Safe clinical practice for patients hospitalised in mental healthcare during a suicidal crisis

Abstract

Preventing suicides is a major issue for patient safety in mental health wards. Safety is assumed to be achieved for suicidal inpatients in clinical practice when procedures are well implemented, without any gaps between practice guidelines and work as done in clinical practice. The approach to implementing safety practices assumes linear causality in which the implementation of a safety measure will yield predictable outcomes in clinical practice. While this approach can provide successful outcomes in systems that are well understood, well tested and well-behaved, it has some limitations when applied to complex and dynamic practices in which the risk is not completely understood, i.e., involving patients hospitalised during a suicidal crisis. Suicidal patients are characterised by aetiological heterogeneity, and each patient needs to be understood and approached differently. Deviations from standards may be necessary to maintain safe clinical practice for patients due to their complexity. However, knowledge of the complexity of safe clinical practice for patients hospitalised during a suicidal crisis is lacking. Patients and healthcare professionals are valuable sources of information about everyday clinical practice in this setting. Still, no studies have explored how suicidal patients experience safe clinical practice, and the knowledge of healthcare professionals’ experiences with safe clinical practice is limited. There is a need to understand the idiosyncrasy of safety within this context and acknowledge its complexity. The overall aim of this thesis was therefore to gain a deeper understanding of the complexity of safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis, as experienced by patients and healthcare professionals. Objectives • To synthesise and describe the qualitative literature regarding suicidal patients’ experiences of safety during hospitalisation in mental healthcare. • To explore suicidal patients’ experiences of safe clinical practice during hospitalisation in mental healthcare. • To explore HCPs’ experiences with safe clinical practice for patients hospitalised during a suicidal crisis. • To synthesise the characteristics of the complexity of safe clinical practice for patients hospitalised during a suicidal crisis. Methods A qualitative case study design utilised multiple methods and data sources, including a systematic review of qualitative literature, individual interviews with patients, and a multi-method approach comprising individual interviews and focus group interviews with healthcare professionals. The complexity of safe clinical practice for suicidal patients was defined as the case, and mental health wards were defined as its context. Results Safe clinical practice as experienced by suicidal patients appears to be related to more than the absence of suicide risk and the need for physical protection. Safe clinical practice for the suicidal patient is highly dependent on patients’ perceptions of their connections with healthcare professionals, the fulfilment of their needs during care and their psychological safety (article I). Furthermore, suicidal patients are multifaceted, showing fluctuating suicidal behaviour, which highlights the importance of embracing personalised activities for safe clinical practice. Patients experience safe clinical practice during hospitalisation in mental health wards during a suicidal crisis, when they are being detected by mindful healthcare professionals, being protected by an adaptive practice and receiving tailor-made treatment (article II). Healthcare professionals experience safe clinical practice for patients hospitalised during a suicidal crisis as dependent on using expertise to make sense of suicidal behaviour, individualising the therapeutic milieu and managing uncertainty (article III). These are examples of capacities that enable healthcare professionals to adapt to challenges and changes in clinical care, and they are vital to the complex dynamic work practices involved in safe clinical practice in this setting. Through synthesising across suicidal patients’ and healthcare professionals’ experiences, the safe clinical practice involves a set of complex characteristics: collaborative detection, adaptive protection and individualised control which all depend on systems of trust. These characteristics demonstrate how nonlinearity and uncertainty characterise the complexity in this context. Additionally, the complexity in safe clinical practice is characterised by establishing psychological and relational safety, which is only created through personalised and trusted relationships. Conclusion This thesis offers a deeper understanding of the complexity of safe clinical practices for patients hospitalised during a suicidal crisis by considering the experiences of patients and HCPs. The inherent complexity of safe clinical practice for patients hospitalised during a suicidal crisis implies that there are unpredictable consequences of top-down safety interventions and that outcomes change over time and for each patient. Thus, safe clinical practice cannot be ensured just by following standards; it also depends on adaptations. To improve safe clinical practices, efforts should be made to embrace rather than efface variability in clinical care. This includes supporting adaptive capacities that enable HCPs to cope with challenges and changes in clinical care. Strategies should be directed toward strengthening expertise development, feedback systems, and systems ensuring support and predictability.