Evidence reviews for supervision required for staff in specialist mental health settings

Evidence reviews for supervision required for staff in specialist mental health settings

Self-harm: assessment, management and preventing recurrence

Evidence review Q

NICE Guideline, No. 225

London: National Institute for Health and Care Excellence (NICE); 2022 Sep.

ISBN-13: 978-1-4731-4702-7

Supervision required for staff in specialist mental health settings

Review question

What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

Introduction

Staff who work with people who self-harm are likely to experience a range of conflicting feelings about their work, and self-harm may have considerable emotional impact on clinicians. It is important that organisations support and maintain the ability of clinicians to work with people who self-harm in a compassionate and respectful way at all times. It can be necessary to intervene to prevent further harm and to ensure the person’s safety, but at the same time, staff need to respect people’s autonomy. This can be a difficult balance at times and requires team and organisational support for individual clinical decision-making. The objective of this review is to identify the views and preferences of staff in specialist mental health settings about the supervision that is required for staff in specialist mental health settings who assess and treat people who have self-harmed.

Summary of the protocol

See Table 1 for a summary of Population, Phenomenon of interest and Context (PPC) characteristics of this review.

Table 1

Summary of the protocol (PPC table).

For further details see the review protocol in appendix A.

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

Qualitative evidence

Included studies

Eleven qualitative studies reported in 12 articles were included for this review. Two articles reported results from the same study (Hagen 2017a, Hagen 2017b).

The included studies are summarised in Table 2.

The studies were carried out in 5 different countries: 3 studies in the UK (Awenat 2017, Littlewood 2019, MacDonald 2021); 1 study in Australia (Kelada 2017); 2 studies in Canada (Christianson 2008, de Stefano 2012); 2 studies in Norway (Berg 2020; Hagen 2017a, Hagen 2017b); 3 studies in the USA (Hoffman 2013, Knox 2006, Wilstrand 2007).

Studies exploring the views and preferences of specialist mental health staff regardless of setting were included in this review. At the time of agreeing the protocol, the objective of the review was to identify the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed. However, the committee later agreed the best way to summarise evidence regarding staff supervision would be to split evidence according to the specialty of the staff rather than the setting, because some specialist staff may work in non-specialist settings, and it would be inappropriate to suggest they should have the same views and preferences on supervision as non-specialist staff. Therefore, this review summarised evidence regarding supervision required by specialist mental health staff, while another review was conducted to summarise evidence regarding skills required by non-specialist staff (see Evidence Report S).

The studies included specialist staff working in the following settings: 3 studies in educational settings, including schools and university counselling services (Christianson 2008, de Stefano 2012, Kelada 2017); 1 study in an emergency department (MacDonald 2021); 4 studies in inpatient psychiatric wards (Awenat 2017, Berg 2020, Hagen 2017a, Hagen 2017b, Wilstrand 2007); 2 studies in varied mental health care settings (Knox 2006, Littlewood 2019).

See the literature search strategy in appendix B and study selection flow chart in appendix C.

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix J.

Summary of included studies

Summaries of the studies that were included in this review are presented in Table 2.

Table 2

Summary of included studies.

See the full evidence tables in appendix D.

Summary of the evidence

The views and preferences of staff on supervision identified in the included studies were categorised into 4 main themes: support to make decisions, emotional support, skill development, frequency and communication. A total of 6 subthemes were associated with the 4 main themes, and these are illustrated in Figure 1 and summarised in Table 3.

See appendix F for full GRADE-CERQual tables.

Figure 1

Theme map.

Table 3

Summary of themes and subthemes.

Economic evidence

Included studies

A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in appendix B and economic study selection flow chart in appendix G.

Excluded studies

Economic studies not included in the guideline economic literature review are listed, and reasons for their exclusion are provided in appendix J.

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

Evidence statements

Economic

No economic studies were identified which were applicable to this review question.

The committee’s discussion and interpretation of the evidence

The outcomes that matter most

The aim of this review question was to identify what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed. The committee agreed that any differentiation between required supervision would likely be due to staff specialty rather than setting specialty, because specialist staff may work in non-specialist settings. As a result, the views members of specialist staff who assess and treat people who have self-harmed or their supervisors were considered the most important for this question. The committee suggested potential themes which may have arisen from the evidence such as respectful behaviour, compassion, understanding function of behaviour, communication style, frequency, support to make decisions and skilled supervision but did not want to constrain the question; therefore, any views and preferences about specialist staff supervision regarded as useful/ not useful or important/ not important by the population were included.

The quality of the evidence

When assessed using GRADE CERQual methodology the evidence ranged in quality from very low to moderate quality, with the majority of the evidence low quality. The recommendations were drafted mostly based on the evidence but in some parts supplemented accordingly with the committee’s own expertise where the evidence was low or very low quality.

In some cases, the evidence was downgraded due to poor applicability where the themes were not based on any research from a UK context, or where the study population were specialist staff who worked with people with suicidal behaviour (which did not specify whether the patients had self-harmed). It was noted where studies were conducted in non-specialist settings, but studies were not downgraded for applicability solely due to this. Some downgrading for adequacy occurred when the richness or quantity of the data was low. Other issues resulting in downgrading were methodological limitations, mainly inadequate explanation of the recruitment approach, concerns about potential influence of researchers on study findings, a lack of researcher reflexivity and a lack of acknowledgement of data saturation, that may have had an impact on the findings.

Benefits and harms

The recommendations about supervision for staff who work with people who have self-harmed were based on the evidence from both specialist and non-specialist staff (see evidence review S) as there was a significant overlap between the kind of supervision both specialist mental health and non-specialist professionals wanted when working with people who have self-harmed. Many of the identified themes in this review were similar to those identified in the non-specialist staff review, with some differences between themes relating to the level of detail or specific needs of non-specialist staff.

There was evidence from both specialist and non-specialist staff that all professionals working with people who self-harm valued different types of supervision for specific purposes, including regular formal supervision, decision-making support during an episode of self-harm to emotional support, and skill development after an episode of self-harm. The committee were concerned that self-harm specific supervision is not currently routinely incorporated into formal supervision practices, despite the prevalence of self-harm and the unique challenges and concerns associated with providing care and support for someone who has self-harmed. The committee had some concerns with the applicability of the findings as most evidence was from staff working with people with suicidal behaviour who had not necessarily previously self-harmed, however, based on their experience and expertise they felt comfortable in applying this evidence to staff working with people who have self-harmed, and agreed to make recommendations on both regular formal self-harm specific supervision and accessible ‘on-the-job’ self-harm specific support.

The committee discussed the theme ‘frequency of supervision and communication style’ and agreed that all staff working with people who self-harm should be able to access formal supervision that is regular, high-quality, structured, and distinct from general clinical supervision and case load management. Based on the evidence and their own experience, the committee made a recommendation that formal supervision should be provided by a senior member of staff with the relevant skills, training and experience, to all staff who work with people who self-harm. For non-specialist staff, the sub-theme ‘supervision culture’ showed that often, formal supervision was not embedded in routine practice and was more of an exception than a rule, provided only in times of crisis. However, there was limited evidence, in terms of quantity, to support making a recommendation about how regular formal supervision should be for staff who work with people who self-harm. The committee agreed the regularity of formal supervision would therefore be dependant on setting-specific factors, such as rates of self-harm, acuteness of self-harm, and available resources. They acknowledged there was insufficient evidence, in terms of quantity, to further specify the mode of supervision, for example internal versus external supervision or group versus individual supervision. The committee discussed the sub-theme ‘sensitivity and empathetic communication’ identified in the specialist staff review and, while they acknowledged the importance of communication style, they agreed that it was not specific to self-harm supervision and did not want to make recommendations on general principles of supervision. Therefore, the committee agreed that all staff should have the opportunity to receive regular formal supervision as needed, but could not be more specific about how this should be delivered based on the strength of the available evidence.

