Implementation burden and hidden labor in a multisite digital psychiatry trial

Background: Multisite digital psychiatry trials increasingly rely on complex onboarding and implementation processes at local research sites. While outcome-focused evaluations are common, less attention has been paid to the site-level labor required to operationalize such studies in real-world settings, particularly at smaller or resource-constrained sites. Methods: This paper adopts a reflexive, practice-based qualitative approach to examine onboarding and implementation processes at a single Latvian research site participating in a multisite digital psychiatry trial (ClinicalTrials.gov: NCT04953208). The analysis is based on systematic reflection informed by site-specific documentation, onboarding timelines, internal communications, and longitudinal involvement in site coordination and implementation activities. An inductive thematic approach was used to identify recurring challenges and contextual factors shaping implementation burden. Results: Five interrelated themes were identified: hidden labor and role overload; resource scarcity at small research sites; fragmented remote communication and technical coordination; multi-role professional contexts and competing demands; and the impact of external systemic disruptions. Findings illustrate how diverse administrative, technical, logistical, and coordination tasks were absorbed into individual roles, often exceeding initial role expectations. Despite limited resources, the site achieved high performance through intensified individual effort, masking the true implementation burden. Reliance on remote coordination redistributed labor onto site personnel, while external crises further amplified workload and uncertainty. Conclusions: This site-level reflexive account highlights the central role of hidden labor in sustaining implementation in multisite digital psychiatry trials. Recognizing and explicitly resourcing implementation work, particularly at small research sites, may improve feasibility, sustainability, and equity across study settings. Reflexive, practice-based approaches offer valuable insight into implementation processes that are often invisible in outcome-focused research.