Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospital Patients: Formative Acceptability Evaluation of an eLearning Continuing Education Training

BACKGROUND

Suicide is the 12th leading cause of death in the United States. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill building are resource intensive and difficult to implement. Novel computer technologies harnessing artificial intelligence are now available, which hold promise for increasing the feasibility of providing trainees opportunities across a range of continuing education contexts to engage in skills practice with constructive feedback on performance.

OBJECTIVE

This pilot study aims to evaluate the feasibility and acceptability of an eLearning training in suicide safety planning among nurses serving patients admitted to a US level 1 trauma center for acute or intensive care. The training included a didactic portion with demonstration, practice of microcounseling skills with a web-based virtual patient (Client Bot Emily), role-play with a patient actor, and automated coding and feedback on general counseling skills based on the role-play via a web-based platform (Lyssn Advisor). Secondarily, we examined learning outcomes of knowledge, confidence, and skills in suicide safety planning descriptively.

METHODS

Acute and intensive care nurses were recruited between November 1, 2021, and May 31, 2022, to participate in a formative evaluation using pretraining, posttraining, and 6-month follow-up surveys, as well as observation of the nurses' performance in delivering suicide safety planning via standardized patient role-plays over 6 months and rated using the Safety Plan Intervention Rating Scale. Nurses completed the System Usability Scale after interacting with Client Bot Emily and reviewing general counseling scores based on their role-play via Lyssn Advisor.

RESULTS

A total of 18 nurses participated in the study; the majority identified as female (n=17, 94%) and White (n=13, 72%). Of the 17 nurses who started the training, 82% (n=14) completed it. On average, the System Usability Scale score for Client Bot Emily was 70.3 (SD 19.7) and for Lyssn Advisor was 65.4 (SD 16.3). On average, nurses endorsed a good bit of knowledge (mean 3.1, SD 0.5) and confidence (mean 2.9, SD 0.5) after the training. After completing the training, none of the nurses scored above the expert-derived cutoff for proficiency on the Safety Plan Intervention Rating Scale (≥14); however, on average, nurses were above the cutoffs for general counseling skills per Lyssn Advisor (empathy: mean 4.1, SD 0.6; collaboration: mean 3.6, SD 0.7).

CONCLUSIONS

Findings suggest the completion of the training activities and use of novel technologies within this context are feasible. Technologic modifications may enhance the training acceptability and utility, such as increasing the virtual patient conversational abilities and adding automated coding capability for specific suicide safety planning skills.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33695.

Safety plan use and suicide-related coping in a sample of Australian online help-seekers

BACKGROUND

Suicide safety plans can improve suicide-related coping skills and reduce suicidal thoughts and behaviours (STBs). However, little is known about their use and impact outside of treatment settings, where most suicidal crises will occur. The current study explored the prevalence of safety plan use among an online sample of help-seekers with lifetime STBs, and whether STBs and suicide-related coping differed between those with and without safety plans. An exploratory aim was to investigate barriers to safety plan use.

METHOD

Participants (N = 1251) completed an online, anonymous survey at a mental health support website (Beyond Blue). The survey measured lifetime STBs, past-month suicidal ideation, suicide-related coping, help-seeking intentions and behaviour.

RESULTS

Despite high levels of past-month suicidal ideation and past-year help-seeking, most participants (89.5 %) did not have a safety plan, and most of those were not familiar with the concept (70.5 %). Participants with safety plans reported a higher rate of past suicide attempts, but higher suicide-related coping and help-seeking behaviour. Among participants without safety plans, negative attitudes toward safety planning were positively associated with suicidal ideation and negatively associated with suicide-related coping.

LIMITATIONS

Participants were primarily female, English-speaking visitors to a mental health support website. Cross-sectional design precludes conclusions being drawn about safety planning effectiveness over time.

CONCLUSION

This study highlights the low prevalence of safety plan use among online help-seekers with lifetime STBs and the need to better promote safety planning as an intervention with autonomous benefits, including crisis preparedness and improved suicide-related coping skills.

Perceived Usefulness of Self-Guided Versus Collaborative Suicide Safety Plans in Online Help-Seekers

Background: Suicide safety plans were originally devised to be paper-based and clinician-guided, but digital self-guided plans are now common. Aim: This study explored whether plan format (paper vs. digital), assistance (self-authored vs. collaboration), and suicide attempt history were associated with differences in suicidal ideation, suicide-related coping, and perceived usefulness. Method: An online sample of safety plan users (N = 131) completed a survey assessing suicidal ideation, suicide-related coping, and perceived usefulness of their plan. t tests compared outcomes by plan format, collaboration, and suicide attempt history. Pearson correlations explored associations between reasons for plan use, suicidal ideation, and suicide-related coping. Results: Suicidal ideation was significantly higher, and perceived usefulness significantly lower in participants with a past suicide attempt (vs. none) and in those who had collaborated to make their safety plan (vs. self-authored). Collaborators were largely health professionals. No significant differences were found between plan formats. Suicide-related coping was associated with higher perceived usefulness overall. Limitations: Our study design was cross-sectional, utilizing a largely young, female, English-speaking, online help-seeking sample. Conclusions: For clients with prior suicide attempts and higher levels of suicidal ideation, meaningful collaboration may be needed to find safety plan coping strategies that are perceived as useful.