The committee discussed the evidence from the theme ‘emotional support’ which showed some staff felt that episodes of self-harm and patient suicides could impact their ability to deliver compassionate care. The committee agreed it was important that the sensitive nature of self-harm was acknowledged during supervision to enable the provision of support, but noted that it was unhelpful and inaccurate to imply that people who have self-harmed are at fault. The committee also agreed that the support needs of staff should not affect the quality of support and care provided to the person who has self-harmed. Therefore, the committee agreed that the delivery of compassionate care should also be promoted as an aspect of supervision, to ensure the support needs of both people who have self-harmed and the staff who work with them are continuously met.

The theme ‘skill development’ captured evidence of the value both specialist and non-specialist staff placed on having time for feedback and reflective practice following an episode of self-harm. There was evidence that staff viewed reflective practice as an invaluable means to learn from their experiences or the experiences of others and improve their clinical practice, however, there was evidence that often this was not prioritised due to time and resource constraints, especially for non-specialist staff. The committee agreed that in their experience, reflective practice was overlooked or rushed and agreed that it should be prioritised within formal supervision for staff who work with people who self-harm. Based on this evidence and their experience, the committee made a recommendation specifying that ongoing skill development and reflective practice should be a key component of formal self-harm supervision for both specialist and non-specialist staff as it promoted confidence and competence.

In addition to formal supervision, the theme ‘support to make decisions’ described how staff valued having accessible and immediate support from senior colleagues when caring for people who self-harm as this acted to promote confidence in difficult situations; this was particularly important for non-specialist staff who valued informal interactions with senior staff to confirm care decisions and feel reassured in their decisions. For specialist staff, uncertainties around responsibility and liability were noted, with staff describing the unclear lines of responsibility in difficult situations where duty of care conflicted with patient autonomy. The committee were concerned that anxiety around fear of litigation in difficult situations could impact quality of care and agreed that supervision support for staff working with people who self-harm should reinforce lines of responsibility and provide advice to facilitate staff in making the most appropriate decisions.

With respect to the theme ‘emotional support’, there was evidence that staff valued receiving professional emotional support following an episode of self-harm or suicide because it helped them to process their experience and normalise their feelings and reactions. However, it was reported that often formal emotional support was not provided, with a particular lack of support noted for specialist staff in educational settings. The committee agreed that, in their experience, support services were not routinely available for specialist staff working in non-specialist settings, such as schools, however, they highlighted that access to support in these situations was improving with the expansion of CAMHS services in schools. There was inadequate evidence, in terms of quantity, to determine whether emotional support should be provided by a clinical supervisor or whether it should be accessed externally, however the committee agreed that in their experience, it was often more appropriate for the member of staff to speak to someone removed from the situation. The committee agreed formal supervision should ensure that all staff working with people who have self-harmed have access to emotional support or emotional support services as needed.

Cost effectiveness and resource use

The committee noted that no relevant published economic evaluations had been identified in the literature review. In addition, the development of a bespoke economic model in this area of the guideline was not prioritised as other areas were considered as higher priorities for primary economic analysis. When drafting the recommendations, the committee agreed that staff in specialist mental health settings working with people who self-harm should receive regular, high-quality formal supervision, the regularity of which should be determined, among other factors, by available resources. The committee noted a likely increase in costs associated with providing staff in specialist mental health settings with formal supervision. However, they expressed the opinion that additional costs are likely to be offset by better health outcomes, by improving the care and quality of life of people who have self-harmed.

The committee discussed the cost implications of providing accessible emotional support or emotional support services to all staff who work with people who self-harm and concluded that in most clinical settings 24 hour support was already available so there would be minimal impact. For specialist staff working in non-clinical settings, such as educational settings, the committee discussed that support should already be available for pastoral care givers and the recommendations mirror the introduction of designated leads in mental health in schools.

Recommendations supported by this evidence review

This evidence review supports recommendations 1.15.1–1.15.2. Other evidence supporting these recommendations can be found in the evidence reviews on supervision in non-specialist settings (evidence report S).

References – included studies

Qualitative

Table

Economic

No studies were identified that met the inclusion criteria.

Appendices

Appendix E. Forest plots

Forest plots for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

No meta-analysis was conducted for this review question and so there are no forest plots.

Appendix F. GRADE-CERQual tables

GRADE-CERQual tables for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed? (PDF, 149K)

Appendix G. Economic evidence study selection

Appendix H. Economic evidence tables

Economic evidence tables for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

No evidence was identified which was applicable to this review question.

Appendix I. Economic model

Economic model for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

No economic analysis was conducted for this review question.

Appendix J. Excluded studies

Excluded studies for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

Excluded qualitative studies

Please note that the current search was undertaken with the search for review questions P (What are the views and preferences of staff in specialist mental health settings, people who have self-harmed and their family members/carers about what skills are required for staff in specialist mental health settings who assess and treat people who have self-harmed?), R (What are the views and preferences of staff in non-specialist mental health settings, people who have self-harmed and their family members/carers about what skills are required for staff in non-specialist mental health settings who assess and treat people who have self-harmed?), and S (What are the views and preferences of staff in non-specialist mental health settings about what supervision is required for staff in non-specialist mental health settings who assess and treat people who have self-harmed?), and the list of excluded studies below only lists the 77 studies that were excluded for all reviews in contrast to the 119 excluded studies specified in the PRISMA diagram. This is because routing used in EPPI-Reviewer to separate the results of review questions P-S (for which a combined search was performed) resulted in EPPI-Reviewer being unable to generate the excluded studies list in the usual format, with the excluded studies for review questions P-S separated. Please see the PRISMA diagram for details of the (119−77 =) 42 studies not listed in the excluded studies tables below, which are studies that met the inclusion criteria for review questions P, R and/ or S.

Table 10. Excluded studies and reasons for their exclusion

Excluded economic studies

Table 11. Excluded studies from the guideline economic review

Appendix K. Research recommendations – full details

Research recommendations for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

No research recommendations were made for this review question.

Appendix L. Qualitative quotes

Qualitative quotes for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed? (PDF, 129K)

Final

Evidence reviews underpinning recommendations 1.15.1 to 1.15.2 in the NICE guideline

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Bookshelf ID: NBK588197PMID: 36595596

Table 1Summary of the protocol (PPC table)

Population

Staff in specialist mental health settings that assess and/or treat people who have self-harmed

Phenomenon of interest

Views and preferences of the population about staff supervision regarded as required/ not required or important/ not important

Themes will be identified from the literature, but may include:

Respectful behaviour
Compassion
Understanding function of behaviour
Communication style
Frequency
Support to make decisions
Skilled supervision

Context

All specialist mental health settings

Table 2Summary of included studies

Study and aim of the study

Population

Methods

Author themes

Awenat 2017

Aim of the study: To investigate staff experiences of working with in-patients who are suicidal

Country UK

N=20 staff members who work with psychiatric in-patients

Mean age (SD): not reported

Role:

Nurses: 8

Nursing assistants/ support workers: 2

Psychiatrists: 4*

Allied health professionals (including clinical psychologists, clinical social workers and occupational therapists): 6*

*Only data from these groups of participants were extracted

Sex (female/ male): 14/6

Setting: Psychiatric inpatient wards

Mean years in post/ experience (range): Not reported (4–38)

Client group (adults, children/ CYP): Not reported

Study dates: Not reported

Data collection and analysis: Semi-structured interviews (average of 64 minutes) were held using a flexible topic guide. Interviews were audio-recorded and transcribed verbatim.

Data were analysed using thematic analysis.

Talking about suicide - not my role to talk about suicide

Berg 2020

Aim of the study: To understand healthcare professionals’ capacities to adapt to challenges and changes in clinical care for suicidal patients hospitalised in mental health wards

Country: Norway

N=32 specialist healthcare professionals

Mean age (SD): not reported

Sex (female/ male): 28/7

Role:

Qualified specialist nurses: 14 in focus groups; 11 in interviews

Medical doctors (consultant psychiatrists): 6 in focus groups; 4 in interviews

Psychologists: 5 in focus groups; 3 in interviews

Setting: Psychiatric inpatient wards

Mean years in post/ experience (range): Not reported (1–24)

Client group (adults, children/ CYP): Adults

Study dates: May to December 2016

Data collection and analysis: Focus groups (90 minutes) with open-ended questions and individual interviews were held to explore themes generated during focus groups. Interviews were audio-recorded and transcribed verbatim.

