title: Understanding the factors associated with mental health practitioners’ engagement in effective suicide prevention activities within an Improving Access to Psychological Therapies (IAPT) service
Creators: name: Sandford, David Martin
Publisher: name: University of Glasgow
Year: 2023

description: Background This thesis comprises of a systematic review and three empirical studies. It developed from efforts to encourage a culture within a primary care mental health service which maintained a focus on suicide prevention, despite the relative rarity of suicide deaths in any individual clinical setting. The service aimed to improve the knowledge and confidence of practitioners in this vital area and recognised the importance of supporting practitioners in the event of them losing a patient to suicide. Methods Three areas for study were selected which may be associated with practitioners’ engagement in suicide prevention efforts. A systematic review of the impact on mental health practitioners of losing a patient to suicide was followed by a qualitative study exploring the impact of such deaths on practitioners within an Improving Access to Psychological Therapies service. A survey of all staff in an NHS Mental Health Trust was conducted using the Attitudes to Suicide Prevention Scale (ASPS) and these data were used to perform a replication of the validation of the scale. A new scale was developed to measure practitioners’ confidence in assessing, formulating and managing the risk of suicide. This was administered to mental health practitioners to assess the psychometric properties of the scale. Results The systematic review included qualitative and quantitative studies (n=54) and found that the most common personal reactions included guilt, shock, sadness, anger and fear of blame. Impact on professional practice included self-doubt and being more cautious and defensive in the management of suicide risk. As quantitative study methodologies were heterogeneous, it was difficult to make direct comparisons across studies. However, across 13 studies (total n = 717 practitioners) that utilised the Impact of Event Scale, between 12% and 53% of practitioners recorded clinically significant trauma scores. The need for training focused on the impact of suicides and the value placed upon informal support were often cited in these studies. The experience of losing a patient through suicide can have a significant impact on mental health professionals, both in terms of their personal reactions and subsequent changes to professional practice. The negative impact, however, may be moderated by cultural and organisational factors and by the nature of support available. In Study one, survey data from all Trust staff were used to explore the psychometric properties of the Attitudes to Suicide Prevention Scale. Two items from the scale displayed poor item-scale correlation, therefore they were excluded from the factor analysis and a further item was also excluded as it used different anchor points. However, analyses of the remaining 11 items were not satisfactory, with no adequate factor structure emerging. Nonetheless, there were statistically significant differences in attitudes between specific staff groups (i.e., those with/with suicide awareness or prevention training, gender and by level of patient contact), but not between groups defined by age range. Generally, however, the scale indicated that there were positive attitudes across all Trust staff. Study two, the development of a scale to measure practitioners’ confidence in assessing, formulating and managing risk of suicide, the analysis indicated a singlefactor structure, good test–retest reliability and statistically significant increases in confidence between pre- and post-training and between pre-training and six-month follow-up. Cohen’s effect size values suggest a moderate to large effect. In Study three, a qualitative study with IAPT practitioners (n=7), analysis of the transcripts identified a number of themes related to the impact on staff. Specifically, the analyses yielded four superordinate themes which were represented in the majority of cases: 1) feeling shocked and upset about the death of a patient; 2) attempting to understand the causes of the suicide; 3) learning from the tragic event; and 4) reflections on what helped in coping with the tragic event. IAPT practitioners reported initial emotional responses of shock, upset, guilt and fear of blame following the death through suicide of a patient. This is consistent with the findings of the systematic review and previous research with mental health practitioners more broadly. Conclusion The studies included in this thesis, improved our understanding of the impact on practitioners of the loss of a patient by suicide. This supported changes within our service to help better prepare and support practitioners for such an eventuality. All practitioners are made aware of the potential for the loss of a patient by suicide, of the likely impact of this and of the support available to them. In order to keep a focus on the prevention of suicide and to improve practitioners’ confidence in this, training has been developed in risk assessment, formulation and management and further training into the psychological moderators of suicidal behaviour and into safety planning has been delivered. Understanding staff attitudes could help identify potential barriers to effective engagement of practitioners in suicide prevention. The selection of the Attitudes to Suicide Prevention Scale for research purposes should be treated with caution and given the findings of Study one there is a sufficient rationale to develop a new measure. Effective engagement is also likely to be affected by practitioners’ confidence in their ability to assess, formulate and manage suicide risk. A newly developed scale (Study two) displays promise as a measure for this purpose. The findings from Study three support the following recommendations from the systematic review. Services and training providers should ensure that practitioners are prepared for the eventuality of a patient suicide and are adequately supported if they experience such a tragic event. The provision of regular suicide prevention training can help create a culture that supports engagement in this vital activity. Training should also; address any negative attitudes to suicide prevention, increase practitioners’ confidence in the assessment, formulation and management of suicide risk, prepare staff for the potential experience of losing a patient through suicide and inform them of what to expect in such an event including the available support.