Suicide Prevention by Peers Offering Recovery Tactics (SUPPORT) for US Veterans With Serious Mental Illness: Community Engagement Approach

BACKGROUND

Peer specialists are hired, trained, and accredited to share their lived experience of psychiatric illness to support other similar individuals through the recovery process. There are limited data on the role of peer specialists in suicide prevention, including their role in intervention development.

OBJECTIVE

To better understand peer specialists within the Veterans Health Administration (VHA), we followed partnership community engagement and a formative research approach to intervention development to (1) identify barriers, facilitators, and perceptions of VHA peer specialists delivering a suicide prevention service and (2) develop and refine an intervention curriculum based on an evidence-informed preliminary intervention framework for veterans with serious mental illness (SMI).

METHODS

Following the community engagement approach, VHA local and national peer support and mental health leaders, veterans with SMI, and veteran peer specialists met to develop a preliminary intervention framework. Next, VHA peer specialist advisors (n=5) and scientific advisors (n=6) participated in respective advisory boards and met every 2-4 months for more than 18 months via videoconferencing to address study objectives. The process used was a reflexive thematic analysis after each advisory board meeting.

RESULTS

The themes discussed included (1) the desire for suicide prevention training for peer specialists, (2) determining the role of VHA peer specialists in suicide prevention, (3) integration of recovery themes in suicide prevention, and (4) difficulties using safety plans during a crisis. There were no discrepancies in thematic content between advisory boards. Advisor input led to the development of Suicide Prevention by Peers Offering Recovery Tactics (SUPPORT). SUPPORT includes training in general suicide prevention and a peer specialist-delivered intervention for veterans with SMI at an increased suicide risk. This training aims to increase the competence and confidence of peer specialists in suicide prevention and the intervention supports veterans with SMI at an increased suicide risk through their recovery process.

CONCLUSIONS

This paper intends to document the procedures taken in suicide prevention intervention development, specifically those led by peer specialists, and to be a source for future research developing and evaluating similar interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05537376; https://classic.clinicaltrials.gov/ct2/show/NCT05537376.

Supported decision-making interventions in mental healthcare: A systematic review of current evidence and implementation barriers

BACKGROUND

There is a growing momentum around the world to foster greater opportunities for the involvement of mental health service users in their care and treatment planning. In-principle support for this aim is widespread across mental healthcare professionals. Yet, progress in mental health services towards this objective has lagged in practice.

OBJECTIVES

We conducted a systematic review of quantitative, qualitative and mixed-method research on interventions to improve opportunities for the involvement of mental healthcare service users in treatment planning, to understand the current research evidence and the barriers to implementation.

METHODS

Seven databases were searched and 5137 articles were screened. Articles were included if they reported on an intervention for adult service users, were published between 2008 and October 2023 and were in English. Evidence in the 140 included articles was synthesised according to the JBI guidance on Mixed Methods Systematic Reviews.

RESULTS

Research in this field remains exploratory in nature, with a wide range of interventions investigated to date but little experimental replication. Overarching barriers to shared and supported decision-making in mental health treatment planning were (1) Organisational (resource limitations, culture barriers, risk management priorities and structure); (2) Process (lack of knowledge, time constraints, health-related concerns, problems completing and using plans); and (3) Relationship barriers (fear and distrust for both service users and clinicians).

CONCLUSIONS

On the basis of the barriers identified, recommendations are made to enable the implementation of new policies and programs, the designing of new tools and for clinicians seeking to practice shared and supported decision-making in the healthcare they offer.

PATIENT OR PUBLIC CONTRIBUTION

This systematic review has been guided at all stages by a researcher with experience of mental health service use, who does not wish to be identified at this point in time. The findings may inform organisations, researchers and practitioners on implementing supported decision-making, for the greater involvement of people with mental ill health in their healthcare.

