baby unit. Themes derived from these interviews were coded into two primary themes and a range of sub-themes. The first primary theme focused on the Model of Care consisting of the following sub-themes: mental health care, physical health care, babies’ care, building mother-baby relationship, fostering relationships with supports, and facilitating community support. The second primary theme centered around the Philosophy of Care comprising of: person-centered care, trauma-informed care, compassion-centered care, recovery-oriented care, attachment-informed care, non-judgmental care, strengths-based care and interdisciplinary care. The model can be used to provide consistency across mother-baby units and to support core capabilities of staff in providing an optimal level of care. Maternal mental illness is a significant global health issue, incorporating a wide range of disorders from postpartum depression to anxiety, psychosis, bipolar and eating disorders ,2. An esThe separation of mother and infant postpartum can be a detrimental and traumatic experience for both . ConsequMBUs are considered the optimal model for treating maternal mental health, as co-admission allows for the woman to receive treatment for her mental health, whilst also receiving support in developing parenting skills ,13,17,22The Lavender MBU was opened in March 2017 to support new mothers requiring specialized perinatal assessment and treatment. This is a statewide public service, and the first of its kind in Queensland, Australia, established to assess and treat women with severe mental illness in the first year postpartum. The service works holistically by improving maternal mental health whilst fostering positive mother-infant attachment and parenting confidence. The Lavender MBU also includes some allied health professions who do not traditionally have roles in these settings, such as physiotherapy, dietetics, and occupational therapy. Understanding the clinical reasoning and experience of these subspecialties will provide new insights for expanding and creating more roles for these professions in the future. The identification of service provision characteristics, together with staff collaboration and feedback, will enable the development of a standardized model of care tailored to the specific needs of perinatal mental health care patients in inpatient settings.The study aims to evaluate and characterize the holistic model of care at an MBU to determine its capacity as a template for use within other MBU services. It will also examine the philosophical foundation underpinning the practices of staff within an MBU. The specific objectives of the study are: to better understand Lavender Mother-Baby staff members’ expectations, perceptions and experiences of their role; to explore barriers and facilitators in implementing a specialized perinatal inpatient unit based on the capability model; and to better understand the workforce training and professional development needs of staff.A cross-sectional, qualitative research study was conducted using an evolved grounded theory approach . This reThe Lavender MBU is an acute mental health inpatient service that provides specialist perinatal assessment and treatment for women with significant mental health difficulties that cannot be managed in the community and their baby(s) . Women eParticipants for this study were multidisciplinary staff  working at the Lavender Mother-Baby Unit between March 2017 and 2022. Both clinical and non-clinical staff  were eligible to participate in the study. Fixed-term contract and permanent staff were included in the study, and casual staff were excluded. Twenty-six staff members participated in this study including 10 nursing staff (38.46%), 10 allied health staff (38.46%), 3 medical staff (11.54%), and 3 managerial/support staff (11.54%). Twenty-four staff members (92.31%) were female, and 2 (7.69%) were male. While all allied health, medical and managerial/support staff were recruited, 62.50% of the nursing cohort was sampled. See Staff members were invited to participate through emails and team meetings. Purposive sampling was conducted to ensure all allied health, medical and managerial/support staff were recruited to capture the diversity of perspectives. Nursing staff were interviewed until saturation was reached.Face-to-face, semi-structured interviews were conducted with staff. Individual and focus group interviews were completed in a private room during a work shift of the staff. At commencement of the interview, informed consent was obtained as participants were briefed about the purpose of the study and the interview procedure. Participants had the opportunity to review the interview questions prior to the interview. Participation was voluntary and non-participation did not affect their working relationship with others. It was reiterated that participants could decline to answer any questions they did not feel comfortable in answering, and cease the interview as required. Interviews were conducted by a trained qualitative researcher independent to clinical care who was an investigator on the research study. Most interviews were conducted in one sitting; however, 3 interviews (11.54%) were conducted over two sittings. In-depth interviews were completed in 30–60 min.The interview guide was self-constructed and consisted of questions surrounding their role in the MBU, their experience of working in an MBU including rewarding and challenging aspects, unique characteristics of an MBU, and core capabilities such as key knowledge and skills. Interviews were recorded and transcribed verbatim by professional transcription software and a research assistant. Transcripts were deidentified and personal identifying names were replaced with a pseudonym. Transcripts were sent to participants to check for accuracy and with the opportunity to remove any undesired information. Data in approved transcripts were extracted and analyzed using Tie et al.  evolved To complete data extraction, concurrent data collection and analysis occurred whereby the research team collected, coded, and analyzed the initial data before further data collection was undertaken. Theoretical sampling occurred from the codes and categories to clarify uncertainties and test interpretations as the study progressed. Initial coding was completed wherein the research team inductively generated as many codes as possible from early data. Intermediate coding was conducted in which codes and categories were reviewed to identify which ones, if any, could refined, or subsumed beneath other categories. Constant comparative analysis facilitated the analytical and iterative process for coding and category development. Memo writing  also occurred to support data analysis. Advanced coding technique was used to facilitate integration of the final grounded theory. In this stage, abstract concepts were reduced into highly conceptual terms that became categories and findings were presented as a set of interrelated concepts. A coherent grounded theory was generated by following “storyline strategy” that facilitated the integration, construction, formulation, and presentation of research findings.Based on analysis of the interviews, the grounded theory was developed around two major themes (Lavender Model of Care and Philosophy of Care), with multiple sub-themes and codes see . See FigThe Lavender Model of Care is a six-dimensional model based on participants’ views of their services, responsibilities, and experiences of working at the mother-baby unit (MBU), including: mental health care, physical health care, looking after baby, mother-baby relationship, fostering relationships, and community support.Providing mental health care to patients was identified to be the primary goal of admission at the MBU: “the key admission goals for mums would be to improve their mental health” .Mental health care commenced with a comprehensive perinatal mental health assessment which included exploration of a consumer’s trauma history, including experiences during childhood and obstetric history. Clinicians sought to understand: “…what their childhood was like, the experiences they had, and things they’d like to change for their babies” .Kate (Psychiatrist) further suggested that assessing for psychosocial risk factors was important to consider during assessment. “It is important for MBU professionals to be able to sort of have the conversation with women about the domestic and family violence, and to have the skills to identify it and ask about it.”Having a thorough knowledge of perinatal mental health disorders, their underlying causes, associated symptoms, and presentation were identified to be essential attributes for working in an MBU: “…to work at a mother-baby unit, it is necessary to have the knowledge of what are the common mental health conditions that can happen. So having the knowledge base of what are the features of depression, antenatal postnatal depression, all the anxiety disorders. How to identify postpartum psychosis, bipolar disorder, and schizophrenia” .