Data were analysed using thematic analysis.

Managing uncertainty - Building mutual collegial trust and support

Christianson 2008

Aim of the study: To explore the experiences of school counsellors who have lost students to suicide

Country: Canada

N=7 people who are/ were a school counsellor

Mean age (SD): not reported

Sex (female/ male): 4/3

Role:

School counsellors: 7

Setting: Schools

Mean years in post/ experience (range): Not reported (15- 31)

Client group (adults, children/ CYP): children (school age)

Study dates: Not reported

Data collection and analysis: Individual in-depth telephone interviews were conducted (two interviews, between 1–2 hours) using semi-structured interview questions. Interviews were transcribed and sent to participants for clarification and verification.

Data were examined inductively using a grounded theory approach. Constant comparative method used to identify major themes, which were linked together into higher-order categories.

National Training/Practice Standards

de Stefano 2012

Aim of the study: to explore the experiences of counsellors in training who work with people who self-harm

Country: Canada

N=12 counselling psychology students

Mean age (range): Not reported (23–37 years)

Sex (female/ male): 12/0

Role:

Counselling psychology students working with people who have self-harmed: 12

Setting: Community settings (high schools, colleges and university counselling centres)

Mean years in post/ experience: Not reported but no clinical experience beyond internship clinical training

Client group (adults, children/ CYP): CYP

Study dates: Not reported

Data collection and analysis: Semi-structured interviews (45–60 minutes) with open-ended questions were held.

Consensual qualitative research method used. Cross-case analysis was used to compare and categorize core ideas across all participants and consensus was used to discuss emerging themes.

Experience provides new but incomplete learning- Supervision provides mixed benefits

Hagen 2017a

Aim of the study: To explore and compare therapists’ and mental health nurses’ experiences of caring for suicidal inpatients

Country: Norway

N=9 specialist mental health professionals

Mean age (range): Not reported (28–60 years)

Sex (female/ male): 3/6

Role:

Mental health nurses: 8

Psychiatrists: 4

Psychologists: 4

Setting: Psychiatric inpatient wards

Mean years in post/ experience (range): Not reported (2–30)

Client group (adults, children/ CYP): adults

Study dates: Not reported

Data collection and analysis: Semi-structured interviews were conducted and confirmatory questions used to clarify experiences and views. Interviews were recorded and transcribed verbatim.

Data were analysed using thematic framework analysis.

Duty and Control

Hagen 2017b

Aim of the study: see Hagen 2017a

Country: Norway

N=8 mental health nurses

Mean age (range): Not reported (43–60 years)

Sex (female/ male): 7/1

Role:

Mental health nurses: 8

Setting: Psychiatric inpatient wards

Mean years in post/ experience (range): Not reported (5–25)

Client group (adults, children/ CYP): adults

See Hagen 2017a

Balancing Emotional Involvement and Professional Distance

Hoffman 2013

Aim of the study: To explore the perspectives of counsellor supervisors to generate an emergent theory of the process of counsellor supervision for trainees who work with people who are suicidal

Country: USA

N=5 counsellor supervisors

Mean age (SD): not reported

Sex (female/ male): 2/3

Role:

Counsellor supervisor: 5

Setting: University counselling service (for mental health staff trainees)

Mean years in post/ experience (range): Not reported (2–12)

Client group (adults, children/ CYP): adults

Study dates: Not reported

Data collection and analysis: Semi-structured individual telephone interviews were conducted (70- 90 minutes) in 3 rounds. Interviews were recorded and transcribed. Follow-up 30-minute semi-structured individual telephone interviews were held within 1 month of the final interview to check the validity of emerging themes.

Constant comparison method used for analysis. Emergent theory iteratively constructed with participants until data saturation.

Role of the supervisor
Working with suicidal clients as a formative learning experience
Supervision differs when a client is suicidal

Kelada 2017

Aim of the study: to understand how school mental health staff and parents of secondary school students view self-harm to determine how parent-school communication and responses to self-harm can be improved

Country: Australia

N= 19 school mental health staff

Mean age (SD): not reported

Sex (female/ male): not reported

Role:

School counsellors: 4

School psychologists: 3

Welfare coordinators: 12

Setting: Schools

Mean years in post/ experience (SD): 12.53 (9.05)

Client group (adults, children/ CYP): adults

Study dates: Not reported

Data collection and analysis: Semi-structured interviews (approximately 30 minutes) with open-ended questions were conducted (4 conducted face-to-face and 15 conducted via telephone). Interviews were recorded and transcribed verbatim.

Data were analysed using thematic analysis.

Support for school mental health staff

Knox 2006

Aim of the study: To explore the experiences of pre-qualified doctors following a patient’s suicide

Country: USA

N=13 psychologists in training

Mean age (SD): 33.08 (6.40)

Sex (female/ male): 8/5

Role:

Graduate doctors in specialist mental-health training: 13

Setting: Community mental health care; hospitals; university clinics; outpatient clinics

Years in post/ experience:

1–10 years: 1

11–20 years: 4

21–30 years: 1

Client group (adults, children/ CYP): adults

Study dates: Not reported

Data collection and analysis: Semi-structured interviews were conducted examining participants’ attitudes and experiences of suicide. Follow-up interviews were conducted 2 weeks after initial interview. Interviews were transcribed verbatim.

Consensual qualitative research method used to analyse data.

Supervisee and supervision

Littlewood 2019

Aim of the study: To explore clinicians’ views of good practice in mental healthcare services in the context of suicide prevention

Country: UK

N=2331 staff members working at mental health service providers

Mean age (SD): not reported

Sex (female/ male): not reported

Role:

Consultant psychiatrists: 232

Service managers: 131

Mental health practitioners: 63

Doctors: 47

Psychologists: 37

Other: 16

Not specified: 1804

Setting: Of the 62 mental health providers that submitted responses:

NHS mental health service providers: 57 (2286/ 2331 responses)

Independent providers: 5 (45/ 2331 responses)

Years in post/ experience: not reported

Client group (adults, children/ CYP): not reported

Study dates: January 2011 to December 2016

Data collection and analysis: Qualitative data on clinicians’ views of good practice within mental healthcare services were collected systematically via questionnaire by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH).

Thematic analysis was used to analyse data within a thematic framework developed from the NCISH ‘10 Key Elements To Improve Safety’ and the NICE Self-harm Quality Standard - QS34.

Establish a sufficiently skilled, resourced and supported staff team

MacDonald 2021

Aim of the study: To explore the experiences and encounters of professionals who care for people who have self-harmed

Country: UK

N=14 healthcare professionals

Mean age (SD): not reported

Sex (female/ male): 12/2

Role:

Nurse: 6 *

Doctor: 7

Project coordinator: 1

*Only data from mental health nurses were extracted

Setting: Emergency department of a large urban hospital

Mean years in post/ experience (SD): around 6 months (not reported)

Client group (adults, children/ CYP): CYP

Study dates: September 2018 to March 2019

Data collection and analysis: In-depth, semi-structured interviews were conducted using a topic guide. Interviews were recorded and transcribed verbatim.

Data were analysed using a thematic analysis approach with the principles of grounded theory applied.

Constructing the ‘patient’: a culture of risk and risk management

Wilstrand 2007

Aim of the study:

Country: USA

N=6 specialist nurses

Mean age (range): 40 (27–53) years

Sex (female/ male): 3/3

Role:

Generalist nurse: 2

Nurses with training in specialist psychiatric nursing*: 4

Nurses with training in psychotherapy*: 1

*Only data from these participants were extracted

Setting: Psychiatric inpatient wards

Mean years in post/ experience (range): 9.4 (1–18)

Client group (adults, children/ CYP): adults and CYP

Study dates: Spring 2002

Data collection and analysis: Narrative interviews were conducted (40–50 minutes) with 2 open-ended questions. Interviews were recorded and transcribed verbatim.

Transcripts were analysed by qualitative content analysis.