Digital safety plan effectiveness and use: Findings from a three-month longitudinal study

Few studies have examined the effectiveness of self-guided smartphone apps for suicide safety planning, despite their increasing use. Participants (n = 610) were self-selected users of the Beyond Now suicide prevention safety planning app with a history of suicidal thoughts and behaviours. Surveys were completed (baseline, one and three months), safety plan content and app usage data was shared. Repeated-measures ANOVAs examined changes in suicidal ideation and suicide-related coping over three months. Multiple regression models were used to predict suicidal ideation and suicide-related coping at one- and three-month follow-ups with plan-related variables: perceived usefulness, personalised content, app use time and co-authoring of the plan with a third party. Significant reductions in suicidal ideation and increases in suicide-related coping were found over three months. Higher suicide-related coping at three months predicted lower suicidal ideation. Higher perceived usefulness and personalised content at three months were associated with higher suicide-related coping, but not suicidal ideation. App use time and co-authoring were not significantly related to suicidal ideation or suicide-related coping. Practitioners should empower clients to create safety plans with personalised (not generic) strategies that a client perceives to be useful. Such plans may strengthen beliefs about coping with suicidal ideation, which in turn reduces suicidal ideation over time.

Smartphone-based safety plan for suicidal crisis: The SmartCrisis 2.0 pilot study

Here we present the findings of the pilot phase of the SmartCrisis 2.0 Randomized Clinical Trial. This pilot study aimed to explore the feasibility and acceptability of a safety plan contained in a smartphone app. Our sample consisted patients with a history of recent suicidal behaviour who installed a smartphone-based safety plan. To explore the satisfaction with of the safety plan, two patient satisfaction surveys were conducted: one qualitative and one quantitative. To explore the objective use of the safety plan, we gained access to texts contained in the safety plans completed by the patients. Participation rate was 77%, while 48.9% patients completed both satisfaction surveys at the end of the pilot phase. N = 105 successfully installed the safety plan. In a scale from 1 to 10, users rated the usefulness of the security plan at 7.4, the usability at 8.9, the degree to which they would recommend it to others at 8.6 and the overall satisfaction with the project including evaluations at 9.6. The most widely completed tab was warning signs. Feeling sad or lonely was the warning sign most commonly reported by patients. The second most completed tab was internal coping strategies. Walking or practicing any other exercise was the strategy most commonly resorted to. Our smartphone-based safety plan appears to be a feasible intervention. Data obtained from this pilot study showed high participation rates and high acceptability by patients. This, together with the general satisfaction with the project, supports its implementation in the clinical practice.

Designing Implementation Strategies for a Digital Suicide Safety Planning Intervention in a Psychiatric Emergency Department: Protocol for a Multimethod Research Project

BACKGROUND

Suicide prevention is currently a national health priority in Canada. Emergency departments (EDs) are critical settings for suicide prevention, and in our local psychiatric ED at the Centre for Addiction and Mental Health, we plan to embed an app-based tool called the Hope app to support suicide safety planning intervention. The app is free and available on app stores, and usability tests have been completed. As a next step to embed this new tool into the routine clinical workflow, research is needed to assess determinants of and design strategies for implementation with the end goal of routinization.

OBJECTIVE

The purpose of this 2-phased research is to implement the app in the routine clinical workflow in our local psychiatric ED. The specific objectives are as follows: (1) understanding ED clinicians' perceptions and experience of implementing the app in routine practice and identifying barriers to and facilitators of implementation (phase 1) and (2) using findings and outputs from phase 1 and collaborating with service users, families, and ED clinicians to co-design implementation strategies for the app (phase 2).

METHODS

We will use an integrated knowledge translation approach throughout this project. In phase 1, we will conduct interviews with ED clinicians to identify implementation determinants using a behavior change framework. In phase 2, a co-design team comprising clinicians, ED service users, and families will design implementation strategies that align with the determinants identified in phase 1.

RESULTS

This protocol presents detailed information about the entire structure of the 2-phased research project. Ethics approval for conducting the qualitative descriptive study (phase 1) has been obtained, and the recruitment and data collection processes will be completed no later than December 2023. Ethics approval for phase 2 is underway.

CONCLUSIONS

Involving multiple knowledge user groups early in the research and decision-making process is crucial for successful implementation. Although co-designing is commonly practiced during innovation development, there is often a misconception that the responsibility for implementing what has been designed falls on others. This research aims to fill this methodological gap in the health informatics literature. By the end of this project, we will have developed theory-informed implementation strategies to support Centre for Addiction and Mental Health ED clinicians in adopting the Hope app to complete safety planning intervention. These strategies, guided by a behavior change framework, will target clinicians' behavior change and seamlessly integrate the app into the routine clinical workflow. In addition, this research project will provide recommendations on how to involve multiple knowledge user groups and offer insights into how the methodology used can be adapted to other areas within the health informatics literature.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50643.

Veteran Experiences With Suicide Ideation, Suicide Attempt, and Social Support in Safety Planning Within the Department of Veterans Affairs

INTRODUCTION

This evaluation examined the role of safety plans, one of a host of clinical suicide prevention interventions available for veterans through the United States Department of Veterans Affairs' national network of health care facilities managed by the Veterans Health Administration (VHA).

