Written by Olivia Sale (CARMS Volunteer) and Lucy Monk (CARMS Research Assistant)
Suicide is a significant global concern1. Suicide deaths on mental health wards account for 8% of all UK suicide fatalities 2. Due to continuous contact patients have with staff, inpatient suicide is considered the most preventable of all suicide deaths3. Inpatient wards present as a good opportunity to offer forms of interventions, such as psychological therapies to support people during their time on the ward. Despite this, suicide prevention focused psychological treatments are a relatively new provision in inpatient services4. The Inpatient Suicide Intervention and Therapy Evaluation (INSITE) project investigated the feasibility and acceptability of Cognitive Behavioural Suicide Prevention (CBSP) for suicidal inpatients. Subsequent to the INSITE pilot randomised controlled trial (RCT)5, Awenat and colleagues6 have conducted a qualitative study exploring staff perceptions of the CBSP intervention trialled on inpatient wards. The research aimed to understand staff views and experiences of barriers and facilitators to implementing a bespoke suicide focussed CBSP intervention in inpatient services.
In previous blog posts, we considered interventions aimed at reducing suicidal experiences in different groups of people. The blog post “Suicidal Experiences and Psychotherapy on Mental Health Inpatient Wards” explored suicide interventions, including CBSP, within inpatient wards. The Cognitive AppRoaches to coMbatting Suicidality (CARMS) project1 evaluates the acceptability of CBSP intervention in service users living in the community who experience psychosis and suicidal thoughts and behaviours. In this blog post, we explore the findings of the study by Awenat and colleagues6 which explored the acceptability of the CBSP intervention among staff working on an inpatient ward. Further, we examine the conclusions made by this study in relation to the CARMS project.
Qualitative interviews and focus groups were conducted with staff from 8 psychiatric wards. Overall, there were 19 participants, including 10 who took part in semi-structured, individual interviews and 9 who took part in the focus group. Purposive sampling was employed to recruit a varied sample of staff from the wards. Staff roles included nurses, healthcare assistants, administrative staff, and psychiatrists. Audio recordings were transcribed and analysed using inductive Thematic Analysis.
Themes were organised into facilitators and barriers relating to: 1) research specific issues regarding the conduct of the RCT and 2) staff views and beliefs regarding the delivery of ward-based suicide prevention psychological therapy for suicidal inpatients6.
Research related barriers:
Staff reported that they felt uninformed about the trial: “I’ve worked here two years. . . to be honest I’d never even heard of it until today.” (FG038). Staff attributed this to poor communication regarding the study and a high staff turnover resulting in many staff involved in the study leaving their posts. Although researchers frequently visited wards to increase staff involvement in the study, these unscheduled interruptions in the day felt chaotic for staff.
Furthermore, staff felt an increased patient care burden, as distress following a therapy session created demands on staff who had to provide more intensive levels of observation, support and the need to record additional documentation: “And we was told about that [risk disclosure] and obviously… asked to start look at the patient, you know make sure the patient was safe and sometimes we had to write on [electronic record].” (FG012)
Research related facilitators:
Staff perceived effective working relationships between researchers and therapists which were built on principles of trust, mutual understanding and shared professional clinical values regarding patient care and understanding the impact of the trial on ward staff. Staff recognised the therapeutic value for inpatients who were simply being provided with a choice of treatment: “I think for our ladies [inpatients] it’s very empowering to be given the choice, because a lot of our ladies come onto the ward and they’re very disempowered.” (FG016).
In addition, staff recognised that the intervention conformed with NHS goals as the service was provided at a crucial time to allow suicidal patients to access interventions. Previous to the introduction of CBSP therapy on the ward, therapy was exclusively offered to patients post-discharge. Staff perceived the introduction of therapy whilst patients were on the ward as timely: “It’s like an in-reach service, so you’re actually providing a service for clients that they usually have been discharged to receive, so at the time when they most need it, when they’re inpatient.” (FG016).