Being burdened with feelings- Feeling abandoned by co-workers and management
Balancing professional boundaries- Feeling confirmed by co-workers and management

Figure 1Theme map

Table 3Summary of themes and subthemes

Themes and subthemes	Quality	No. of studies	Study populations (no. of studies)
1. Support to make decisions
1.1 Confidence and competence	Low	4	Psychiatrists (2); School mental-health counsellors (1); Counsellor supervisor (1); Mental health practitioners (1); Psychologists (1)
1.2 Responsibility and liability	Low	3	Qualified specialist nurses (1); Consultant psychiatrists (1); Psychologists; Specialist mental health personnel (1); Counsellor supervisor (1)
2. Emotional support
2.1 Processing experience and sharing emotional burden	Low	6	School counsellors (1); Mental health nurses (2); Counsellor supervisor (1); Graduate doctors in specialist mental-health training (1); Consultant psychiatrists (1); Mental health practitioners (1); Psychologists (1)
3. Skill development
3.1 Feedback and reflective practice	Moderate	5	Counsellor supervisor (1); School counsellors (1); School psychologists (1); Consultant psychiatrists (1) Mental health practitioners (3); Psychologists (1)
4. Frequency and communication
4.1 Sensitive and empathetic communication style	Very low	3	Graduate doctors in specialist mental-health training (1); Counsellor supervisor (1); Psychology counselling students (1)
4.2 Regular supervision	Low	3	School counsellors (1); School psychologists (1); Consultant psychiatrists (1); Mental health practitioners (1); Psychologists (1); Mental health nurses (1)

Study
Awenat, Yvonne, Peters, Sarah, Shaw-Nunez, Emma et al (2017) Staff experiences and perceptions of working with in-patients who are suicidal: qualitative analysis. The British journal of psychiatry : the journal of mental science 211: 103–108 [PMC free article: PMC5537568] [PubMed: 28642259]
Berg, Siv Hilde, Rortveit, Kristine, Walby, Fredrik A. et al (2020) Adaptive capacities for safe clinical practice for patients hospitalised during a suicidal crisis: a qualitative study. BMC psychiatry 20: 316 [PMC free article: PMC7304097] [PubMed: 32560682]
Christianson, Carley L. and Everall, Robin D. (2008) Constructing bridges of support: School counsellors’ experiences of student suicide. Canadian Journal of Counselling 42: 209–221
de Stefano, J., Atkins, S., Noble, R. N. et al (2012) Am I competent enough to be doing this?: A qualitative study of trainees’ experiences working with clients who self-injure. Counselling Psychology Quarterly 25: 289–305
Hagen, Julia; Hjelmeland, Heidi; Knizek, Birthe Loa (2017) Relational Principles in the Care of Suicidal Inpatients: Experiences of Therapists and Mental Health Nurses. Issues in mental health nursing 38: 99–106 [PubMed: 27901635]
Hagen, Julia; Knizek, Birthe Loa; Hjelmeland, Heidi (2018) Former suicidal inpatients’ experiences of treatment and care in psychiatric wards in Norway. International journal of qualitative studies on health and well-being 13: 1461514 [PMC free article: PMC5906934] [PubMed: 29652227]
Hagen, Julia; Knizek, Birthe Loa; Hjelmeland, Heidi (2017) Mental Health Nurses’ Experiences of Caring for Suicidal Patients in Psychiatric Wards: An Emotional Endeavor. Archives of psychiatric nursing 31: 31–37 [PubMed: 28104055]
Hoffman, Rachel M.; Osborn, Cynthia J.; West, John D. (2013) Clinical supervision of counselors-in-training working with suicidal clients: A grounded theory investigation. The Clinical Supervisor 32: 105–127
Kelada, Lauren; Hasking, Penelope; Melvin, Glenn A. (2017) School response to self-injury: Concerns of mental health staff and parents. School psychology quarterly : the official journal of the Division of School Psychology, American Psychological Association 32: 173–187 [PubMed: 28414505]
Knox, Sarah, Burkard, Alan W., Jackson, Julie A. et al (2006) Therapists-in-training who experience a client suicide: Implications for supervision. Professional Psychology: Research and Practice 37: 547–557
Littlewood, Donna L., Quinlivan, Leah, Graney, Jane et al (2019) Learning from clinicians’ views of good quality practice in mental healthcare services in the context of suicide prevention: a qualitative study. BMC psychiatry 19: 346 [PMC free article: PMC6836656] [PubMed: 31694598]
MacDonald, S., Sampson, C., Biddle, L. et al (2021) Theorising health professionals’ prevention and management practices with children and young people experiencing self-harm: a qualitative hospital-based case study. Sociology of health & illness 43: 201–219 [PMC free article: PMC9904420] [PubMed: 33113234]
Wilstrand, C., Lindgren, B. M., Gilje, F. et al (2007) Being burdened and balancing boundaries: a qualitative study of nurses’ experiences caring for patients who self-harm. Journal of psychiatric and mental health nursing 14: 72–8 [PubMed: 17244008]