“If they  understand mum and her diagnosis well, then it’s easy to be able to give her the best care that you can because you are aware of what borderline is, how they present; or the presentations of schizophrenia, how they present; or how a postnatal depression looks like” .Understanding the impact of a mother’s mental health on her relationship and interactions with her baby was also important, and indicated the level of acuity of her mental illness. “Each person’s intervention is different because the situation is different. For example, we had a lady who had OCD traits, she was very cautious and apprehensive initially because of some compulsion that she felt during baby’s bath time. So, we provided her support and assistance with bathing her baby, just so she doesn’t feel alone and compelled to complete” . Amy furthered “Somebody comes in unwell, that they are feeling that they want to adopt their babies out because they feel that they are not coping because they are unwell. And to see that person even three weeks later to be shocked by their own thoughts, that they even thought that.”Participants further highlighted that MBU patients may present in times of crisis, so being able to assess for capacity and manage emotional dysregulation was important. “A good understanding of mental health is critical, and the capacity factor in understanding that within mental health acute crisis situations, there is a specific time when our patients will actually have the capacity and the ability to have insight into addressing their needs, so being quite sensitive to when would be appropriate to be addressing specifically identified needs, identified through the psychosocial screening process” . “If a woman with a personality disorder experiences emotional dysregulation, we will have one to one intervention with the woman and develop a management plan specific to her” .Given that a range of individual and group interventions  were offered to patients, having proficiency in executing diverse interventions was deemed to be critical. “We do a lot of sensory work as we get a lot of postnatal depression, anxiety, and personality disorder cases. And sensory modulation is amazing for that population” .“As a psychologist we have to be well versed in a number of interventions such as ACT [Acceptance and Commitment Therapy], CBT [Cognitive Behavioral Therapy], and DBT [Dialectical Behavioral Therapy] and even the relationship like Gottman work is a necessity… We do exposure response prevention for OCD [Obsessive Compulsive Disorder] patients, help with some depression support and anxiety support … to do with cognition diffusion. We do behavioral activation stuff minimizing self-harm or providing safer alternatives. Also do kind of red zone distress and tolerance stuff…Having good understanding of trauma and trauma interventions is important to work at a mother-baby unit. Groups that we run are for managing thoughts, mindfulness, diffusion of thoughts, mindful eating, emotional regulation, distress tolerance” .From a nursing perspective, a range of emotional, practical and recreational interventions were conducted to improve mental health. “We do art therapies that they show interest in or something we got equipment for, like we do pampering sessions. Take them for a walk. Sit in the courtyard with them, mainly listening to their concerns and showing them that their feelings are validated” . “In groups, we target advocacy for patients especially those who are under the Act [Mental Health Act 2016], like helping people understand their rights and services that we can provide. We do crisis counselling, grounding strategies or mindfulness strategies. I suppose assessing if people need that sensory support, like if they have done sensory toolkit with OT” .Staff reported that embedding interventions that other health professionals had recommended, and using both pharmacological and psychosocial interventions were important. “Our main focus becomes like a psychotropic management but there are other non-psychotropic interventions that we use in terms of monitoring or supporting patients. For example, sometimes I tell patients not to use medication for anxiety but to use other non-pharmacological therapy like use a fidget when distressed” .“In order to prepare consumers [patients] to feel comfortable with recommendations, we need to involve a lot of psychoeducation and sometimes do a brief CBT. As well as some mindfulness… and sometimes recommend medications too” .Assessment and treatment of patients’ physical needs was reported to be an important aspect as “physical health is often a big issue with them” . The physiotherapists, Osha and Penny, both affirmed that they assessed post-birth issues related to pelvic floor, bowel and bladder difficulties, and exercise engagement, as well as pain that may affect their mental health.“We normally go over the pregnancy and how that might have impacted the patient, we focus on their return to exercises, the importance of exercise for their mental and physical health and their pelvic floor…I would normally do a detailed physical assessment on everybody, so check their bladder and bowel, their delivery, their exercise history, their musculoskeletal history” .“There is a lot of pain, there is a lot of chronic pain, vaginal, incontinence itself, debilitating, there is a lot of emotion that goes with that, there is also a lot of pain that goes hand in hand often with mental health” .Physiotherapists provided a range of interventions based on the consumer’s interest and stage of recovery to target these physical health issues and promote positive mental health recovery, such as through walking, mother-baby exercise, pilates exercise, psychoeducation and starting a morning routine with exercises.“We get them back into things they used to enjoy as…they just lock themselves at home and don’t go out, so even though a walk seems very simple, that is very beneficial. Obviously, there is a huge benefit of getting them out and exercising on their mood and so we try to do it every day and try to get them into that pattern of starting the day and waking up, or ending the day. We do a healthy lifestyle group with the dietitian. Regarding return to exercise, the importance of exercise for their mental and physical health, and their pelvic floor.” .Dietitians focused on supporting the dietary aspects of recovery and providing management of underlying medical comorbidities, such as eating disorders, diabetes, or coeliac disease. “I do dietary assessment which involves looking at nutritional profiles of mother…Depending on the stage of recovery, we look into eating disorders and look into medical complication or food allergies. And we also do nutrition restoration, so if there’s any undernutrition, we do dietary planning” . Dietitians worked in collaboration with the OT to conduct cooking groups; where the OT will focus on the skills of cooking  and the dietitian will focus on the nutritional aspects.Sleep support was also provided to promote favorable mental health. “If needed, we provide protected sleep for the first few days. If they come in and they’re really fatigued and busted, we stand beside them and support them” . Post-caesarean recommendations in line with obstetric direction were also reinforced by the nursing staff, such as “not able to lift baby” or “use a hospital bed”  as mothers may be admitted within the first six weeks post-birth.Participants highlighted that caring for babies was a central element of care as participants “don’t just switch off from babies” . Given the link between poor maternal mental health and difficulties with child health , nursing staff focused on providing support with these child health issues. “A lot of babies have had reflux and colic, a reason, perhaps, that their babies being so unsettled, and that’s contributed to their mental health decline” .“We need an awareness around child health issues because you know often, that can be a precipitating factor in a woman’s current mental health presentation, and so it’s important that we as nurses are able to… offer that advice and guidance. Obviously making sure that it’s evidence based” .Interventions related to sleep and settling, such as education around sleep cycles, responsive settling, understanding baby cues, settling strategies and following the baby’s lead, were important aspects of babies’ care. To ensure the safety of the baby when sleeping, co-sleeping is prohibited on the unit. “One agreement that we recently created was the safe sleep agreement regarding mothers and babies not co-sleeping together. We don’t allow that because of sudden infant death syndrome, mothers being medicated and highly sedated, and as mothers may have thoughts of harm towards baby” .Both allied health and nursing staff highlighted the importance of feeding. “First and foremost, assessment is safety, assessing if baby is getting fed properly and regularly” .“Ninety percent of child health problems are dietary, often its weaning solids or feeding difficulties” . They described the need for educating mothers on breastfeeding, particularly surrounding medication intake, bottle-feeding and introduction of solids. Mothers often seek guidance on when to breastfeed after taking medications. “Mums are guided for things like medication and their interactions with breastfeeding. We have to assess how bubs (babies) are going developmentally in regard to feeding… breastfeeding, formula feeding or introduction to solids” .Nursing staff also taught mother-crafting skills to those who lacked confidence. “Some of them have never had anything to do with babies, so the basics, like breastfeeding, sterilizing bottles, interacting with their babies, even baby cares like giving the baby a bath, some of them don’t feel confident with doing that” . The OT (Natasha) also explained that assessing the safety and quality of activities of daily living, that mother and baby participate in, was an important part of her role. “We do functional task assessment, we go into community with babies, look at, you know, parent’s occupations in the community, public transport, shopping, cooking, or that kind of support”.As most staff were adult mental health staff, responding to baby physical deterioration and escalating appropriately was also highlighted. “Other core competencies include knowing how to do resuscitation of babies…and to be aware of deterioration and wellbeing in babies, and knowledge of who to contact in such situations” .Staff identified that assessment of infant development and providing strategies to mothers to promote favorable development, such as through play and baby massage, were crucial interventions. “We look into normal baby development: their physical, emotional, social, language development” .