Barriers to Cognitive Behavioural Suicidal Prevention therapy:
Staff recognised that perceptions of which patients were suitable for treatment was influenced by their own pre-existing judgements of who could benefit from therapy. Participants provided their own experiences on the ward of discussing suicidal thoughts with patients; “in case you might say the wrong things…and that might, would trigger off a thought in them.” (042). Also, staff shared they would have liked more support to enable them to understand the therapy and to increasingly engage with therapists regarding inpatient progress in therapy; “We didn’t really have any great knowledge of what it would be that patients would be doing and what benefits it might have.” (035)
Facilitators to Cognitive Behavioural Suicide Prevention therapy:
The intervention was noted to support existing clinical priorities on the ward such as provision of a necessary service within the wards which enhanced the with professional development of staff. For example, staff believed they could take on a more supportive role of inpatients who were sharing experiences of suicidal thoughts with the trial therapist. Moreover, staff observed improvements in patients’ understanding of their suicidal experiences. This resulted in increased personal agency to utilise coping strategies developed in therapy sessions: “One patient who’d said she found it very helpful having the therapy, it had really, kind of, helped her understand a bit more about herself and what her risks were and how to manage her suicidal thoughts…” (009).
The introduction of CBSP therapy was well received, although staff identified barriers regarding the implementation of the intervention. Staff were concerned about the additional workload they experienced as a result of the trial. They believed that discussion about suicide could trigger suicidal behaviour which resulted referring inpatients to the trial who were judged as stable or likely to engage in the therapy and not necessarily inpatients who could benefit from the intervention the most. This reflected inadequate communication and knowledge of the organisation and purpose of the intervention.
The introduction of the intervention was further inhibited by staff and researcher lack of communication. Some barriers may be the result of a lack of research culture on the inpatient wards. Although clinical research is a significant aspect of practice in NHS settings7, staff considered research as disconnected from clinical practice.
The increase in suicide fatalities post-discharge8 does not reflect a success of suicide interventions in inpatient groups, rather it demonstrates the challenges and difficulties of suicide prevention in community settings. Psychological interventions, including CBSP, are considered crucial to improving various outcomes in inpatients with suicidal experiences. The current paper6, in addition to other research9, points towards a clear need for evaluating a range of prevention initiatives in inpatient settings.
Strengths and limitations
To date, this is the first study to investigate perceptions and practices of ward staff on the accessibility and value of psychological treatment for suicidal inpatients (CBSP)6. Flexibility in offering an interview or a focus group increased the opportunity for participation in the study. Offering choice caters to participants who would feel more comfortable speaking openly on a 1 to 1 or group basis which increases the likelihood of eliciting more honest and representative data. As researchers on the randomised controlled trial part of the project interviewed ward staff in this qualitative study, there was a potential for researcher bias in the study. However, researchers ensured that they engaged in a reflexive self-scrutiny process throughout the study and stressed the importance of the aim to collect honest opinions about the acceptability of the intervention to ward staff.
A key barrier identified in the research process was poor communication of intervention implementation due to high staff turnover alongside perceived increases in workload. Results of the study may differ in organisations with less demand and more stable workforces. Although the sample size of the study is acceptable, it is imperative to recognise that the views and experiences of mental health staff in one locality may not be representative of the wider mental health staff population. Researchers noted they would have liked more participation from staff who attended the ward periodically, such as psychiatrists, whose participation in the study was limited. Staff further acknowledged this in interviews, demonstrating that the absence of certain members of staff in the study was noticed: “some of the medical staff here weren’t really fully au fait with what [INSITE] was all about and. . . and they play just an integral part.” (FG030). Another limitation was the gender restriction of the sample, as interviewers and the majority of the participants were female. As the sample was self-selected, it was difficult to control the distribution of genders in the sample but this is worth considering in future studies.
Implications for practice
These findings highlight the importance of considering the views and experiences of staff involved in the implementation of psychological interventions on inpatient wards. The results of the study identified facilitators and barriers to implementing the suicide-prevention intervention (CBSP) which should be considered when designing future psychological interventions for implementation in inpatient services. Many barriers identified by ward staff may have been resolved if they felt that they received adequate communication regarding the organisation, purpose and theoretical background of the CBSP intervention. In addition, barriers involving the level of understanding of the therapy and suitability of patients for the trial may have been resolved by introducing adequate training and information resources for ward staff. Therefore, when delivering psychological therapies on mental health wards, communication and staff training should be considered to improve the acceptability and effectiveness of the intervention.