Table 10Excluded studies and reasons for their exclusion

Study	Code [Reason]
Balcombe, Lucille; Phillips, Louise; Jones, Julia (2011) ENGAGEMENT WITH YOUNG PEOPLE WHO SELF-HARM. Mental Health Practice 15: 14–18	- No direct qualitative data on phenomena of interest
Barekatain, M., Aminoroaia, M., Samimi, S. M. A. et al (2013) Educational needs assessment for psychiatry residents to prevent suicide: A qualitative approach. International Journal of Preventive Medicine 4: 1200–1205 [PMC free article: PMC3843308] [PubMed: 24319561]	- Country not in PICO
Berg, Siv Hilde; Rortveit, Kristine; Aase, Karina (2017) Suicidal patients’ experiences regarding their safety during psychiatric in-patient care: a systematic review of qualitative studies. BMC health services research 17: 73 [PMC free article: PMC5259991] [PubMed: 28114936]	- Systematic review - included studies checked for relevance
Berger, E.; Hasking, P.; Reupert, A. (2014) “We’re Working in the Dark Here”: Education Needs of Teachers and School Staff Regarding Student Self-Injury. School Mental Health 6: 201–212	- No direct qualitative data on phenomena of inte rest
Berger, Emily; Hasking, Penelope; Martin, Graham (2013) ‘Listen to them’: Adolescents’ views on helping young people who self-injure. Journal of adolescence 36: 935–45 [PubMed: 24011109]	- Population not in PICO Only 10% (N=263) of participants had self-harmed
Best, R. (2005) An educational response to deliberate self-harm: Training, support and school-agency links. Journal of Social Work Practice 19: 275–287	- Population not in PICO Participants are non-specialist staff who do not normally assess as treat people who have self-harmed
Brown, J. and Beail, N. (2009) Self-harm among people with intellectual disabilities living in secure service provision: a qualitative exploration. Journal of Applied Research in Intellectual Disabilities 22: 503–513	- Population not in PICO Study defined self-harm as inclusive of repetitive stereotypical self-injurious behaviour such as head-banging. The study included people who had intellectual disabilities who had self-harmed but did not specify how many of the participants’ method of self-harm was repetitive stereotypical self-injurious behaviour
Davis, Taijah (2020) Applied suicide intervention skills training program (ASIST): An evaluation of school counselor preparedness for immediate suicide intervention. Dissertation Abstracts International Section A: Humanities and Social Sciences 81: No-Specified	- Full text not provided Only part of text provided in PDF, the rest not available
De Silva, Eve; Bowerman, Lisa; Zimitat, Craig (2015) A suicide awareness and intervention program for health professional students. Education for health (Abingdon, England) 28: 201–4 [PubMed: 26996645]	- No direct qualitative data on phenomena of interest
Duperouzel, H. and Fish, R. (2008) Why couldn’t I stop her? Self injury: The views of staff and clients in a medium secure unit. British Journal of Learning Disabilities 36: 59–65	- Study conducted pre-2000 Paper includes 2 studies - 1 (Fish 2000) conducted pre-2000; the other study is not referenced
Eckerström, Joachim, Flyckt, Lena, Carlborg, Andreas et al (2020) Brief admission for patients with emotional instability and self-harm: A qualitative analysis of patients’ experiences during crisis. International Journal of Mental Health Nursing 29: 962–971 [PubMed: 32406168]	- No direct qualitative data on phenomena of interest Themes explored patients perspectives of a specific intervention (brief admission)
El-Den, Sarira, O’Reilly, Claire L., Murphy, Andrea L. et al (2019) A systematic review of healthcare professionals’ knowledge, attitudes and confidence in relation to suicide. Research in Social & Administrative Pharmacy 15: e8–e9	- Conference abstract
Elzinga, Elke, de Kruif, Anja J. T. C. M., de Beurs, Derek P. et al (2020) Engaging primary care professionals in suicide prevention: A qualitative study. PloS one 15: e0242540 [PMC free article: PMC7704003] [PubMed: 33253178]	- No direct qualitative data on phenomena of interest Primary healthcare professionals provided feedback on a specific suicide prevention training course; they did not discuss required skills
Ferguson, M. S., Reis, J. A., Rabbetts, L. et al (2018) The effectiveness of suicide prevention education programs for nurses: A Systematic Review. Crisis 39: 96–109 [PubMed: 28990823]	- Systematic review - included studies checked for relevance
Fish, R. M. (2000) Working with people who harm themselves in a forensic learning disability service: experiences of direct care staff. Journal of Learning Disabilities (14690047) 4: 193–207	- Study conducted pre-2000
Fisher, G. and Foster, C. (2016) Examining the needs of paediatric nurses caring for children and young people presenting with self-harm/suicidal behaviour on general paediatric wards: Findings from a small-scale study. Child Care in Practice: 1–14	- No direct qualitative data on phenomena of interest
Fox, C. (2011) Working with clients who engage in self-harming behaviour: experiences of a group of counsellors. British Journal of Guidance & Counselling 39: 41–51	- No direct qualitative data on phenomena of interest
Gelkopf, Marc, Roffe, Ziva, Behrbalk, Pnina et al (2009) Attitudes, opinions, behaviors, and emotions of the nursing staff toward patient restraint. Issues in mental health nursing 30: 758–63 [PubMed: 19916810]	- Country not in PICO
Granek, L., Nakash, O., Shapira, S. et al (2020) Oncologists, oncology nurses and oncology social workers experiences with suicide: impact on patient care. Journal of Psychosocial Oncology 38: 543–556 [PubMed: 32342799]	- Country not in PICO
Gryglewicz, K., Monahan, M. M., Chen, J. I. et al (2020) Examining the effects of role play practice in enhancing clinical skills to assess and manage suicide risk. Journal of Mental Health 29: 549–557 [PMC free article: PMC9202230] [PubMed: 30633596]	- Quantitative study
James, M. and Warner, S. (2005) Coping with their lives - women, learning disabilities, self-harm and the secure unit: A Q-methodological study. British Journal of Learning Disabilities 33: 120–127	- No direct qualitative data on phenomena of interest
Jordan, Joanne, McKenna, Hugh, Keeney, Sinead et al (2012) Providing meaningful care: learning from the experiences of suicidal young men. Qualitative health research 22: 1207–19 [PubMed: 22785623]	- Population not in PICO Study included men who had experienced suicidal ideation but did not specify whether any participants had self-harmed
Keogh, Brian; Doyle, Louise; Morrissey, Jean (2007) Suicidal behaviour. A study of emergency nurses’ educational needs when caring for this patient group. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association 15: 30–5 [PubMed: 17760238]	- Literature review
Leavey, Gerard, Mallon, Sharon, Rondon-Sulbaran, Janeet et al (2017) The failure of suicide prevention in primary care: family and GP perspectives - a qualitative study. BMC psychiatry 17: 369 [PMC free article: PMC5697339] [PubMed: 29157221]	- No direct qualitative data on phenomena of interest
Lee, Frances (2016) Self-harm training in secondary schools: An educational psychology intervention using interpretative phenomenological analysis. Educational and Child Psychology 33: 105–116	- Population not in PICO
Leung, M., Chow, C. B., Ip, P. K. P. et al (2019) Self-harm attempters’ perception of community services and its implication on service provision. International Journal of Nursing Sciences 6: 50–57 [PMC free article: PMC6608664] [PubMed: 31406869]	- No direct qualitative data on phenomena of interest
Lindeman, M. A.; Kuipers, P.; Grant, L. (2015) Front-line worker perspectives on indigenous youth suicide in Central Australia: Contributors and prevention strategies. International Journal of Emergency Mental Health 17: 191–196	- No direct qualitative data on phenomena of interest
Lindgren, B. M., I, O. Ster, Astrom, S. et al (2011) ‘They don’t understand … you cut yourself in order to live.’ Interpretative repertoires jointly constructing interactions between adult women who self-harm and professional caregivers. International Journal of Qualitative Studies on Health and Well-being 6: 7254 [PMC free article: PMC3166521] [PubMed: 21897829]	- No direct qualitative data on phenomena of interest
Long, Maggie; Manktelow, Roger; Tracey, Anne (2016) “Knowing that I’m not alone”: client perspectives on counselling for self-injury. Journal of mental health (Abingdon, England) 25: 41–6 [PubMed: 26651377]	- No direct qualitative data on phenomena of interest
Lukaschek, K.; Erazo, N.; Ladwig, K. H. (2016) Police deployment after railway suicide: A qualitative content analysis of 127 narrative reports. Nervenheilkunde 35: 329–335	- Study not in english
Maple, M.; McKay, K.; Sanford, R. (2019) The attempt was my own! suicide attempt survivors respond to an Australian community-based suicide exposure survey. International Journal of Environmental Research and Public Health 16: 4549 [PMC free article: PMC6888602] [PubMed: 31752077]	- No direct qualitative data on phenomena of interest
Maple, Myfanwy, McKay, Kathy, Hess, Nicole C. L. et al (2019) Providing support following exposure to suicide: A mixed method study. Health & social care in the community 27: 965–972 [PubMed: 30680822]	- Population not in PICO Participants are people providing support to people bereaved by suicide
Martin, Catherine and Chapman, Rose (2014) A mixed method study to determine the attitude of Australian emergency health professionals towards patients who present with deliberate self-poisoning. International emergency nursing 22: 98–104 [PubMed: 24207085]	- No direct qualitative data on phenomena of interest
Marzano, Lisa; Ciclitira, Karen; Adler, Joanna (2012) The impact of prison staff responses on self-harming behaviours: prisoners’ perspectives. The British journal of clinical psychology 51: 4–18 [PubMed: 22268538]	- No direct qualitative data on phenomena of interest
Mason, Karen; Geist, Monica; Clark, Mollie (2019) A Developmental Model of Clergy Engagement With Suicide: A Qualitative Study. Omega 79: 347–363 [PubMed: 28604228]	- Population not in PICO
McAllister, Margaret, Moyle, Wendy, Billett, Stephen et al (2009) ‘I can actually talk to them now’: qualitative results of an educational intervention for emergency nurses caring for clients who self-injure. Journal of clinical nursing 18: 2838–45 [PubMed: 19374701]	- No direct qualitative data on phenomena of interest
McGrath, Ryan L., Parnell, Tracey, Verdon, Sarah et al (2020) Trust, conversations and the ‘middle space’: A qualitative exploration of the experiences of physiotherapists with clients with suicidal thoughts and behaviours. PloS one 15: e0238884 [PMC free article: PMC7482971] [PubMed: 32913352]	- Population not in PICO