MATERIALS AND METHODS

Interviews were conducted with veterans who had experienced suicidal ideation or a suicide attempt since enrolling in the Department of Veterans Affairs health care system (N = 29). Topics included negative life experiences, triggers for suicidal ideation or a suicide attempt, ability to recall and utilize safety plans in crisis, safety plan elements found most and least useful, and improvements to safety planning.

RESULTS

Eighteen (62.07%) of the veterans in the sample had attempted suicide. Drug use was by far the most triggering and overdose was the most negative life event to subsequent ideation or attempt. Although all at-risk veterans should have a safety plan, only 13 (44.38%) created a safety plan, whereas 15 (51.72%) could not recall ever creating a safety plan with their provider. Among those who did recall making a safety plan, identifying warning signs was the most remembered portion. The most useful safety plan elements were: recognizing warning signs, supportive people and distracting social settings, names and numbers of professionals, giving the veteran personal coping strategies, options for using the plan, and keeping their environment safe. For some veterans, safety plans were seen as insufficient, undesirable, not necessary, or lacking a guarantee. The suggested improvements included involving concerned significant others, specific actions to take in a crisis, and potential barriers and alternatives.

CONCLUSIONS

Safety planning is a critical component in suicide prevention within VHA. However, future research is needed to ensure safety plans are accessible, implemented, and useful to veterans when in crisis.

An Ideal-Type Analysis of People's Perspectives on Care Plans Received from the Emergency Department following a Self-Harm or Suicidal Crisis

People presenting to Emergency Departments (EDs) in a self-harm/suicidal crisis in England receive a psychosocial assessment and care plan. We aimed to construct a typology of peoples' perspectives on crisis care plans to explore the range of experiences of care plans. Thirty-two semi-structured interviews with people who presented to EDs following a self-harm/suicidal crisis in England were analysed using an ideal-type analysis. Cases were systematically compared to form clusters of cases with similar experiences of care plans. People's perspectives on care plans fitted into three types: (1) personalised care plans (n = 13), consisting of advice or referrals perceived as helpful; (2) generic care plans (n = 13), consisting of generic advice that the person already knew about or had already tried; and (3) did not receive a care plan (n = 6) for those who reported not receiving a care plan, or who were only provided with emergency contacts. Care planning in the ED following a suicidal/self-harm crisis was perceived as supportive if it provided realistic and personalised advice, based on what had/had not worked previously. However, many people reported not receiving a helpful care plan, as it was ill-fitted to their needs or was not considered sufficient to keep them safe, which may mean that these patients are at increased risk of repeat self-harm.

A Suicide Prevention Intervention for Emerging Adult Sexual and Gender Minority Groups: Protocol for a Pilot Hybrid Effectiveness Randomized Controlled Trial

BACKGROUND

Suicide attempts and suicide death disproportionately affect sexual and gender minority emerging adults (age 18-24 years). However, suicide prevention strategies tailored for emerging adult sexual and gender minority (EA-SGM) groups are not widely available. The Safety Planning Intervention (SPI) has strong evidence for reducing the risk for suicide in the general population, but it is unclear how best to support EA-SGM groups in their use of a safety plan. Our intervention (Supporting Transitions to Adulthood and Reducing Suicide [STARS]) builds on content from an existing life skills mobile app for adolescent men who have sex with men (iREACH) and seeks to target core risk factors for suicide among EA-SGM groups, namely, positive affect, discrimination, and social disconnection. The mobile app is delivered to participants randomized to STARS alongside 6 peer mentoring sessions to support the use of the safety plan and other life skills from the app to ultimately reduce suicide risk.

OBJECTIVE

We will pilot-test the combination of peer mentoring alongside an app-based intervention (STARS) designed to reduce suicidal ideation and behaviors. STARS will include suicide prevention content and will target positive affect, discrimination, and social support. After an in-person SPI with a clinician, STARS users can access content and activities to increase their intention to use SPI and overcome obstacles to its use. EA-SGM groups will be randomized to receive either SPI alone or STARS and will be assessed for 6 months.

METHODS

Guided by the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework, we will recruit and enroll a racially and ethnically diverse sample of 60 EA-SGM individuals reporting past-month suicidal ideation. Using a type-1 effectiveness-implementation hybrid design, participants will be randomized to receive SPI (control arm) or to receive SPI alongside STARS (intervention arm). We will follow the participants for 6 months, with evaluations at 2, 4, and 6 months. Preliminary effectiveness outcomes (suicidal ideation and behavior) and hypothesized mechanisms of change (positive affect, coping with discrimination, and social support) will serve as our primary outcomes. Secondary outcomes include key implementation indicators, including participants' willingness and adoption of SPI and STARS and staff's experiences with delivering the program.