Future studies could evaluate the acceptability of the psychological intervention with ward staff during the study. In this way, any adjustments can be made during the study and staff may feel that they are more involved in the implementation of the intervention. Due to the lack of psychological therapies for suicide prevention available within inpatient services, the CARMS project could help to identify effective ways to potentially deliver therapy on the ward consistently. Conclusions made by the current study 6 regarding barriers and facilitators to implementing CBSP interventions should be considered in relation to the CARMS project in order to achieve an acceptable therapy among service users and ward staff.
A bit about Olivia Sale:
“I am currently a final year undergraduate Psychology student working as a volunteer Research Assistant with the CARMS project. Last year I completed a professional placement year as part of my degree as an Honorary Art Psychotherapy Service Assistant, where I co-facilitated an Art Psychotherapy group in the Early Interventions into psychosis service. I continued to work as an Art Psychotherapy Service Assistant through the coronavirus pandemic. I hope to start a Master’s degree in Clinical Psychology when I finish my undergraduate degree.”
A bit about Lucy Monk:
“I currently work for the CARMS project as a research assistant on the CARMS trial and have done so for the last 12 months, I previously worked as an assistant psychologist on a female assessment ward. I have several years of clinical experience which has varied from substance detox to acute wards.”
- Gooding, P. A., Pratt, D., Awenat, Y., Drake, R., Elliott, R., Emsley, R., … & Haddock, G. (2020). A psychological intervention for suicide applied to non-affective psychosis: the CARMS (Cognitive AppRoaches to coMbatting Suicidality) randomised controlled trial protocol. BMC psychiatry, 20(1), 1-14.
- The University of Manchester (2018, October) The National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report: England, Northern Ireland, Scotland, Wales. https://documents.manchester.ac.uk/display.aspx?DocID=38469
- Appleby, L., Shaw, J., Kapur, N., Windfuhr, K., Ashton, A., Swinson, N., While, N., Lowe, R., Bickley, H., Flynn, S., Hunt, I. M., McDonell, S., Pearson, A., Cruz, D. D., Rodway, C., Roscoe, A., Saini, P., Turnbull, P., Burns, J., … Stones, P. (December, 2006). Avoidable deaths: Five-year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). The University of Manchester. https://www.research.manchester.ac.uk/portal/files/70178286/avoidable_deaths_full_report_december_2006.pdf
- Durrant, C., Clarke, I., Tolland, A., & Wilson, H. (2007). Designing a CBT service for an acute inpatient setting: a pilot evaluation study. Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 14(2), 117-125.
- Haddock, G., Pratt, D., Gooding, P. A., Peters, S., Emsley, R., Evans, E., … & Awenat, Y. (2019). Feasibility and acceptability of suicide prevention therapy on acute psychiatric wards: randomised controlled trial. BJPsych open, 5(1).
- Awenat, Y. F., Peters, S., Gooding, P. A., Pratt, D., Huggett, C., Harris, K., … & Haddock, G. (2019). Qualitative analysis of ward staff experiences during research of a novel suicide-prevention psychological therapy for psychiatric inpatients: Understanding the barriers and facilitators. PloS one, 14(9), e0222482.
- Innovation & Research Unit (2017, April 4). NHS England research plan. NHS England. https://www.england.nhs.uk/wp-content/uploads/2017/04/nhse-research-plan.pdf
- The University of Manchester (2016, October) The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Making Mental Health Care Safer: Annual Report and 20-year Review. https://documents.manchester.ac.uk/display.aspx?DocID=37580
- Hawton, K., & Pirkis, J. (2017). Suicide is a complex problem that requires a range of prevention initiatives and methods of evaluation. The British Journal of Psychiatry, 210(6), 381-383.