Adaptive capacities for safe clinical practice for patients hospitalised during a suicidal crisis: a qualitative study

Abstract

Background: Safe clinical practice for patients hospitalised in mental health care during a suicidal crisis is situated within a dynamic, non-linear and uncertain context. Under such complex conditions, the adaptive capacity is considered vital to handling challenges and changes in clinical care. This study aimed to explore safe clinical practice for suicidal patients hospitalised in mental health wards through understanding healthcare professionals' (HCPs') capacities to adapt to challenges and changes in clinical care. Methods: This study applied a qualitative design with focus group and individual interviews. Twenty-five HCPs participated in the focus groups, and 18 participated in individual interviews. The study was conducted in open and locked wards in a university hospital in Norway providing specialised mental health services for patients with mental illness. Results: HCPs described their adaptive capacities for clinical practice relative to three themes. 1) HCPs used expertise to make sense of suicidal behaviour to support complex decision making. Their strategies included setting aside forms and checklists to prioritise trust and making judgements based on more than just patients' spoken words. They improved their understanding by seeking others' perspectives through collaborative sense-making processes involving the healthcare team and patient. 2) HCPs individualised the therapeutic milieu to address the diversity of patients with suicidal behaviour by creating individual clinical pathways, making trade-offs between under-and over-protection and adjusting observations. 3) HCPs described managing uncertainty as necessary for providing safe clinical practice. They managed uncertainty as a team by developing mutual collegial trust and support and creating a shared understanding. Conclusion: HCPs' adaptive capacities are vital to the complex set of practices involved in safe clinical practice for patients hospitalised during a suicidal crisis. By using expertise, individualising the therapeutic milieu, and managing uncertainty, HCPs individually and collectively develop their capacities to adapt to challenges and changes in clinical care. HCPs cannot easily ensure safe clinical practice by following standards; safe clinical practice depends on HCPs' adaptations. Ward systems that ensure collegial trust and support, as well as arenas that foster shared understanding and situational awareness, are needed.

The Role Of Collaborative Learning In Resilience In Healthcare - A Thematic Qualitative Meta-Synthesis Of Resilience Narratives

“…As shown in the ndings, the collaborative activities often consisted of different forms of trade-offs to get appropriate information, coordinate events, negotiate prioritizations, and align different needs. Similar to other resilience in healthcare studies [52,53], this study found that the complex demands, competing interests and a diversity of stakeholders focusing on different outcomes resulted in the need to choose some type of adjustment of practice over another. While such trade-offs might be necessary to maintain situational processes and functions, adaptations and adjustments do not always provide positive outcomes for service quality and safety [2,41].…”

Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective

“…39 In an interview study healthcare professionals describe they set forms and checklist aside to prioritise trust during suicide risk assessment. 40 Approximately half of the suicide victims in all cohorts had a documented prior suicide attempt, and it is shown that previous suicide attempt, especially repeated, imply higher risk for suicide persisting over decades. 41 Learning from cases of the successful treatment of patients who have survived prior suicidal crises could thus be of importance for improving suicide prevention in healthcare.…”

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis

“…A narrative synthesis was conducted of findings across two embedded units of analysis: the experiences of patients and the experiences of HCPs (Table 1) [40]. The original data consisted of three samples collected through a multi-method case study approach [40] consisting of a systematic review of 20 peer-reviewed articles published between 1999 and 2016 on patient experiences of being hospitalised in a psychiatric ward or facility during a suicidal crisis (sample 1) [41]; individual interviews with 18 patients hospitalised during a suicidal crisis (sample 2) [42]; and focus group and individual interviews with 35 HCPs responsible for the care of suicidal patients (sample 3) [43]. The methods of the case study are described in a published study protocol [44] and the first author's PhD thesis [45].…”

“…The methods of the case study are described in a published study protocol [44] and the first author's PhD thesis [45]. Interview guides have been previously published, see supplemental file 2 in Berg et al 2020a [46] and additional file 1 in Berg et al 2020b [47].…”