RESULTS

Study activities began in September 2021 and are ongoing. The study was approved by the institutional review board of the University of Pennsylvania (protocol number 849500). Study recruitment began on October 14, 2022.

CONCLUSIONS

This project will be among the first tailored, mobile-based interventions for EA-SGM groups at risk for suicide. This project is responsive to the documented gaps for this population: approaches that address chosen family, focus on a life-course perspective, web approaches, and focus on health equity and provision of additional services relevant to sexual and gender minority youth.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05018143; https://classic.clinicaltrials.gov/ct2/show/NCT05018143.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48177.

Predictive Importance of Social Contacts on U.S. Veteran Suicide Safety Plans

OBJECTIVE

Safety planning is a suicide prevention intervention that relies partly on an individual's social relationships as distractions during or help in a suicidal crisis. The primary objectives of this study were to estimate rates of missingness on social aspects of safety plans to determine whether rates differ by demographic characteristics and diagnoses and to examine whether missing social contacts on safety plans may affect clinical outcomes.

METHODS

Data were drawn from the U.S. Department of Veterans Affairs San Diego Healthcare System's electronic medical record (N=1,602 individuals) from 2018 to 2021. Safety plans were coded according to the absence of listed distraction or help contacts, and clinical records of suicide attempts, suicide deaths, and use of crisis services were recorded for 1 year after completion of the safety plan.

RESULTS

In total, 30% of plans lacked a contact for distraction or help. Male veterans were less likely to have a distraction contact listed, and veterans identifying as Hispanic or Latino were more likely to have a help contact listed. The lack of a help contact (odds ratio [OR]=2.11) and having neither distraction nor help contacts (OR=2.45) were associated with a markedly higher risk for next-year suicide attempt or death. The lack of a help contact was associated with increased odds of a next-year psychiatric inpatient hospitalization (OR=1.90) and an emergency department visit (OR=1.88).

CONCLUSIONS

A lack of social contacts on safety plans may be a potential indicator for increased suicide risk among veterans.

The Effectiveness of the Safety Planning Intervention for Adults Experiencing Suicide-Related Distress: A Systematic Review

The safety planning intervention (SPI) is gaining momentum in suicide prevention practice and research. This systematic review sought to determine the effectiveness of the SPI for adults experiencing suicide-related distress. Systematic searches of international, peer-reviewed literature were conducted in six databases (Cochrane Trials, Embase, Emcare, Medline, PsycINFO and Web of Science), including terms for safety planning, suicide, and suicide-related outcomes. A total of 565 results were included for screening. Result screening (title/abstract and full-text), data extraction and critical appraisal were conducted in duplicate. Twenty-six studies met the inclusion criteria. Studies were primarily quantitative (n = 20), largely with general adult or veteran samples; a small number of studies explored the perspectives of staff and significant others. Half of the studies included the SPI as a standalone intervention, while the other half examined the SPI in combination with other interventions. Most interventions were delivered in-person, with a hard-copy safety plan created, while a smaller number explored internet-based interventions. Primary measures included: suicidality (ideation, behavior, deaths; 10 studies), suicide-related outcomes (depression, hopelessness; 5 studies) and treatment outcomes (hospitalizations, treatment engagement; 7 studies). The evidence supports improvements in each of these domains, with complementary findings from the remaining quantitative and qualitative studies suggesting that the SPI is a feasible and acceptable intervention. While positive, these findings are limited by the heterogeneity of interventions and study designs, making the specific impact of the SPI difficult to both determine and generalize. Conversely, this also points to the flexibility of the SPI.HighlightsThe Safety Planning Intervention (SPI) is a valuable indicated intervention for general adult and veteran populations experiencing suicide-related distress, primarily in face-to-face, clinical settings.Quantitative findings indicate associations between the SPI and improvements in suicidal ideation and behavior, decreases in depression and hopelessness, along with reductions in hospitalizations and improvements in treatment attendance.Qualitative studies suggest the SPI is acceptable and feasible, with areas for development.SPIs have been shown to be adaptable to the clinical area in its modality (digital or paper-based), delivery (face-to-face or online), facilitation (clinician or self-administered) and multiplicity (as stand-alone or combined intervention).

Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospitalized Patients: Protocol for Formative and Pilot Feasibility Research

Background

Suicide is the 10th leading cause of death in the United States, with >47,000 deaths in 2019. Most people who died by suicide had contact with the health care system in the year before their death. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill-building are resource intensive and difficult to implement. Advances in artificial intelligence technology hold promise for improving the scalability and sustainability of training methods, as it is now possible for computers to assess the intervention delivery skills of trainees and provide feedback to guide skill improvements. Much remains to be known about how best to integrate these novel technologies into continuing education for health care providers.