“My job is to look at developmental assessments. So, I’m concerned about baby’s behavior. I do Ages and Stages, and look into their social and emotional development” . Physiotherapists and OTs also described focusing on developmental assessment, play ideas, and tummy time.Protecting children was reported to be a critical aspect. “We follow Queensland Health guidelines on liaising with Child Safety as we have the sanctuary obligation as mandatory reporting of potential harm to infants” . Nursing staff played a key role in assessing mother-baby interactions: “With assessments, we realize if mum is being unsafe with the baby, then the Child Safety process is followed” . As the social worker, Hannah highlighted that her role was to educate mothers involved with Child Safety around processes and interventions. “If the infant goes into Child Safety, we arrange conversations with those mothers around the concerns and help the mothers understand the process of Child Safety so they know the focus is of them being reunified and so empowering and advocating for the mum, to basically effect the changes that Child Safety are requesting in order for them to be reunited”.Developing the mother-baby relationship was found to be an important dimension of care. Foundational in their clinical practice was that staff focused on the relationship between the dyad, conceptualizing the mother and baby to be one unit. “There is a lot more at stake in terms of working with two within the one... right at the core, is trying to figure out how they work together. They face difficulties getting to know each other, so we need to work together and help them develop a relationship [with their baby], so we need to nurture that” .Many mothers had difficulty forming loving and warm attachments to their baby due to their mental illness and previous trauma. “Mothers come in with reporting no attachment or very little attachment or highly avoidant of their baby, or express intrusive harm, thoughts and thinking that, well in the words of a patient, that they’re monsters…Their presentation gets in the way of attachment or bonding or normalizing to motherhood, thus having a good understanding and skills to deal with how trauma impacts attachment is important to work at an MBU” .“A lot of them [mothers] expressed that they don’t feel anything when they look at their babies, maybe they love their babies, but they don’t feel it…I find it challenging when mums perhaps put themselves first before their babies to the point that baby will be hungry, but they will see their needs first” .The multidisciplinary team at the Unit strived to improve the mother-baby relationship: “Sometimes they stay on the unit longer than they might on an acute unit because we’re working on the relationship between Mums and Bubs” . Quella (Psychologist) stated that, “Mothers are really anxious. At the start, they don’t know how to care for babies, they come in low in confidence. So, we work on improving attachment, developing a loving bond, and closeness between them”.Nursing staff utilized a range of mother-baby oriented interventions to build the mother-baby relationship, such as: role modelling and coaching of mothercraft skills; play time; providing the voice of the baby to the mothers; encouraging attachment building exercises ; and helping mothers understand baby cues during daily activities. “We do role modelling, like settling the bub or feeding or like engaging with babies. We do art therapy where mothers make baby footprints, for example” .Similarly, allied health professionals employed a range of strategies to help foster maternal-infant attachment, such as “group sessions on attachment and bonding, so touching on Circle of Security concepts” , and providing “psychological strategies and tools to build relationship with their babies” . The Physiotherapist (Penny) encouraged mothers to engage in exercises with their baby as a way to develop a warm attachment.The OT (Natasha) shared that, as mothers are easily overwhelmed and bothered by things that they can see, hear and touch, she used sensory modulation approaches to help mothers understand their sensory preferences and, in turn, bond with their baby: “The Sensory Profile that I see most in Lavender, is mothers who have sensory sensitivity and particularly to auditory input, visual input, and sometimes touch as well. So, mothers then struggle to connect with babies as the sensory input provided by a baby and their activities is quite overwhelming. Just think about the auditory input of babies crying and the visual input when playing with bright and colorful toys. But by understanding their Sensory Profile, this helps them understand themselves better and then they interact better.”Fostering social support from their partners, family, and friends was a pivotal dimension of care, as “we look into the important role that family plays” . “Because mother and infant dyads don’t exist in isolation, they are a part of a much bigger whole. Of course, that whole is those key support people around them, whether that be a partner or family or friend or community” .Family members and other social supports were engaged throughout “admission and care planning, discharge planning, to ensure a holistic and realistic care plan” . They were also supported with education and resources. “We speak about family members from the very beginning, so from pre-admission we start gathering all the information about family members or supportive people around the woman, and then incorporate them in treatment and strengthen their relationships…We also include family members in, or create, discharge meetings as well; whether based on site or on the phone, we provide them with psychoeducation, resources or like websites” .Families and partners were also involved in therapy approaches to support the implementation and awareness of strategies: “We do discuss in meetings the component of why she’s finding things difficult, it is probably because of the way that she processes the sensory information or because of their [partner’s] own sensory processing. It’s just very powerful when they understand this about themselves. It is important for partners to look from the other person’s point of view as to why they are struggling or what are the challenges; this helps them in understanding each other. So, it’s not always about Dad doing everything to make sure the environment is clean and quiet, but it’s also mum figuring out what dad’s needs are as well” . Lavender utilized counselling as an important strategy to foster patients’ relationship with their partners. “Mothers are counselled about father’s situation and journey to parenthood; how fathers were impacted by their wives’ mental health condition, how she should communicate about her mental health with dad’s and think about broader family structure” .“We do modelling with mum and dad of what it looks like to play with their child, engage with their child and build that social emotional connection when they are eating” . Recreational family activities are encouraged to foster family relationships: “On weekends where there are mums and dads, they play with their babies and chat with each other. We are hoping to arrange family barbeques” .Facilitating community support was reported to be an important dimension of care to help “set them up for their whole life” . This included supporting mothers and linkages with community services for transition back to home post-discharge. “We help support the transition to community services or we keep supporting that woman through consultation and liaison, and provide umbrella support for up to three months post-discharge” .“I do discharge planning and follow-up in the community to make sure they’re engaged post-discharge as well. I do consultation and liaison with community services state-wide. Can be, for example, writing a letter and advocating for childcare as it is free for 10 weeks post-discharge, or other individual programs for mothers and babies care as they might need physio sometimes” .As a range of needs are identified during admission that cannot be addressed in the limited admission, and require ongoing support, community services are referred to. “Some things can be addressed during the acute admission phase; other things are identified and then recommendations are made for post discharge care, to then facilitate and support the woman or partners or significant others to link in with relevant services down the track” .As a Statewide service, telehealth services were utilized as an important tool to connect patients with different services and improve access. “We do seven-day follow-up and also connect them to other services, sometimes we do face-to-face or do telehealth, especially in far areas of the state” .As mothers admitted had complex needs, patients required support from a range of different services  and were supported to link up with these services.