Michail, Maria and Tait, Lynda (2016) Exploring general practitioners’ views and experiences on suicide risk assessment and management of young people in primary care: a qualitative study in the UK. BMJ open 6: e009654 [PMC free article: PMC4716217] [PubMed: 26758263]	- No direct qualitative data on phenomena of interest
Montross Thomas, Lori P., Palinkas, Lawrence A., Meier, Emily A. et al (2014) Yearning to be heard: what veterans teach us about suicide risk and effective interventions. Crisis 35: 161–7 [PubMed: 24698725]	- No direct qualitative data on phenomena of interest
Moseley, R. L., Gregory, N. J., Smith, P. et al (2019) A ‘choice’, an ‘addiction’, a way ‘out of the lost’: exploring self-injury in autistic people without intellectual disability. Molecular autism 10: 18 [PMC free article: PMC6458651] [PubMed: 31007885]	- No direct qualitative data on phenomena of interest
Mughal, F., Troya, M. I., Dikomitis, L. et al (2020) Role of the GP in the management of patients with self-harm behaviour: A systematic review. Cancer Prevention Research 13: E364–E373 [PMC free article: PMC7015161] [PubMed: 32041771]	- No direct qualitative data on phenomena of interest
Newman, C. F. (2005) Reducing the risk of suicide in patients with bipolar disorder: Interventions and safeguards. Cognitive and Behavioral Practice 12: 76–88	- Literature review
Ngune, I., Hasking, P., McGough, S. et al (2020) Perceptions of knowledge, attitude and skills about non-suicidal self-injury: A survey of emergency and mental health nurses. International journal of mental health nursing [PubMed: 33269517]	- Quantitative study
O’Connor, Sophie and Glover, Lesley (2017) Hospital staff experiences of their relationships with adults who self-harm: A meta-synthesis. Psychology and psychotherapy 90: 480–501 [PubMed: 28035740]	- No direct qualitative data on phenomena of interest
O’Donovan, A. and Gijbels, H. (2006) Understanding Psychiatric Nursing Care with Nonsuicidal Self-Harming Patients in Acute Psychiatric Admission Units: The Views of Psychiatric Nurses. Archives of Psychiatric Nursing 20: 186–192 [PubMed: 16846779]	- Full text not provided
Perry, Amanda E., Waterman, Mitch G., House, Allan O. et al (2019) Implementation of a problem-solving training initiative to reduce self-harm in prisons: a qualitative perspective of prison staff, field researchers and prisoners at risk of self-harm. Health & justice 7: 14 [PMC free article: PMC6717963] [PubMed: 31368051]	- No direct qualitative data on phenomena of interest
Pierret, A. C. S., Anderson, J. K., Ford, T. J. et al (2020) Review: Education and training interventions, and support tools for school staff to adequately respond to young people who disclose self-harm - a systematic literature review of effectiveness, feasibility and acceptability. Child and Adolescent Mental Health [PubMed: 33277965]	- No direct qualitative data on phenomena of interest
Popadiuk, Natalee; Young, Richard A.; Valach, Ladislav (2008) Clinician perspectives on the therapeutic use of the self-confrontation procedure with suicidal clients. Journal of Mental Health Counseling 30: 14–30	- No direct qualitative data on phenomena of interest Study lacks direct qualitative data on either skills or supervision
Rebair, Annessa and Hulatt, Ian (2017) Identifying nurses’ needs in relation to suicide awareness and prevention. Nursing standard (Royal College of Nursing (Great Britain) : 1987) 31: 44–51 [PubMed: 28247791]	- Full text not provided
Reeves, A. and Mintz, R. (2001) Counsellors’ experiences of working with suicidal clients: An exploratory study. Counselling and Psychotherapy Research 1: 172–176	- Population not in PICO
Reichardt, Jane (2016) Exploring school experiences of young people who have self-harmed: How can schools help?. Educational and Child Psychology 33: 28–39	- Full text not provided
Rippon, Daniel; Reid, Keith; Kay, Gail (2018) Views on restrictive practices on young people in psychiatric wards. Nursing Times 114: 4–4	- No direct qualitative data on phenomena of interest
Ross, Victoria; Kolves, Kairi; De Leo, Diego (2017) Teachers’ Perspectives on Preventing Suicide in Children and Adolescents in Schools: A Qualitative Study. Archives of suicide research : official journal of the International Academy for Suicide Research 21: 519–530 [PubMed: 27578394]	- Population not in PICO
Rossetti, Jeanette, Jones-Bendel, Trish, Portell, Pauline et al (2012) Changing attitudes about self-injury prevention management: lessons learned. Journal of psychosocial nursing and mental health services 50: 42–6 [PubMed: 22533841]	- Literature review
Russell-Broaddus, C. A. (2004) The suicidal patient’s experience of nursing care in the emergency room. msn: N.PAG p-N.PAG p	- Full text unavailable
Scheckel, Martha M. and Nelson, Kimberly A. (2014) An interpretive study of nursing students’ experiences of caring for suicidal persons. Journal of professional nursing : official journal of the American Association of Colleges of Nursing 30: 426–35 [PubMed: 25223291]	- Population not in PICO
Shamsaei, Farshid; Yaghmaei, Safura; Haghighi, Mohammad (2020) Exploring the lived experiences of the suicide attempt survivors: a phenomenological approach. International Journal of Qualitative Studies on Health & Well-Being 15: 1–11 [PMC free article: PMC7172699] [PubMed: 32223374]	- Country not in PICO
Sharpe, T. L., Jacobson Frey, J., Osteen, P. J. et al (2014) Perspectives and Appropriateness of Suicide Prevention Gatekeeper Training for MSW Students. Social Work in Mental Health 12: 117–131	- Population not in PICO
Shilubane, Hilda N., Bos, Arjan Er, Ruiter, Robert Ac et al (2015) High school suicide in South Africa: teachers’ knowledge, views and training needs. BMC public health 15: 245 [PMC free article: PMC4369108] [PubMed: 25884473]	- No direct qualitative data on phenomena of interest
Shtivelband, Annette; Aloise-Young, Patricia A.; Chen, Peter Y. (2015) Sustaining the Effects of Gatekeeper Suicide Prevention Training. Crisis 36: 102–109 [PubMed: 25708255]	- No direct qualitative data on phenomena of interest
Sousa, Marta, Goncalves, Rui Abrunhosa, Cruz, Ana Rita et al (2019) Prison officers’ attitudes towards self-harm in prisoners. International journal of law and psychiatry 66: 101490 [PubMed: 31706411]	- Quantitative study
Stallman, Helen M. (2020) Online needs-based and strengths-focused suicide prevention training: Evaluation of Care · Collaborate · Connect. Australian Psychologist 55: 220–229	- No direct qualitative data on phenomena of interest
Stanley, Nicky, Mallon, Sharon, Bell, Jo et al (2010) Suicidal students’ use of and attitudes to primary care support services. Primary Health Care Research and Development 11: 315–325	- No direct qualitative data on phenomena of interest
Sun, Fan-Ko, Long, Ann, Boore, Jennifer et al (2006) Patients and nurses’ perceptions of ward environmental factors and support systems in the care of suicidal patients. Journal of clinical nursing 15: 83–92 [PubMed: 16390527]	- Country not in PICO
Sun, Fan-Ko, Long, Ann, Chiang, Chun-Ying et al (2019) A theory to guide nursing students caring for patients with suicidal tendencies on psychiatric clinical practicum. Nurse education in practice 38: 157–163 [PubMed: 31302590]	- Country not in PICO
Sun, Fan-Ko, Long, Ann, Chiang, Chun-Ying et al (2020) The psychological processes voiced by nursing students when caring for suicidal patients during their psychiatric clinical practicum: A qualitative study. Journal of clinical nursing 29: 525–534 [PubMed: 31715048]	- Country not in PICO
Sweeney, F.; Clarbour, J.; Oliver, A. (2018) Prison officers’ experiences of working with adult male offenders who engage in suicide-related behaviour. Journal of Forensic Psychiatry and Psychology 29: 467–482	- No direct qualitative data on phenomena of interest
Talseth, Anne-Grethe and Gilje, Fredricka L. (2011) Nurses’ responses to suicide and suicidal patients: a critical interpretive synthesis. Journal of clinical nursing 20: 1651–67 [PubMed: 21366737]	- Systematic review - included studies checked for relevance
Taylor, B. (2003) Exploring the perspectives of men who self-harm. Learning in Health & Social Care 2: 83–91	- No direct qualitative data on phenomena of interest
Taylor, Tatiana L., Hawton, Keith, Fortune, Sarah et al (2009) Attitudes towards clinical services among people who self-harm: systematic review. The British journal of psychiatry : the journal of mental science 194: 104–10 [PubMed: 19182168]	- Systematic review - included studies checked for relevance
Vandewalle, J., Deproost, E., Goossens, P. et al (2020) The working alliance with people experiencing suicidal ideation: A qualitative study of nurses’ perspectives. Journal of advanced nursing 76: 3069–3081 [PubMed: 32830365]	- Population not in PICO
Vatne, May and Naden, Dagfinn (2018) Experiences that inspire hope: Perspectives of suicidal patients. Nursing ethics 25: 444–457 [PubMed: 27521246]	- No direct qualitative data on phenomena of interest
Vedana, Kelly Graziani Giacchero, Magrini, Daniel Fernando, Miasso, Adriana Inocenti et al (2017) Emergency Nursing Experiences in Assisting People With Suicidal Behavior: A Grounded Theory Study. Archives of psychiatric nursing 31: 345–351 [PubMed: 28693869]	- No direct qualitative data on phenomena of interest
Vrale, G. B. and Steen, E. (2005) The dynamics between structure and flexibility in constant observation of psychiatric inpatients with suicidal ideation. Journal of psychiatric and mental health nursing 12: 513–8 [PubMed: 16164500]	- Population not in PICO
Warrender, D. (2015) Staff nurse perceptions of the impact of mentalization-based therapy skills training when working with borderline personality disorder in acute mental health: a qualitative study. Journal of psychiatric and mental health nursing 22: 623–33 [PubMed: 26148873]	- No direct qualitative data on phenomena of interest Qualitative data are feedback on training for a specific psychosocial intervention (Mentalisation-Based Therapy)
Wheatley, Malcolm and Austin-Payne, Hannah (2009) Nursing staff knowledge and attitudes towards deliberate self-harm in adults and adolescents in an inpatient setting. Behavioural and cognitive psychotherapy 37: 293–309 [PubMed: 19393121]	- Quantitative study
Whisenhunt, J. L., Chang, C. Y., Flowers, L. R. et al (2014) Working with clients who self-injure: A grounded theory approach. Journal of Counseling and Development 92: 387–397	- No direct qualitative data on phenomena of interest