Objective

In Project WISE (Workplace Integrated Support and Education), we aim to develop e-learning training in suicide safety planning, enhanced with novel skill-building technologies that can be integrated into the routine workflow of nurses serving patients hospitalized for medical or surgical reasons or traumatic injury. The research aims include identifying strategies for the implementation and workflow integration of both the training and safety planning with patients, adapting 2 existing technologies to enhance general counseling skills for use in suicide safety planning (a conversational agent and an artificial intelligence–based feedback system), observing training acceptability and nurse engagement with the training components, and assessing the feasibility of recruitment, retention, and collection of longitudinal self-report and electronic health record data for patients identified as at risk of suicide.

Methods

Our developmental research includes qualitative and observational methods to explore the implementation context and technology usability, formative evaluation of the training paradigm, and pilot research to assess the feasibility of conducting a future cluster randomized pragmatic trial. The trial will examine whether patients hospitalized for medical or surgical reasons or traumatic injury who are at risk of suicide have better suicide-related postdischarge outcomes when admitted to a unit with nurses trained using the skill-building technology than those admitted to a unit with untrained nurses. The research takes place at a level 1 trauma center, which is also a safety-net hospital and academic medical center.

Results

Project WISE was funded in July 2019. As of September 2021, we have completed focus groups and usability testing with 27 acute care and 3 acute and intensive care nurses. We began data collection for research aims 3 and 4 in November 2021. All research has been approved by the University of Washington institutional review board.

Conclusions

Project WISE aims to further the national agenda to improve suicide prevention in health care settings by training nurses in suicide prevention with medically hospitalized patients using novel e-learning technologies.

International Registered Report Identifier (IRRID)

DERR1-10.2196/33695

Safety Planning: Why It Is Essential on the Day of Discharge From In-patient Psychiatric Hospitalization in Reducing Future Risks of Suicide

Individuals who suffer from mental illness are at an increased risk for suicide. That risk is substantially higher in the post-discharge period from psychiatric hospitalization. Safety planning intervention (SPI) is a common intervention tool that is utilized to mitigate the risk of suicide. Current research notes promising results of SPI use in the emergency department (ED); however, there is limited research regarding SPI use during psychiatric hospitalization on the day of discharge. This paper aims to evaluate current research on the topic and establish a need for more widespread use of SPI during psychiatric hospitalization.

An Open Trial of a Suicide Safety Planning Group Treatment: "Project Life Force"

In 2008, the Department of Veterans Affairs mandated that clinicians oversee the construction of a Suicide Safety Plan for every patient who is identified as "high risk" for suicide. While the Suicide Safety Plan is a mandated "best practice," there are currently no recommended guidelines for its augmentation in a group setting. To address this gap, a novel group intervention, "Project Life Force," (PLF; a 10-session manualized psychotherapy), was developed and piloted. Results indicate high feasibility and acceptability. Exploratory analysis revealed statistically significant decreases in suicidal thoughts/behaviors, depression, and hopelessness. Feedback from Veterans and PLF therapists is also discussed. Despite some limitations (e.g. small sample size) exploratory results suggest that PLF may be a promising treatment for Veterans with suicidal symptomology.

Staff Perspectives of Safety Planning as a Suicide Prevention Intervention for People of Refugee and Asylum-Seeker Background

Background: Safety planning involves the co-development of a personalized list of coping strategies to prevent a suicide crisis. Aims: We explored the perspectives of workers regarding safety planning as a suicide prevention strategy for people of refugee background and those seeking asylum in Australia. Method: Participants attended suicide prevention training, specific to refugees and asylum seekers, at which safety planning was a key component. Semistructured, posttraining interviews (n = 12) were analyzed thematically. Results: Four key themes were identified: safety planning as a co-created, personalized activity for the client; therapeutic benefits of developing a safety plan; barriers to engaging in safety planning; strategies to enhance safety planning engagement. Limitations: First-hand refugee and asylum-seeker experiences were not included. Conclusion: As a relatively low-cost, flexible intervention, safety planning may be valuable and effective for these groups.

The feasibility of using smartphone apps to manage self-harm and suicidal acts in adolescents admitted to an inpatient mental health ward

Objective

The aim of this study is to assess the feasibility (uptake, retention and adherence) and acceptability of a combination of smartphone apps to deliver a digitized safety plan, BeyondNow, and personalized management strategies, BlueIce, with adolescents discharged from a mental health inpatient ward following self-harm, suicidal ideation and/or behavior.

Methods

Participants in this pre-post pilot study included 20 adolescents between 13–18 years, presenting with self-harming or suicidal behaviors in an inpatient psychiatric ward at a tertiary pediatric hospital. Participants were familiarized with the apps and completed baseline measures prior to discharge. They used the apps for six weeks before completing the follow-up survey, which measured feasibility and acceptability of the apps, as well as suicide resilience.