“We have to link them with a community dietitian if they have an eating disorder. But to find a dietitian, they [the mothers] get triaged, but the dieticians at a public service isn’t always available state-wide, so we have to utilize other avenues such as contacting health precincts in certain catchment areas. We have to make sure that there will be dietitians available in their local community that might be linked with a certain GP” .“Sometimes we need private practitioners such as mother-infant therapists, governmental day programs such as Together in Mind and non-government organizations who run peer support programs and Circle of Security. Sometimes other psychological programs, domestic violence prevention services or women’s legal services, a refugee or migrant women’s resource centers, and trauma services need to be arranged” .“We help patients in identifying the community support around them, improving their access to community support, and how to navigate legal systems, in relation to family law, mediation etc., looking at Child Safety and facilitating and liaising with them” .Community support services and relevant external stakeholders were also reported to be included in multidisciplinary care reviews and other meetings, and invited to take part in collaborative care planning. “Most of the time we do care planning jointly with other service case managers when we handover patients. We invite them for care reviews and ask them what their role would be post-discharge and we also keep them in the loop post-discharge” .The Philosophy of Care Principles were underpinned by clinical practice and their attitudes towards patients and families. These included: Person-centered care, Trauma-informed care, Compassion-centered care, Recovery-oriented care, Attachment- and family-focused care, Strengths-based care, Non-judgmental care, and Interdisciplinary care.The treatment and therapeutic programs were guided by patients’ preferences and goals: “…it’s about what client wants…I look at the person and tailoring what it is I have to say to the person’s personality and style rather than being prescriptive” .“Some mothers are really active in their adult life, they want to go to gym, in that case I take them to gym and design gym program for them” .“We take in consideration consumers’ [patients’] goals and practices and our job is to make them achieve those goals” .Understanding the mother’s experience with trauma, such as during childhood, recent pregnancy-related difficulties, and other stressors, was highlighted as vital. “We look into the trauma history from the past. It can be very sensitive and that can be very triggering to people, how their childhood was like, if they were happy with their childhood, and whether there were things they’d like to change because it often impacts on how they perceive their goals with parenting…What’s happened in the past with them, how has their pregnancy experience been like for you, and you break that down into trimesters first, second, and 3rd trimester. Did they have any miscarriage, termination, stillbirths?” .Recognizing the signs of trauma in the mother’s behaviors and how they interact with their baby was also viewed as significant. “You need to understand the mother’s background and her previous attachment trauma as it helps explain her behavior. For example, a mother may push someone away because they’ve been rejected a lot in the past and they want to protect themselves” .Additionally, adopting interventions to address trauma was perceived to be foundational. “Having a good understanding of trauma, and trauma interventions, such as avoiding re-traumatization, is important to work at MBU. And understanding those trauma responses, such as dissociation and avoidance, are important” .A key philosophy of care was to show compassion and empathy towards every patient, particularly as the patients had been through difficult situations, and to support optimal outcomes in the therapeutic relationship. “With mental health patients we have to be kind, compassionate, and understanding” .“When you hear their background, you become more compassionate and think, wow, that must be really hard” .“I try to be very sensitive and always kind because in my 30 years’ experience, I have learned kindness, compassion, and rapport building makes a lot of differences in other people’s lives” .Clinical care was recovery-oriented, as staff held hope for the patients in improving their mental state, maternal-infant attachment, and overall functioning. Staff voiced that they played a role in the recovery process and were heartened by the difference they could observe from start to end of admission. “We become part of that recovery-based journey and you see big differences in patients. They come in depressed and leave functioning and continuing on the road of recovery” .Staff also noted the positive change in the relationship between the mother and her baby over the course of the admission. “It’s amazing when you see new mums coming in, struggling with having no feelings of love, or no feelings of that real mother-child bond, and then seeing that build in confidence before they leave. They get so organized and recover so much when you look at them at discharge” .To support recovery, staff focused on the transition back into the community after discharge. “From the physio’s perspective, I focus on getting them back into things they used to enjoy, and things mums want to do post-discharge” .A foundational principle was to “think about mother and baby together, and keeping in mind who is around them to provide support” , such as the partner, grandmother of the baby, friends and other key support people. “Thinking about the dyad, that mother-infant relationship, and in the context of the family, is imperative to the work we do within a mother-baby unit” . Consideration of the mother, baby and the dyad together was identified as crucial, with staff reporting: “I guess the challenge or difference is that we are working with mother-baby dyad and we have to be mindful of that, we have to consider them both while designing appropriate interventions” .“Within Lavender, I think it is that mother-baby dyad that is unique, so you have to consider both together” .Strengthening the attachment relationship between mother and family was highlighted by Hanna  when she explained, “We look into patient’s attachment history and how it is impacting on their current mental health and relationship with their infant and partners, and how it impacts their current health and what interventions could basically improve and strengthen their attachment.”Staff were also upskilled in working with families through recognized programs: “What we’ve done is, with particularly the nursing staff, they’re all gradually going through, attending the Family Partnership Training through Child Health, and which they’ve said is very beneficial” .Being non-judgmental was highlighted to be a core attribute for clinicians when interacting with mothers struggling with parenting and who had difficult backgrounds that affected their presentation. “It requires us to be non-judgmental, especially in this unit. It’s the hardest unit because there are babies involved and you do feel protectiveness towards them…They come from all different backgrounds, all different childhoods, different mothers, crafting abilities and you have to be non-judgmental in meeting them, treating them and caring for them” . Another nurse (Victoria) also acknowledged that “definitely, being non-judgmental is a big thing because we see mums from all walks of life”. Clinicians also responded to mothers during individual and group therapy sessions in a non-judgmental manner. “In group settings we discuss a series of topics of interests and encourage them to ask questions and give them answers in a non-judgmental way” .The Lavender Model of Care was found to be strength-based, where patients’ strengths were harnessed to facilitate recovery. “We look at their strengths and what they do well and try to exploit that towards their recovery rather than focusing on their deficits” .Staff also felt it was important to support women in their mothering role: the “goal is to empower mums to see their potential as a mother, as a lot of women come in with a lack self-esteem and confidence, so our job is to make them stronger” .Women were empowered to manage their mental illness to support their recovery. “How do I live with mental illness and how can I parent with mental illness and so to give them that empowerment, to give them that knowledge and to watch them grow from their mental condition” .The model of care was revealed to be underpinned by an interdisciplinary approach, where professionals from different backgrounds brought their unique knowledge and skills together towards the single goal of a patient’s recovery. Adopting an interdisciplinary way of working was also perceived to be more effective than working in a silo.