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. This study addresses this gap by examining hidden implementation labor from a single-site reflexive perspective. Methods: This study adopts a reflexive qualitative case study approach to examine onboarding and implementation processes at a single research site participating in a multisite digital psychiatry trial (ClinicalTrials.gov: NCT04953208). The analysis draws on longitudinal experiential data, supported by site-specific documentation, onboarding timelines, troubleshooting records, device-management materials, data quality assurance activities, and internal communications generated during site coordination and implementation activities. 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 show how 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. This pattern is conceptualized as a high-performance paradox, in which apparent site efficiency may conceal substantial hidden labor and role compression. 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. The study contributes a practice-based methodological perspective on how implementation burden can be identified through reflexive analysis of site-level trial processes.