Results

Seventeen participants completed the pilot. Most of the sample accessed both apps at least once, three accessed the BeyondNow safety plan five times or more, and six used the BlueIce toolbox five times or more. A total of 73.5% of the sample that experienced a crisis used at least one of the apps at least once. Forty seven percent felt that the apps would not keep them safe when in crisis, although almost all of the sample rated both apps as easy to use (94% for BeyondNow, and 82% for BlueIce). Medium to large effect sizes were also found with regard to improvements in suicide resilience.

Conclusion

Both apps were found to be feasible and acceptable in this population, and easy to use, although no conclusions can be drawn regarding the clinical efficacy of the apps.

Development of a Clinical Pathway for the Assessment and Management of Suicidality on a Pediatric Psychiatric Inpatient Unit

Purpose

This article describes steps taken by a mental health inpatient multidisciplinary team to develop a clinical pathway for the assessment and management of suicidality in a pediatric psychiatric inpatient unit.

Patients and Methods

The setting for this project is a 19-bed inpatient psychiatry unit providing care for children and adolescents (6-17 years of age) in a tertiary care pediatric hospital in Ontario, Canada. Three Lean methodologies were used: 1) The A3 process was used to articulate a problem statement and help clarify expectations, determine goals, and uncover, address and encourage discussion of potential issues; 2) Process mapping was used to show how work process activities are sequenced from the time of the patient's admission to discharge; and 3) Standard work, where consideration was given to the breakdown of the work into categories which are sequenced, organized and repeatedly followed. Generally accepted methodologies for developing clinical pathways were used to create a framework and algorithm for the assessment and management of suicidality in psychiatrically hospitalized children and adolescents.

Results

The clinical pathway development resulted in six steps from admission to discharge: intake process, inclusion/exclusion criteria, data integration and treatment formulation, interventions, determination of readiness for discharge, and the discharge process.

Conclusion

This framework, developed with the aim to standardize care for psychiatrically admitted suicidal children and adolescents, may serve as a flexible template for use in similar settings and could be adapted according to local realities and resources.

Development and Feasibility of a Safety Plan Mobile Application for Adolescent Suicide Attempt Survivors

Past suicide attempts are a powerful predictor of suicide. This study developed and evaluated the feasibility of a mobile application for creating safety plans, which include coping strategies that can be immediately accessed and used by suicide attempt survivors during a crisis. A safety plan mobile application, called Brake of My Mind, was developed (study 1). Heuristic evaluation (for experts) and user evaluations (for health professionals and adolescent suicide attempt survivors) were performed. A pilot test was then conducted based on the theory of planned behavior to evaluate the feasibility of Brake of My Mind (study 2). Three adolescent suicide attempt survivors used a pilot version of Brake of My Mind. Attitude toward suicide attempts, subjective norms, perceived behavioral control, and suicide intentions were assessed before, immediately after, and 1 week after using Brake of My Mind. Brake of My Mind showed very few low-priority usability problems, and it was considered a "good" and "acceptable" application. In study 2, median scores for attitudes toward suicide attempts, perceived behavioral control, and suicide intentions decreased over time after using Brake of My Mind. The subjective norm scores did not change. Brake of My Mind is an acceptable application for adolescent suicide attempt survivors that appears effective in decreasing their positive attitude toward suicide attempts.

Group ("Project Life Force") versus individual suicide safety planning: A randomized clinical trial

One in five suicide deaths is a Veteran and in spite of enhanced suicide prevention services in the Veterans Health Administration (VHA), twenty Veterans die by suicide each day. One component of the VHA's coordinated effort to treat high-risk suicidal Veterans, and diminish suicide risk, is the use of the safety plan. The current study aims to examine a novel intervention integrating skills training and social support with safety planning for Veterans at high-risk for suicide, "Project Life Force" (PLF). A randomized clinical trial (RCT) will be conducted examining if Veterans who are at high-risk for suicide will benefit from the novel group intervention, PLF, compared to Veterans who receive treatment as usual (TAU). We plan to randomize 265 Veterans over the course of the study. The primary outcome variable is the incidence of suicidal behavior, during follow-up, established using a rigorous, multi-method assessment. Secondary outcomes include depression, hopelessness, suicide coping and treatment utilization. Exploratory analyses include safety plan quality and belongingness for those in both arms as well as group cohesion for those in the PLF intervention. Strengths and limitations of this protocol are discussed.