“At Lavender, we follow a multidisciplinary team approach, which is really positive. There is lots of sharing, assessments, discussions or working together with the other members of the MDT. Say, for example, combining with the physio for a healthy lifestyle type approach or combining with the OT for functional assessments and community engagement or with social worker, child health nurse, pharmacist, psychiatrist…What we could do together as a team is lot more than what we could do as an individual” .“We basically have a service therapeutic model where all the staff skill set adds on and works much efficiently than what an individual professional can offer” .In particular, the allied health team collaborated closely together. “We have got the whole allied team that works together as a unit across different facets of patient’s recovery” .A key forum in which staff communicated with each other regarding the care plan, were the community and inpatient case reviews. “Community case reviews happens twice a week, that’s the intake multidisciplinary meeting, attended by consultants, team leaders for the social worker, me, nursing team leader. We discuss case review and intake assessments” .Regarding inpatient case reviews: “we do case review as well, so you get discussion with the multidisciplinary team. So, after that meeting is finished, I would generally go down and do a mutual help meeting, so that also runs in conjunction with our other Allied Health members” .This study is the first to qualitatively explore the model of care and philosophy of care undertaken by multidisciplinary clinicians in a psychiatric MBU. The Lavender Care Framework includes six dimensions to the model of care, and eight underpinning philosophical foundations of care. The dimensions of the model of care included mother’s mental health care, physical health care, baby’s care, building the mother-baby relationship, fostering relationships with supports, and facilitating community support. Foundations of the philosophy of care that were identified include: person-centered care, trauma-informed care, compassion-centered care, recovery-oriented care, attachment-informed care, non-judgmental care, strength-based and interdisciplinary care. The Lavender Care Framework provides an overarching practice framework for management of mothers with significant mental illnesses who are co-admitted. The Framework outlines key goals and therapeutic strategies employed from admission to discharge, including assessment, treatment, and discharge planning. The domains also inform the development of a core capability framework for clinicians that highlights knowledge, skills and attitudes considered highly pertinent for multidisciplinary clinicians working in this specialized area.The dimension of ‘mental health care’ underpins the primary goal of the service, and includes a comprehensive understanding of psychiatric disorders and associated causes, risk factors, assessment and treatment options. Clinicians also considered it imperative to understand the impact these health issues have on the child and support network of the patient. This is in keeping with recommended care for women, who may require a wide range of targeted psychosocial interventions based on their history and needs, as well as support for any partner or family member involved . ‘PhysicThe model of care elements in the Lavender Care Framework are also consistent with existing patient-centered clinical assessment tools for mothers in the perinatal period . The New Mum Star, an outcome measure for a nurse-led home-visiting program for first-time mothers in the community, consists of similar domains: health and wellbeing, looking after baby, baby’s development, safety and stability, connecting with babies, relationships, life skills, goals and aspirations, and family and support network . Anothern = 11) [Only one other study has examined the perspectives of staff working in a psychiatric mother-baby unit (n = 11) . While Gn = 11)  also ideThe philosophical foundations of care highlight the underpinning lens—“ways of being” and attitudes that were considered important by healthcare staff working at MBUs. Analogous to the base of an iceberg underneath the water, the philosophy of care constitutes paradigms that permeate every interaction provided at the MBUs. The staff reported that being patient-centered was important as it meant patients and carers were involved throughout the admission process to support the mother’s recovery and wellbeing . This tyThe Lavender Care Framework acknowledges the impact that maternal mental illness has on a mother’s relationship with her baby and her practical skills in caring for her baby, as well as treatment approaches to support mothers in these ways. Psychiatric episodes are triggered by childbirth, causing significant morbidity and mortality, including suicide being a leading cause of maternal deaths . This reThe Lavender Care Framework is in in line with other models. For instance, similar to the Biopsychosocial Model, the biological, psychological, and social characteristics of both the mother and the baby are assessed and treated . The Framework is also congruent with the World Health Organization International Classification of Functioning, Disability and Health as components of health condition , body functions and structures , activities and participation , environment , and personal factors  are recognized as targets during goal setting, care planning and post-discharge support . The LavWhile a purposive sampling strategy ensured that a large proportion of nursing staff and all other multidisciplinary clinicians were recruited from the mother-baby unit of interest, only one mother-baby unit’s staff were examined. Despite the Lavender Care Framework being consistent with other models, this may limit the generalizability to other MBUs. While predominantly individual interviews were completed, some nursing staff were interviewed in a focus group with only nurses of varying levels, which may have biased the information obtained. While other units highlight the benefit of peer support workers , there iThe Lavender Care Framework may be used to support core capabilities of staff working in an MBU. The core capabilities may outline key knowledge, skills and attitudes of multidisciplinary staff in an MBU as this is a specialized area and requires high expertise. Reflecting on these dimensions and philosophical foundations informs selection, onboarding and ongoing training support for staff to provide care that is specific to MBUs. The Lavender Care Framework also ensures that there is comprehensive and high-quality assessment and treatment to aid a mother’s recovery. The Framework has benefits for other MBUs and may be particularly relevant for new MBUs that are being established. Having a consistent model and philosophy of care will support high reliability healthcare and systemic agreement between different units. This is particularly useful for MBUs that share catchments together  or will pool data together for benchmarking purposes. This Framework can be embedded in MBU service profiles which are helpful for stakeholders  to understand what an MBU admission focuses upon. Future studies could also investigate international differences in MBU staff perspectives and examine how we can best evaluate these domains of intervention.This study presents a framework that identifies the key dimensions of intervention and philosophical foundations of care that clinicians consider important in the care of women with significant mental illnesses and their baby. This study used qualitative approaches to develop a framework which enables holistic and comprehensive care, is evidence-based, and overcomes shortcomings of existing models. The results highlight six dimensions that inform care planning within an MBU setting and provide a template for setting holistic recovery goals that targets mental health, physical health, baby’s health, mother-baby relationship, and community relationships. Finally, the study reveals philosophical underpinnings of healthcare staff working at MBUs to support care that is respectful, compassionate and oriented around the consumer’s strengths. The Lavender Care Framework is pivotal in supporting the unique needs of mothers with severe mental illness co-admitted with their baby in an acute inpatient setting.