Table 11Excluded studies from the guideline economic review

Study	Reason for Exclusion
Adrian, M., Lyon, A. R., Nicodimos, S., Pullmann, M. D., McCauley, E., Enhanced “Train and Hope” for Scalable, Cost-Effective Professional Development in Youth Suicide Prevention, Crisis, 39, 235–246, 2018 [PubMed: 29183240]	Not relevant to any of the review questions in the guideline - this study examined the impact of an educational training ongoing intervention, and the effect of the post-training reminder system, on mental health practitioners’ knowledge, attitudes, and behaviour surrounding suicide assessment and intervention. As well, this study was not a full health economic evaluation
Borschmann R, Barrett B, Hellier JM, et al Joint crisis plans for people with borderline personality disorder: feasibility and outcomes in a randomised controlled trial. Br J Psychiatry. 2013;202(5):357–364. [PubMed: 23637110]	Not relevant to any of the review questions in the guideline - this study examined the feasibility of recruiting and retaining adults with borderline personality disorder to a pilot randomised controlled trial investigating the potential efficacy and cost-effectiveness of using a joint crisis plan
Bustamante Madsen, L., Eddleston, M., Schultz Hansen, K., Konradsen, F., Quality Assessment of Economic Evaluations of Suicide and Self-Harm Interventions, Crisis, 39, 82–95, 2018 [PubMed: 28914094]	Study design - this review of health economics studies has been excluded for this guideline, but its references have been hand-searched for any relevant health economic study
Byford, S., Barrett, B., Aglan, A., Harrington, V., Burroughs, H., Kerfoot, M., Harrington, R. C., Lifetime and current costs of supporting young adults who deliberately poisoned themselves in childhood and adolescence, Journal of Mental Health, 18, 297–306, 2009	Study design – no comparative cost analysis
Byford, S., Leese, M., Knapp, M., Seivewright, H., Cameron, S., Jones, V., Davidson, K., Tyrer, P., Comparison of alternative methods of collection of service use data for the economic evaluation health care interventions, Health Economics, 16, 531–536, 2007 [PubMed: 17001749]	Study design – no comparative cost analysis
Byford, Sarah, Barber, Julie A., Harrington, Richard, Barber, Baruch Beautrais Blough Brent Brodie Byford Carlson Chernoff Collett Fergusson Garland Goldberg Harman Harrington Hawton Huber Kazdin Kazdin Kerfoot Kerfoot Kerfoot Knapp Lindsey McCullagh Miller Netten Reynolds Sadowski Shaffer Simms Wu, Factors that influence the cost of deliberate self-poisoning in children and adolescents, Journal of Mental Health Policy and Economics, 4, 113–121, 2001 [PubMed: 11967471]	Study design – no comparative cost analysis
Denchev, P., Pearson, J. L., Allen, M. H., Claassen, C. A., Currier, G. W., Zatzick, D. F., Schoenbaum, M., Modeling the cost-effectiveness of interventions to reduce suicide risk among hospital emergency department patients, Psychiatric Services, 69, 23–31, 2018 [PMC free article: PMC5750130] [PubMed: 28945181]	Not relevant to any of the review questions in the guideline - this study estimated the cost-effectiveness of outpatient interventions (Postcards, Telephone outreach, Cognitive Behaviour Therapy) to reduce suicide risk among patients presenting to general hospital emergency departments
Dunlap, L. J., Orme, S., Zarkin, G. A., Arias, S. A., Miller, I. W., Camargo, C. A., Sullivan, A. F., Allen, M. H., Goldstein, A. B., Manton, A. P., Clark, R., Boudreaux, E. D., Screening and Intervention for Suicide Prevention: A Cost-Effectiveness Analysis of the ED-SAFE Interventions, Psychiatric services (Washington, D.C.), appips201800445, 2019 [PubMed: 31451063]	Not relevant to any of the review questions in the guideline - this study estimated the cost-effectiveness of suicide screening followed by an intervention to identify suicidal individuals and prevent recurring self-harm
Fernando, S. M., Reardon, P. M., Ball, I. M., van Katwyk, S., Thavorn, K., Tanuseputro, P., Rosenberg, E., Kyeremanteng, K., Outcomes and Costs of Patients Admitted to the Intensive Care Unit Due to Accidental or Intentional Poisoning, Journal of Intensive Care Medicine, 35, 386–393, 2020 [PubMed: 29357777]	Study design – no comparative cost analysis
Flood, C., Bowers, L., Parkin, D., Estimating the costs of conflict and containment on adult acute inpatient psychiatric wards, Nursing economic$, 26, 325–330, 324, 2008 [PubMed: 18979699]	Study design – no comparative cost analysis
Fortune, Z., Barrett, B., Armstrong, D., Coid, J., Crawford, M., Mudd, D., Rose, D., Slade, M., Spence, R., Tyrer, P., Moran, P., Clinical and economic outcomes from the UK pilot psychiatric services for personality-disordered offenders, International Review of Psychiatry, 23, 61–9, 2011 [PubMed: 21338300]	Not relevant to any of the review questions in the guideline
George, S., Javed, M., Hemington-Gorse, S., Wilson-Jones, N., Epidemiology and financial implications of self-inflicted burns, Burns, 42, 196–201, 2016 [PubMed: 26670160]	Study design – no comparative cost analysis
Gunnell, D., Shepherd, M., Evans, M., Are recent increases in deliberate self-harm associated with changes in socio-economic conditions? An ecological analysis of patterns of deliberate self-harm in Bristol 1972–3 and 1995–6, Psychological medicine, 30, 1197–1203, 2000 [PubMed: 12027054]	Study design - cost-of-illness study
Kapur, N., House, A., Dodgson, K., Chris, M., Marshall, S., Tomenson, B., Creed, F., Management and costs of deliberate self-poisoning in the general hospital: A multi-centre study, Journal of Mental Health, 11, 223–230, 2002	Study design – no comparative cost analysis
Kapur, N., House, A., May, C., Creed, F., Service provision and outcome for deliberate self-poisoning in adults - Results from a six centre descriptive study, Social Psychiatry and Psychiatric Epidemiology, 38, 390–395, 2003 [PubMed: 12861446]	Study design – no comparative cost analysis
Kinchin, I., Russell, A. M. T., Byrnes, J., McCalman, J., Doran, C. M., Hunter, E., The cost of hospitalisation for youth self-harm: differences across age groups, sex, Indigenous and non-Indigenous populations, Social Psychiatry and Psychiatric Epidemiology, 55, 425–434, 2020 [PubMed: 31732765]	Study design – no comparative cost analysis
O’Leary, F. M., Lo, M. C. I., Schreuder, F. B., “Cuts are costly”: A review of deliberate self-harm admissions to a district general hospital plastic surgery department over a 12-month period, Journal of Plastic, Reconstructive and Aesthetic Surgery, 67, e109–e110, 2014 [PubMed: 24183058]	Study design – no comparative cost analysis
Olfson, M., Gameroff, M. J., Marcus, S. C., Greenberg, T., Shaffer, D., National trends in hospitalization of youth with intentional selfinflicted injuries, American Journal of Psychiatry, 162, 1328–1335, 2005 [PubMed: 15994716]	Study design – no comparative cost analysis