Stakeholder Perspectives on Using and Developing the MYPLAN Suicide Prevention Mobile Phone Application: A Focus Group Study

The objective of this study was to explore different stakeholder perspectives on the MYPLAN app for suicide prevention safety planning. The study was a comparative analysis of 4 focus groups with Danish MYPLAN stakeholders, young users, adult users, relatives, and clinicians. The focus groups were audio recorded, transcribed, and subjected to a thematic analysis. The analysis contextualized the participants' experiences of the benefits and limitations of MYPLAN. While participants believed that MYPLAN could potentially interrupt early stages of a suicidal process, clinicians' involvement in safety planning was considered important. MYPLAN could potentially give users a sense of increased personal control but learning how to effectively safety plan was not perceived to be simple and additional support should be considered for MYPLAN users.

Safety Planning to Manage Suicide Risk with Older Adults: Case Examples and Recommendations

Adults age 65 and older have high rates of suicide, despite recent efforts to reduce the suicide rate in this population. One suicide prevention strategy with burgeoning empirical support is safety planning; however, there is a lack of information and resources on safety planning for older adults to support uptake of this evidence-based practice in clinical settings where older adults are commonly seen. Safety plans can address risk factors for suicide in older adults, including social isolation, physical illness, functional limitations, and use of highly lethal means. Safety plans also promote relevant protective factors, including increasing use of coping strategies, social support, and help-seeking. Clinicians may encounter challenges and barriers to safety planning with older adults. This paper describes a collaborative, creative approach to safety planning that is relevant and useful for this vulnerable population. Using two case examples, we illustrate how to engage older adults in safety planning, including ways to minimize barriers associated with the aging process.

Evaluating the Feasibility and Effectiveness of an Australian Safety Planning Smartphone Application: A Pilot Study Within a Tertiary Mental Health Service

OBJECTIVE

The purpose of this study was to examine the feasibility and effectiveness of a suicide prevention smartphone application.

METHOD

Thirty-six non-Aboriginal Australians aged between 16 and 42 years (67% female) were recruited from a tertiary mental health service where they were receiving treatment for suicide risk. Participants were asked to use the BeyondNow safety planning smartphone application to manage their suicide safety plan during a 2-month trial, as an adjunct to treatment as usual. A survey battery designed to measure feasibility and effectiveness of the smartphone app plus treatment as usual intervention was completed at baseline and follow-up.

RESULTS

A vast majority of participants used the app to view and edit their safety plans and reported that the app was easy to use. A reduction was observed in participant severity and intensity of suicide ideation, and suicide-related coping increased significantly. No significant changes were observed in suicide resilience.

CONCLUSIONS

The BeyondNow safety planning smartphone application was shown to be feasible and effective as an adjunct to mental health treatment among patients at risk of suicide.

Quality Improvement Evaluation of the Feasibility and Acceptability of Adding a Concerned Significant Other to Safety Planning for Suicide Prevention With Veterans

Suicide among veterans remains a serious public health issue, and poor social support is identified as a robust risk factor for suicide. The U.S. Department of Veterans Affairs uses a standard safety planning procedure for suicide prevention. While this intervention can help veterans identify social support sources, it does not directly incorporate a concerned significant other (CSO). Research suggests that veterans prefer a family member or friend to help shoulder the burden of a potential crisis. This qualitative feasibility project examined the role of CSOs in safety planning with veterans. Interviews were conducted with 29 veterans and four CSOs to investigate whether veterans wanted a CSO involved in their safety plan and to investigate associated logistical issues for implementation. Overwhelmingly, veterans (79.13%) reported that having a CSO directly involved in their safety plan would be helpful. Qualitative data are presented highlighting practical concerns for mental health providers developing safety plans with veterans.

The Impact of Safety Plans in an Outpatient Clinic

BACKGROUND

Safety plans are recommended as tools to mitigate suicide risk; however, their effectiveness remains unclear.

AIM

To evaluate the impact of safety plans on patient care at an outpatient mental health clinic.

METHOD

In this retrospective chart review, patients' treatment engagement, health-care utilization, and risk behaviors were measured. Patients served as their own historical controls, and we compared outcomes in the 6 months before and 6 months after creation of safety plans.

RESULTS

In all, 48 patient charts were identified. Hospitalizations were significantly reduced and use of crisis calls significantly increased after implementation of safety plans. There were five suicide attempts before safety plan completion and one after, representing a trend toward statistical significance. Outpatient encounters increased by 18%, missed appointments increased by 34%, psychiatric emergency room visits decreased by 47%, and a 69% reduction in inpatient hospital days was observed, all trending toward statistical significance. No differences were seen in episodes of violence or self-injurious behavior.

LIMITATIONS

The study sample was small and there was a lack of randomization.

CONCLUSION

Results suggest that safety plans can lead to improvements in utilization of care and patient engagement. Further research is needed to better understand the clinical impact of safety plans on high-risk patients.