Patients with rhegmatogenous retinal detachment (RRD) require face-down positioning (FDP) for 3–6 months or longer after pars plana vitrectomy (PPV) combined with silicone oil (SO) tamponade. This paper aimed to identify the factors that influenced FDP compliance. This study adopted semi-structured interviews with patients who require FDP after SO tamponade. Constructivist grounded theory was utilized in this study. The qualitative data was analyzed and coded via NVivo 11.0 through open coding, axial coding and selective coding. Twenty-four RRD patients were involved. The interviews yielded five main themes that defined home FDP compliance were identified: posture discomfort, doctor-patient communication, psychological factors, occupational character, and family factors. A theoretical model of the influencing factors of postural compliance of FDP was constructed based on the interview analysis. A variety of factors can affect FDP conformity. We can increase compliance of RRD patients by enhancing comfort, encouraging doctor-patient communication, providing comprehensive care, promoting community-based intervention, and strengthening family education. The difficulty of treating RRD varies depending on the location, size, and duration of detachment and the age of the patients2. If surgery is not performed in time, it can lead to permanent loss of vision3. Retinal detachment is a heterogeneous condition, ranging from limited chronic detachments to high bullous detachments, which can progress slowly or rapidly with subsequent vision loss. The difficulty coefficients of surgery are significantly increased, from a single localized retinal tear to complex cases of advanced vitreoretinopathy4. Retinal detachment mainly occurs in patients with older age, high myopia (myopia degree greater than -6.00D), history of ocular trauma, or a family history of retinal detachment5. Pars plana vitrectomy (PPV) is a common surgical procedure for retinal detachment7. After vitrectomy, SO is often filled in the vitreous cavity, and the retina is pressed by its buoyancy to maintain the pressure in the vitreous cavity  every day. Regardless of the body position, such as prone, seated and standing, the eyes must remain parallel to the floor9  is a potentially blinding condition characterized by the separation of the retinal neurosensory layer from the pigment epithelial layer12. Clinical studies have found that compliance with home FDP may be even worse13. Poor compliance may result in a longer SO tamponade time, causing a series of complications like high intraocular pressure, cataract, SO emulsification, keratopathy, and the formation of the epiretinal membrane15, as well as an extended retinal reattachment time or unsatisfactory vision improvement, which may trigger doctor-patient contradictions and disputes. The following questions deserve further consideration. What are the challenges that patients face when they are in FDP? What features of medical personnel should assist patients in improving their posture?Previous studies have been based primarily on patient compliance with in-hospital FDP after SO tamponade. Studies have shown that patients’ compliance with the FDP in hospitals gradually decreased over timePrevious studies focused on the degree of standardization of FDP in hospital settings, which cannot be used for physician assessment and clinical guidance of patients' long-term home FDP. In addition, previous literatures were quantitative studies and overlooked the effects of factors such as self-perception, beliefs, real-life stress and family support on FDP adherence. In conclusion, there is a lack of a comprehensive study on the influencing factors that affect patients’ FDP compliance, especially home adherence. In this paper, we use a qualitative research method to investigate the compliance of long-term home FDP in patients with RRD after hospital discharge, taking into account psychological and family social factors, in order to provide a theoretical basis for improving patients’ compliance with long-term FDP after hospital discharge.17. Grounded theory is a qualitative research method that employs systematic procedures to create and infer a theory based on real-world facts about a certain phenomenon18. Constructivist ground theory developed by Charmaz, assumed that the theory is developed by researcher based on data, constructed with participants usually by interviews19. The unique characteristics of constructivist ground theory, simultaneous data collection and analyses, theoretical sampling, constant comparison at each stage of analysis, development of memos for reflexive and comparative analysis, are used to guide the analytical process of building a theory20. This paper intends to conduct a qualitative study using constructivist grounded theory to investigate the factors affecting FDP compliance in RRD patients who residence at home after SO tamponade, with the goal of identifying positive coping styles and intervention measures to improve FDP self-management in these patients.Qualitative research is a method in which the researcher analyzes, categorizes, and refines certain common characteristics and connotations, based on subjective information about the research subject obtained from in-depth interviews, participant observation, inquiries into archives or records, and articulates the findings in writing16. This approach helps to reveal the factors that influence home FDP adherence, as well as to better understand and grasp the reasons for poor compliance in patients with RRD.This qualitative study is based on individual semi-structured interviews guided by grounded theory. Grounded theory creates a theoretical model “through observing a study population and developing a comparative analysis of their speech and behavior”20. Theoretical sampling is applied to explore an unclear analysis category, which contributes to define the specific participants. After the semi-structure interview outline is created, the researchers will start simultaneous data collection and analysis. Constant comparison is used to analyses and build categories by comparing data with data, codes with codes, and incidents with incidents21. Memoranda are an informal approach to record researchers’ idea, reflection, and possible connection before starting and when collecting and analysis data22.The guideline of using constructivist grounded theory have some common characteristics, including theoretical sampling, constant data collection, analysis, and comparison; as well as, memo writing and theoretical developmentTo ensure the diversity of the research team and the rigor of the interview content, this study included a total of 12 experts, three each of ophthalmologists with senior professional titles, attending psychiatrist, nursing experts with senior professional titles, and psychologists with senior professional titles.The participants were recruited from the ophthalmic ward of a general hospital in Taiyuan, China. This study focused on RRD patients who require FDP after vitrectomy with SO tamponade. The patients invited to the study had the following characteristics: (1) diagnosed with RRD, (2) PPV surgery with SO tamponade, (3) FDP for at least 3 months after surgery, and (4) all patients signed an informed consent form and voluntarily agreed to participate in the study. Exclusion criteria: (1) communication barriers, including psychological problems, (2) unable to complete the interview and communication independently, and (3) refuse to accept telephone interview.24, which was suggested by Glaser and Strauss (1967) as “the process of data collection for generating theory whereby the analyst jointly collects, codes, and analyzes his data and decides what data to collect next and where to find them, in order to develop the theory as it emerges” (p. 45). Data were collected through one-on-one telephone semi-structured interviews from November 2021 to April 2022. The interview length of each patient was around 30 min, and the interviews were conducted in a quiet or private environment. The researchers consist of twelve personnel with senior professional titles in different occupations. The outline for the semi-structured interviews was developed by researchers after reviewing similar papers and group discussions, and the initially developed outline was adjusted after the pre-interview. The researchers evaluated the FDP of RRD patients and conducted in-depth interviews with the patients with poor self-management. The interviewer asked, “Is your self-management of FDP consistent with the requirements of medical staff?”. The final questions were as follows: (1) “Could you tell me your feelings and thoughts in the FDP?”; (2) “What are the main difficulties in maintaining this position?”; (3) “How do you relieve when you are feeling uncomfortable?”; (4) “How does FDP make changes to your daily life?”; (5) “Would you share any other information not mentioned?”  to identify specific topics27. (1) Open coding. The transcribed text is treated with privacy, and the document name is set to be replaced by the number when the respondent is included, such as P1, P2, …, P24. Define the content of each paragraph, find out and encode the subtopics. (2) Axial coding. Classify the relationship and logical order obtained by open coding, refine the theme, and integrate and conceptualize the data. (3) Selective coding. It refers to the selection of a “core category” that plays a leading role after systematic analysis in the category. Memo writing was also applied to data analysis to get the conceptual and theoretical ideas through free writing by the analysts22. Researcher reflexivity was the important part of the coding process. The memos, field notes, and the feeling of the participants combined to add credibility to the findings.The interview data were analyzed based on grounded theory, which is characterized by a constant comparative method of analysis . In this study, the process of analysis began at the same time as data collection, as well as, constant comparisonResearch ethics approval was obtained from Shanxi Bethune Hospital (YXLL-2022-090). The research was performed in accordance with relevant guidelines, and informed consent was obtained from all participants or their families. It has been performed in accordance with the Declaration of Helsinki. The dataset analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.All of the interview participants had the cognitive ability to read and understand the participant’s information sheet and agreed to participate in the study voluntarily by signing the informed consent sheet. Before the interview, all researchers had no prior relationship with the participants. The researchers introduced themselves and explained the purpose and methods of the study. Participants can drop out of the study at any time. The researchers promised not to use any personal identifiers in research reports or publications.This study involves human participants and was approved by the Shanxi Bethune Hospital Ethics Committee.A total of 24 patients were included in this study. The median age was 59 years old  Table . The demThere was no doubt that physical and eye discomfort caused by long-term FDP was an essential factor for the poor compliance of RRD patients. Although the doctors and nurses informed the patients of the possible discomfort of the eye and the body of long-term FDP before the operation, the patient still felt unable to maintain this position for 3 months or even longer.