Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework

Abstract

Objective: The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians’ experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. Method: We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. Results: An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. Conclusions: The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent ‘inconvenient truths’ that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture–based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.

The state of psychiatric research in the Asia Pacific region

“…Researchers have identified that mental health interventions alone were ineffective in reducing suicide rates, rather, it was more important to address major social determinants such as employment and relationship issues (Jorm, 2020). Ongoing critique of the validity of traditional risk stratification algorithms and questions of whether psychiatrists should be expected to predict suicide in patients (Turner, Stapelberg, Sveticic, & Dekker, 2020) relate to this. With ongoing government commitment to funding suicide prevention initiatives, publications on suicide prevention will likely remain high in the coming years.…”

Implementing a systems approach to suicide prevention in a mental health service using the Zero Suicide Framework

“…A review of literature on Just Culture was undertaken, and although initially more traditional approaches to Just Culture (Marx, 2001; Reason, 2016; Wachter and Pronovost, 2009) were considered, a decision was made that Restorative Just Culture (RJC) provided a more compelling way forward. A separate publication outlines learnings about the importance of RJC in the context of ZSF implementation (Turner et al, 2020).…”

“…A new approach to learning from clinical incidents, Gold Coast Clinical Incident Response Framework (GC-CIRF), was developed, which was structured around principles of RJC (including the strong engagement of all stakeholders), human factors, complexity and safety II (GCMHSS 2020a; Turner et al, 2020). The new process also supports enhanced quality and strength of recommendations arising from these reviews.…”

“…In addition, several domains of just culture and second victim experiences have shown significant improvements since initiatives improving incident reporting processes and staff support programme were introduced in 2018 (Turner et al, 2020). In 2019, over 60% agreed that the organisation understands that staff may need help in processing and resolving potential effects of their involvement in incidents and offers a variety of resources in overcoming these.…”

From evidence-based medicine to evidence-informed practice: Comments on Turner et al. 2020

“…Complex psycho-socio-cultural factors impact the aetiology and outcomes of mental disorders and of related concerns such as suicidality. In their recent article, Turner et al (2020) clearly articulate the value of combining the Zero Suicide Framework with principles of a Just Restorative Culture. This article also acknowledges ongoing debates and concerns about the Zero Suicide Movement.…”