Sikkerhet innen selvmordsforebygging i spesialisthelsetjenesten: pasienterfaringer og systemerfaringer
Safe Clinical Practice for Patients Hospitalized in a Suicidal Crisis
Suicide prevention in psychiatric care is arguably complex and incompletely understood as a patient safety issue. By collecting data on suicidal patients and health care professionals this Ph.D study aims for a deeper understanding of what constitutes safe clinical practice.
The main activity in 2016 for the Ph.D. study "Safe Clinical Practice for Patients Hospitalized in a Suicidal Crisis" have been data collection. The data collection have consisted of the following activities: • Focus groups interviews with health care professionals Five focus group interviews with a total of 27 health care professionals (nurses, doctors, psychologists) were conducted to explore and identify relevant categories and perspectives for the professionals related to the practice of providing safe care for patients hospitalized in a suicidal crisis. • In- depth interviews with health care professionals Furthermore individual in-depth interviews were conducted with 19 health care professionals (nurses, doctors and psychologists) to collect data on the professionals’ individual sense making of everyday clinical practice guided by the resilient health care approach. A resilient health care approach provides perspectives through which to understand this complexity by understanding everyday clinical practice. • In-depth interview with patients The patient-study was conducted to collect data on the suicidal patient’s experiences with safe clinical practice during in patient care. Five hospital wards which included both open and closed psychiatric wards were engaged in the recruitment of patients to the study. 18 patients participated in the study. The patients that were included in the study were hospitalized, could self-identify as "being in a suicidal crisis" during or in close proximity to their hospital stay and were assessed by clinicians in charge to be stabilized to participate in the study. Data on patients’ experiences were collected through individual in-depth interviews (1-2 interviews pr participant). • Context mapping Furthermore, context mapping was conducted by collecting documents regarding national laws, guidelines, political strategies etc. related to safe clinical practice for suicidal patients in psychiatric hospital wards. Additionally, meetings were arranged with ward managers and policy makers to understand their context for safety management. The interview data will be analysed, triangulated and disseminated in 2017-2018.
Safe Clinical Practice for Patients Hospitalized in a Suicidal Crisis
Research activity in 2015 for this PhD study have mainly been directed towards development of the theoretical, ethical, philosophical and methodological framework for the study. Presentations related to the framework have been given at national and international conferences.
Background Although suicides rarely occur in in-patient care, these events are clinically important and among the most concerning patient safety issues in psychiatric care. Currently, the discipline of patient safety in psychiatric care is poorly understood, in-patient suicide prevention included. Attempts to understand and define patient safety have drawn on the terminology and systems of patient safety in general. Nevertheless, patients hospitalized in a suicidal crisis introduce new types of safety issues. The complexity in clinical practice for the suicidal patient in hospital wards is specifically characterized by multiple stakeholders that interacts daily with patients in high suicide risk, in a context of uncertainty of how to assess and manage the patients’ suicide risk. A resilient health care approach provides a perspective to understand complexity through studying every day clinical practice. By including suicidal patients and health care professionals as sources of knowledge a deeper understanding of what constitutes safe clinical practice can be achieved.This descriptive study aims to provide a deeper understanding of safe clinical practice for patients hospitalized in a suicidal crisis. The specific research questions (RQ) for the study are: RQ 1. How do patients and health care professionals describe the meaning of safety, the components of, and the conditions for safe and unsafe clinical practice for the suicidal patients? RQ 2. How do patients and health care professionals describe the experiences with patient safety measures for suicidal patients? Research activity in 2015 As a part of the methodological and theoretical framework of the study, a literature review of resilient health care (RHC) studies were conducted. 26 resilient health care studies were analyzed regarding their methods, main topic, data sources and system boundaries (micro-meso-macro level). The review found that RHC studies have mainly collected data at micro level within single empirical settings with case boundaries limited to the sharp end of the system. Only a few studies have applied a multi-level approach including e.g. organizational data and national health care strategies. The paper was presented at the Resilient Health Care Network in Sidney in August 2015. Findings from the literature review have informed the methodological and theoretical framework for the current study of safe clinical practice for patients hospitalized in a suicidal crisis. The study perspectives and rationale of the framework have been presented at the 8.th National conference on suicide research and prevention in Norway in November 2015. Further, several presentations of the framework have been given to patient safety researchers and clinicians in psychiatric care. The study protocol will be submitted in a BMJ Open during spring 2016. The paper titled “Suicidal patients’ experiences of safety in psychiatric in-patient care: a systematic review of qualitative studies” have been submitted to BMC health services research sept 2015. The results of this study have informed the development of the interview guide to be used in the data collection of patient experiences. Three obligatory PhD courses (30 ECTS) have been completed at University of Stavanger in 2015, in addition to a Resilience in health care Masterclass at Kings College London May 2015.