“I’m too skinny to hold the FDP position because when I get down, the bones in my chest pinch and I can’t breathe well. My son bought a metal frame for me to sit on and get down on.” P3In addition to chest discomfort, other patients reported discomfort in other parts of the body as well.“I was sitting in the FDP and my waist was mainly uncomfortable.” P1“My head was uncomfortable when I got down. Sometimes I felt nauseous and wanted to vomit.” P5“That position made it difficult for me to breathe, and my throat, arms and shoulders were uncomfortable.” P13“Whole body was uncomfortable” P23Through the word frequency query function of QRS NVivo 11.0 software (minimum length set to “2”). It was found that “no”, “comfortable”, “feel”, and “now” were the most frequent word throughout the interview, suggesting that posture discomfort was the main factor affecting patients’ self-management. Most patients chose the prone or seated position for FDP. In the prone position, a U-shaped pillow was placed under the face, but prolonged time in this position can lead to poor breathing and physical discomfort. In the seated position, the U-shaped pillow was usually not placed, and breathing was maintained by placing the hand under the forehead, which may lead to hand discomfort  rose when I didn’t lower my head in the early stage.” P10“When I lied down, my eyes were swollen and blurred.” P22In addition to physical discomfort, some patients experienced eye swelling after SO tamponade, which may increase discomfort and decrease compliance.“For example, sometimes things are held in the wrong place and not focused on one point.” P10“I had no idea how far it  was more than a meter away. There was no sense of distance.” P10“I was afraid to leave the house. I can’t do anything. I still put in a lot of effort on my own walkway straightly, and I was unable to work.” P23SO may also lead to blurred vision, binocular anisometropia, glare, and a variety of other symptoms, all of which can have an impact on the patient’s daily work and life. Compared with glare, binocular anisometropia had a higher impact on patients. The former can be alleviated by wearing sunglasses or going out in dim light; however, the latter was difficult to overcome. Furthermore, the focus deviation of SO-tamponade patients' eyes might cause inconvenience in daily tasks, taking objects, parking, etc. The reduction of balance caused by focus deviation was linked to some life restrictions on the patients. Patients’ feelings of powerlessness over “simple things” may lead to anxiety in the long-term phase, which had a certain relationship with patients' compliance.Doctor-patient communication refers to the communication between doctors and patients during the diagnosis and treatment of diseases in order to facilitate the treatment of patients’ diseases and meet their health needs. It is a two-way conversation. Compliance with the FDP must be closely monitored by the medical staff and the patient (or the patient’s family). Lack of clarity in medical staff advices or lack of proactive questioning about FDP adjustments, adjustment made by patient, and less follow-up visits may reduce FDP compliance and increase some complications.“They (doctors and nurses) did not explain the length of time and importance of FDP. They just said I had to get down.” P2“All this time, the doctor probably thought I might not be so severe, and at first she said it was necessary to get down for five or six hours a day, and then she did not say (change) and I did not ask the doctor. I just did not keep lying down.” P20From a health care perspective, inadequate patient education on FDP, unclear recommendations for FDP time modifications, and infrequent follow-up visits to patients are the main reasons for poor FDP compliance. The low knowledge and acceptance reflect the lack of patient education by healthcare providers. Lack of clarity in medical advice occurred mainly during the discharge and the follow-up process. Specifically, the FDP time and posture requirements may not be clearly explained at the time of discharge; and at the follow-up time, the doctor may forget to explain the FDP time adjustment. This often leads to a misunderstanding between the doctor and patient. The doctor may think that no special instructions mean the medical advice is the same as before; the patient may think there is no special emphasis therefore may reduce the time of FDP or even not to maintain it.“When I was in the hospital, the nurses checked the accuracy and length of postoperative FDP several times a day, gave guidance and advice, encouraged me, and told me the posture was important. When I went home, there was no one to monitor and remind me or care if I had enough time to do it.” P15The low number of follow-up visits is an inevitable reality. Medical staff are stressed and busy, and a great deal of time and energy is devoted to inpatients and outpatients, which makes extended care a relatively inadequate. In addition, some patients are far from the hospital and do not feel the care and encouragement of the medical staff, which also makes them less compliant.“I did not go for a follow-up last time and did not ask my doctor how to get down, and I lied in a prone position less now.” P16“I need to work on weekdays and have time on weekends. However, the doctor I wanted to make an appointment with was not available on the weekend and I did not make an appointment with another doctor for a follow-up appointment.” P9Regarding the patients, there are three main reasons for poor adherence. First, patients may forget to ask about FDP adjustments; in addition, they become tired of adhering to the position during follow-up and are likely to make their own adjustments, mainly by reducing the duration of the FDP. Second, they may have reduced their time in the FDP on their own when they knew their eye condition had improved and the doctor did not “emphasis” the FDP time. Third, some currently employed patients prefer to come in on weekends for follow-up visits; however, the outpatient time for doctors is usually scheduled on weekdays. For these three reasons, they may modify and adjust the FDP time on their own. Fewer follow-up visits also lead to poor adherenceThe influence of psychological factors on FDP is mainly in two aspects. First, FDP needs to be adhered to for a long time. As time passes, some postoperative discomfort relieves and mood relaxes gradually, and patients may become noncompliant and seek a more comfortable body position. Second, the lack of improvement in vision during long-term adherence to FDP may lead to a lack of self-efficacy. Chronic blurred vision raises doubt about the recovery of vision after SO extraction.“When I first started, walking upright for a little longer made my eyes uncomfortable, and now that I can walk without any discomfort, I don’t maintain the required prone position as strictly as I did when I first had the surgery.” P10“I felt that I have made a full recovery after 3 months. I was so tired to lie in the prone position, I stopped doing it.” P23“They (eyes) kept level with the ground when I was in the hospital. But when I returned, I always felt as if it had been a waste of time.” “I figured it didn’t matter whether I lay down or not.” P13As time passes and some symptoms subside, patients may become less compliant. Some patients believe it is human nature to seek a more comfortable body position.“After 3 months of staying prone position, my vision did not improve, so I spent less time on that.” P25Patients’ compliance behaviors were directly influenced by self-efficacy. Although medical staff indicated that maintaining the FDP did not help the patient’s vision during SO tamponade, however, as time passes, patients may worry about whether their vision will improve after the SO is removed.Each patient has different division of labor. Inevitably, different positions correspond to different levels of salary. This makes the economic level of each family different and has a great impact on the standard of living.“We live so far away that it costs 500 or 600 RMB for the travel. I am a farmer and I am over 80 years old. I did not have much source of income. The cost of the surgery was very high for me and health insurance only reimbursed half of it.” P3The analysis of the interview results suggests that the compliance of currently employed patients may be relatively better than that of unemployed patients. This is mainly related to the fact that the unemployed are mostly composed of a group of farmers who perform more physically demanding work. Secondly, the unemployed and freelancers have lower health insurance reimbursement rates than the employed or retired.