Wendi Cross, a gifted and innovative colleague in our department, presented at our Family Research Roundtable yesterday. One of the ways she is contributing to the field is to raise awareness about, and develop methodology to study, the factors surrounding implementation of an evidence-based intervention (be it training, prevention, or therapeutic intervention) that influence its ultimate impact. Right now her focus is on implementers of an intervention, but in the course of discussion she mentioned that there are other extra-intervention factors, such as institutional and organizational factors that influence how, how much, and how well evidence-based interventions are put into practice after someone is trained.
This got me thinking about what might be the institutional factors that enable (rather than hinder) adoption and competence in evidence-based risk assessment. I started making a list of these. In the course of doing so, I realized that, without having the language for it, this is part of what I have been working to build in to my trainings about risk assessment. I accompany training about risk-factors with documentation examples and templates and with a map of the procedures, options, and services available to a clinician if elevated risk is identified. It dawned on me that the reason participants find this part of it helpful is that it embeds the training in institutional resources.
Here is my initial brainstorm of potential institutional/organizational enabling factors. Whether these actually make a difference is an empirical question, of course, but these are the ones that occur to me based on my experience:
- Documentation prompts. Embedding risk assessment in required documentation templates can support risk assessment training by providing ongoing “booster training” in risk factors and risk formulation. In terms of risk assessment training this is "external" to the training, but can enable its implementation.
- Clear instruction about what to do when risk is detected. As I noted above, my trainings bring together risk assessment with specific information about resources and procedures at the local level. We have gotten feedback that this improves implementation of the risk formulation training.
- A non-blaming, supportive environment. Clinicians will distance themselves from patients with suicide risk if they fear they will be blamed (in any way) if injures or kills him/herself. There needs to be a consistent message from every level of an organization that understands how difficult clinical work is. There needs to be a healthy respect for the courage it takes to stick with a person at risk—especially if the person is not as cooperative as we would like (see my previous posts about patient choice). A non-blaming environment needs to be in place around all kinds of clinical issues and outcomes, not just suicide—otherwise it will not appear genuine.
- A culture that emphasizes patient choice, informed consent, and meeting people where they are. A “comply or bye-bye” approach will probably discourage thorough and honest risk assessment. In a previous post on risk and patient choice I gave an example of how to handle a patient’s refusal to comply with a recommendation to attend a partial hospitalization program. I have a suspicion that clinicians sometimes downplay risk or avoid asking too many questions about suicide when we suspect that a patient would not comply with the recommendation that higher risk would compel us to make. For example, if a clinician knows that the patient will refuse an E.D. for evaluation, the clinician might de-emphasize or not ask about risk factors that could signal need for such an evaluation, thereby avoiding appearing negligent for not referring.
In contrast, we might promote risk assessment if the clinician knows his her her job is to make an assessment, inform the patient of options, present risks and benefits, and work with whatever the patient decides. I think this would be a significant mindset shift for many systems, and one that I think could be one of those enabling factors.
We can take a lesson from our colleagues in family medicine about how to continue a supportive, therapeutic relationship with patients who do not follow our recommendations (who do not abide by the "social contract" as discussed in this post). Family physicians are accustomed to recommending treatments, medications, and interventions, and knowing that some proportion of patients will not end up following them. This is not without frustration, to be sure. But, except in rare cases, family physicians continue to work the patient, meeting the patient where he or she is, and hoping to move them slowly toward change. As one of our clinical leaders pointed out to me yesterday, that is where a motivational interviewing (MI) approach would come in handy. And, in fact, one of ther research fellows at our institution is studying on an MI intervention with suicidal individuals in the emergency department.
There are lots of others, but these are the ones that first come to mind. I welcome comments with other ideas about factors, outside of training and the individual clinician, that would enable good care and assessment for patient with risk for suicide.