Sikkerhet for inneliggende pasienter i suicidal krise
Prosjektets formål er å øke kunnskapen om hvordan sikkerhet for inneliggende pasienter i suicidal krise forstås. Som en del av forarbeid til kvalitative intervju ble en systematisk litteraturstudie utført. Foreløpige resultater fra litteraturstudien viser betydningen av tilknytning for å forstå pasientens perspektiv på sikkerhet.
Selvmordsforebygging er et viktig innsatsområde for pasientsikkerhet i psykiatri i flere land, hvor begreper og systemer fra den generelle sikkerhetsdisiplinen tas i bruk, men hva er sikkerhet for pasienter i suicidal krise består av er fortsatt underforstått. Sikkerhet for den suicidale pasient skal skapes til tross for usikkerhet i evidensgrunnlaget, i en praksis med faglige, juridiske og etiske utfordringer. I dette systemet har aktører ulike behov og opplevelser av hva som er sikker og usikker behandling av suicidale pasienter. Med formål om økt kunnskap om hvordan sikkerhet for den inneliggende pasienten i suicidal krise forstås, innhenter dette prosjektet ulike aktørers erfaringer med sikkerhetspraksis. Prosjektet danner grunnlag for en Ph.D i risikostyring og samfunnssikkerhet. Metoden for prosjektet består av 1: systematisk litteraturstudie og 2: kvalitativ datainnsamling av pasienters og personalets erfaringer med sikkerhet. Foreløpige resultater fra den systematiske litteraturstudien av suicidale pasienters erfaringer med sikkerhet i psykiatrisk sengepostbehandling ble lagt frem på "3rd Nordic Conference on Research in Patient Safety and Quality in Healthcare"(Berg, Rørtveit og Aase, 2014). Det planlegges publisering av studien i tidsskrift i 2015. I litteraturstudien ble 19 kvalitative studier av suicidale pasienters erfaringer med psykiatrisk sengepostbehandling inkludert. Pasienterfaringene fremkom som ulike behov, og ble gruppert i tre temaer; «Oppleve trygghet gjennom å bli validert», "Få kontroll gjennom problemløsning og innsikt», og «Bli beskyttet for suicidale impulser av støttende personale». Pasienter erfarte at de var svært sensitive til hvordan de ble møtt av helsepersonell i den suicidale krisen, og møtet opplevdes å ha påvirkning på den suicidale prosess. Imøtekommelse av behovene var elementært for å komme seg ut av den suicidale krisen, mens manglende imøtekommelse av behov ga pasientene økt lidelse, økte selvmordstanker og var en trigger for økende suicidal atferd. Litteraturstudiet bidrar til en forståelse av hva trygghet er for den suicidale pasient. Sikkerhet for pasienter i suicidal krise kan ikke oppstå uten at de føler seg trygge. Validering, kontroll og beskyttelse er viktig for å oppleve seg trygg på seg selv, andre og livet. Disse behovene kan ikke møtes uten at de opplever å bli tilknyttet helsepersonell. Det fremkom mangler på studier som var designet på å undersøke pasienters erfaringer med sikkerhetstiltak, og med begrepet sikkerhet. Videre er det behov for å undersøke pasientenes opplevelse av trygghet og tilknytning i pasientsikkerhetstiltak, samt hva sikker og usikker behandling er for den suicidale pasient.
Methodological Approaches in Resilient Health Care Studies –A Literature Review
Resilient Health Care Network, Novotel Sydney Manly Pacific, 11-13 August, 2015.
Hva er pasientsikkerhet for selvmordstruede pasienter i psykiatrisk sengepost?
8. nasjonale konferanse om selvmordsforskning og –forebygging, Kristiansand, 18-19.November, 2015.
Suicidal patients’ experiences of safety in psychiatric in-patient care: a systematic review.
Manuscript sent for review to BMC Health Services Research 2016
A Literature Review of Methodological Approaches in Resilient Health Care Studies. PhD paper.
University of Stavanger, May 2015.
The social construction of patient safety for suicidal patients in psychiatric hospital wards. PhD paper
Universitety of Stavanger, June 2015.
Berg, Siv Hilde. A discourse analytical approach to resilient health care studies. PhD paper
University of Stavanger, Okt 2015.
A qualitative review of suicidal patients experiences of quality and safety in psychiatric inpatient care
The 3rd Nordic Conference on Research in Patient Safety and Quality in Healthcare, 2014