“I have been maintaining FDP for 6 months, and I have spent tens of thousands of RMB on this surgery, and I have no source of income, so I definitely have to find something to do, otherwise I can’t afford to support my family.” P23For some patients, the cost of surgery accounts for a large portion of household expenses. In addition, these patients are unable to perform heavy work for up to 6 months after surgery, and their family income is significantly reduced. The above reasons lead to an imbalance of income and expenditure for these patients’ families, forcing them to work and thus not securing enough FDP time.Family factors inevitably influence patients’ compliance with FDP. In the Chinese culture, each family member feels obligated to perform household chores, especially women. Generally, family members can accept that patients do not do housework in the short term due to the maintenance of the FDP after surgery; however, in the long term, most female patients cannot avoid doing housework.“It was winter, and I still needed to cook and pick up the kids. When I had free time, I just lied down for a while.” P23Some female patients need to take care of their families and do housework after surgery. The burden of housework poses a challenge to their FDP time. Some patients felt they had spent a lot of money on surgery, and not doing housework added to their feelings of guilt.“After 100 days, I did not get down anymore, and my son kept scolding me, saying that it must be bad for my health if I lied there every day and did not move back and forth.” P3The reasons for poor FDP compliance were related to the lack of knowledge of FDP management among family members. Some family members did not understand the necessity and importance for FDP, believed that staying in bed all the time was not good for the patient’s health, and even urged them to reduce the time of FDP.16. Constructivism as the philosophical foundation of ground theory. Constructivist ground theory assumes that as human being, the researcher is biased, since they have their own opinions, values, and professional cognition. In constructivist ground theory, researchers assume that data and analyses are social constructions, and participants and researchers alike construct meanings. Therefore, any analysis developed through research can both reflect the participants’ experiences and the researcher’s perception of the phenomenon. Evidently, the constructivist ground theory, differs from the original version of ground theory by Glaser and Strauss, which claimed that the original theory is discovered in the data, and it is not influenced by the researchers. Constructivist ground theory can be considered as an innovation of ground theory20.Grounded theory is a theoretical model “through observing a study population and developing a comparative analysis of their speech and behavior”Under the guidance of constructivist grounded theory, this study carried out a qualitative study in the form of in-depth interviews, and obtained five themes of home FDP compliance of SO filled RRD patients, namely posture discomfort, doctor-patient communication, psychological factors, occupational character, and family factors Fig. . On this28. Most of the investigated patients used ordinary U-shaped pillows to maintain their posture, with poor air permeability. The hand long-term support on the forehead resulted in neck, arm or lumbar discomfort. Providing comfortable, inexpensive and easy-to-use support for patients is essential to improve compliance with FDP29. Upper body support from the chest to the pelvis helps to place the upper body above the lower body, thereby reducing back stress. Limb exercises and postural alternations during FDP maintenance are also useful in the treatment of back, neck, shoulder and lower back discomfort28. In addition, the study has shown that the simple oil massage can reduce immediate pain in patients undergoing FDP, while aromatherapy massage with essential oil had a long-term effect on pain relief30. Patients are advised to choose a physiotherapy bed. The facial sinkhole in front of the bed is designed to accommodate the patient’s facial breathing. To divert attention, increase comfort and pleasure, and make FDP maintenance more user-friendly, patients can also see electronic devices or drink water through the sinkhole. Hara et al.11 found that patients who used the TV-watching table was more satisfied than the patients who did not use it. Therefore, the improvement of care system is crucial to physical and mental health of patients, especially for the patients with elderly, obesity, coronary heart disease, and vertebral column troubles32. Due to the high refractive index of SO, the refractive index of the eye changes significantly and the visual acuity decreases significantly10. For patients with postoperative refractive partials, glasses are recommended for partial correction to facilitate daily walking and living.Previous studies have shown a number of ways to improve compliance with FDP and to make its application more pleasant for patients. Postural comfort after SO tamponade is strongly associated with FDP compliance9. In conclusion, encouraging patients to take additional medications and to perform interchangeable FDP may be effective approach to maintain this position. To address the issue of psychological relaxation, follow-up, care, and inquiring patients should be enhanced, and patients should be asked to follow medical advice to reduce complications.By standardizing medical practices, ambiguity in medical prescriptions due to omissions can be greatly reduced. We need to develop a review process for SO-filled patients. The FDP adjustment protocol, including: PPV procedure time, follow-up time, tear location, and prone time, should be pasted in the medical follow-up records of patients after SO filling to ensure the process is completed. Patients with high IOP need to be reminded to follow up on time, and seek medical attention for special conditions at any time. Doctors can extend the FDP time appropriately, and prescribe IOP-lowering medications according to the patient's condition. Other studies have found that IOP in FDP varies depending on the face-down position; FDP has the lowest IOP in the seated position and the highest IOP in the prone positionFor unemployed patients who are labor-intensive due to their occupational characteristics, a diagnostic proposal can be issued and the patient’s community can be contacted to seek help and solutions to find suitable jobs and alleviate economic stress during the FDP. In addition, hospitals and communities can actively contact relevant social institutions such as women's federations and disability federations to provide assistance to patients with difficult family conditions. Health education is crucial to improve patients' self-care and self-efficacy. To enhance patients’ understanding of primary disease and FDP and to master and standardize FDP, the department can regularly push demonstration action videos in WeChat groups, hold lectures on the Internet to enhance patients’ confidence with examples of recovered patients, and conduct patient education through cases of disease complications and recurrence caused by poor FDP compliance.33. Encourage patients' families to actively participate with patients in patient education, learning, and health guidance to increase family attention to patients’ FDP. Attempts to reduce the stress of household chores and prevent patients from compromising their postural time due to family obligations are also effective. At the same time, medical staff and patients’ families should spend more time in accompanying, explaining, and reassuring patients and providing timely psychological support. In conclusion, timely follow-up visits and health education are necessary to improve patient self-management, maximize the standardization of FDP, save medical resources, improve patient satisfaction, and promote doctor-patient communication.The patient’s family plays an important role in the management of FDP. When family members are knowledgeable about self-management, they can act as supervisors and guides to promote higher compliance. Studies have shown that family-centered education greatly improves treatment adherenceThis study has the following limitations: (1) The coding and theoretical model may be subjective. The representativeness of the small sample and the generalizability of the findings have not been tested with a large sample. Whether the theoretical model can explain the influencing factors of FDP compliance still needs to be further explored. (2) The respondents of this study were ophthalmology patients from Bethune Hospital in Shanxi. Considering the differences in economic levels, medical models and health education approaches in different regions, the study results may have some limitations. (3) At present, there is no clear standard for patient's compliance with the FDP. This study may have some bias in determining the compliance of patients according to the consistency between the patient’s position time and the doctor’s requirements, also the standardization of the posture. (4) In order to minimize bias and power asymmetry among different interviewers, a trained physician was selected as the interviewer. This interviewer had a senior professional title in ophthalmology, and was able to give professional explanations about the patient’s condition and postoperative complications or discomfort. However, we must admit that this may not be entirely avoidable .Supplementary Table 1.