Ostertag, L., Golay, P., Dorogi, Y., Brovelli, S., Cromec, I., Edan, A., Barbe, R., Saillant, S., Michaud, L., Self-harm in French-speaking Switzerland: A socio-economic analysis (7316), Swiss Archives of Neurology, Psychiatry and Psychotherapy, 70 (Supplement 8), 48S, 2019	Conference abstract
Ougrin, D., Corrigall, R., Poole, J., Zundel, T., Sarhane, M., Slater, V., Stahl, D., Reavey, P., Byford, S., Heslin, M., Ivens, J., Crommelin, M., Abdulla, Z., Hayes, D., Middleton, K., Nnadi, B., Taylor, E., Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial, The Lancet Psychiatry, 5, 477–485, 2018 [PMC free article: PMC5994473] [PubMed: 29731412]	Not self-harm. In addition, the interventions evaluated in this economic analysis (a supported discharge service provided by an intensive community treatment team compared to usual care) were not relevant to any review questions
Palmer, S., Davidson, K., Tyrer, P., Gumley, A., Tata, P., Norrie, J., Murray, H., Seivewright, H., The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial, Journal of Personality Disorders, 20, 466–481, 2006 [PMC free article: PMC1852260] [PubMed: 17032159]	Not self-harm
Quinlivan L, Steeg S, Elvidge J, et al Risk assessment scales to predict risk of hospital treated repeat self-harm: A cost-effectiveness modelling analysis. J Affect Disord. 2019;249:208–215. [PubMed: 30772749]	Not relevant to any of the review questions in the guideline - this study estimated the cost-effectiveness of of risk assessment scales versus clinical assessment for adults attending an emergency department following self-harm
Richardson JS, Mark TL, McKeon R. The return on investment of postdischarge follow-up calls for suicidal ideation or deliberate self-harm. Psychiatr Serv. 2014;65(8):1012–1019. [PubMed: 24788454]	Not enough data reporting on cost-effectiveness findings
Smits, M. L., Feenstra, D. J., Eeren, H. V., Bales, D. L., Laurenssen, E. M. P., Blankers, M., Soons, M. B. J., Dekker, J. J. M., Lucas, Z., Verheul, R., Luyten, P., Day hospital versus intensive out-patient mentalisation-based treatment for borderline personality disorder: Multicentre randomised clinical trial, British Journal of Psychiatry, 216, 79–84, 2020 [PubMed: 30791963]	Not self-harm
Tsiachristas, A., Geulayov, G., Casey, D., Ness, J., Waters, K., Clements, C., Kapur, N., McDaid, D., Brand, F., Hawton, K., Incidence and general hospital costs of self-harm across England: estimates based on the multicentre study of self-harm, Epidemiology & Psychiatric Science, 29, e108, 2020 [PMC free article: PMC7214546] [PubMed: 32160934]	Study design – no comparative cost analysis
Tsiachristas, A., McDaid, D., Casey, D., Brand, F., Leal, J., Park, A. L., Geulayov, G., Hawton, K., General hospital costs in England of medical and psychiatric care for patients who self-harm: a retrospective analysis, The Lancet Psychiatry, 4, 759–767, 2017 [PMC free article: PMC5614771] [PubMed: 28890321]	Study design – no comparative cost analysis
Tubeuf, S., Saloniki, E. C., Cottrell, D., Parental Health Spillover in Cost-Effectiveness Analysis: Evidence from Self-Harming Adolescents in England, PharmacoEconomics, 37, 513–530, 2019 [PubMed: 30294758]	This study is not a separate study from one already included in the guideline for topic 5.2 (Cottrel 2018). This secondary analysis presents alternative parental health spillover quantification methods in the context of a randomised controlled trial comparing family therapy with treatment as usual as an intervention for self-harming adolescents of (Cottrel 2018), and discusses the practical limitations of those methods
Tyrer, P., Thompson, S., Schmidt, U., Jones, V., Knapp, M., Davidson, K., Catalan, J., Airlie, J., Baxter, S., Byford, S., Byrne, G., Cameron, S., Caplan, R., Cooper, S., Ferguson, B., Freeman, C., Frost, S., Godley, J., Greenshields, J., Henderson, J., Holden, N., Keech, P., Kim, L., Logan, K., Manley, C., MacLeod, A., Murphy, R., Patience, L., Ramsay, L., De Munroz, S., Scott, J., Seivewright, H., Sivakumar, K., Tata, P., Thornton, S., Ukoumunne, O. C., Wessely, S., Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: The POPMACT study, Psychological medicine, 33, 969–976, 2003 [PubMed: 12946081]	Study design - no economic evaluation
Van Roijen, L. H., Sinnaeve, R., Bouwmans, C., Van Den Bosch, L., Cost-effectiveness and Cost-utility of Shortterm Inpatient Dialectical Behavior Therapy for Chronically Parasuicidal BPD (Young) Adults, Journal of Mental Health Policy and Economics, 18, S19–S20, 2015	Conference abstract
van Spijker, B. A., Majo, M. C., Smit, F., van Straten, A., Kerkhof, A. J., Reducing suicidal ideation: cost-effectiveness analysis of a randomized controlled trial of unguided web-based self-help, Journal of medical Internet research, 14, e141, 2012 [PMC free article: PMC3517339] [PubMed: 23103835]	Not self-harm

Evidence reviews for supervision required for staff in specialist mental health settings

Supervision required for staff in specialist mental health settings

Review question

Introduction

Summary of the protocol

Table 1

Methods and process

Qualitative evidence

Included studies

Excluded studies

Summary of included studies

Table 2

Summary of the evidence

Figure 1

Table 3

Economic evidence

Included studies

Excluded studies

Economic model

Evidence statements

Economic

The committee’s discussion and interpretation of the evidence

The outcomes that matter most

The quality of the evidence

Benefits and harms

Cost effectiveness and resource use

Recommendations supported by this evidence review

References – included studies

Qualitative

Table

Economic

Appendices

Appendix A. Review protocols

Appendix B. Literature search strategies

Appendix C. Effectiveness evidence study selection

Appendix D. Evidence tables

Appendix E. Forest plots

Forest plots for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

Appendix F. GRADE-CERQual tables

Appendix G. Economic evidence study selection

Appendix H. Economic evidence tables

Economic evidence tables for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

Appendix I. Economic model

Economic model for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

Appendix J. Excluded studies

Excluded studies for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

Excluded qualitative studies

Excluded economic studies

Appendix K. Research recommendations – full details

Research recommendations for review question: What are the views and preferences of staff in specialist mental health settings about what supervision is required for staff in specialist mental health settings who assess and treat people who have self-harmed?

Appendix L. Qualitative quotes

Table 1Summary of the protocol (PPC table)

Table 2Summary of included studies

Figure 1Theme map

Table 3Summary of themes and subthemes

Table 10Excluded studies and reasons for their exclusion

Table 11Excluded studies from the guideline economic review