Haylor Helen, Sparkes Tony, Armitage Gerry, Double Keith, Edwards Lisa
First Response, Bradford District Care NHS Foundation Trust, Bradford, UK.
Faculty of Management, Law and Social Sciences, University of Bradford, Bradford, UK.
Int J Ment Health Nurs. 2025 Oct;34(5):e70136. doi: 10.1111/inm.70136.
Effective suicide prevention strategies in community mental health services demand high standards of patient safety. The nature of suicide is complex and uncertain. However, learning needs to be sensitive to the fear of blame. Little is known about how health services investigate suicides post hoc, how they examine why a suicide might have occurred, and how they generate any organisational learning that might improve patient safety. The aim of this novel qualitative study was to explore the accounts of key people involved in the serious incident investigation process regarding the subsequent organisational learning. Carers, clinicians, investigators and senior managers were recruited via regional and national networks; data were collected through focus groups and individual interviews. The dominant themes that emerged from this analysis did not reflect the tenor of the literature related to the investigative process and organisational learning, accepting that the literature is relatively sparse. A reflexive thematic analysis developed an understanding of mitigations against a fear of blame which appeared protective of all participants' positions, including those specific to suicide risk. We argue that mitigation operated as a barrier to organisational learning and improving patient safety in adult community mental health services. The findings are discussed in the context of organisational culture, learning and wider system thinking. The concept of mitigation against a fear of blame constructs new insights into this ambiguous and emotionally demanding sphere of patient safety.
社区精神卫生服务中有效的自杀预防策略需要高标准的患者安全保障。自杀的本质复杂且难以确定。然而，学习需要对指责恐惧保持敏感。对于卫生服务机构如何在事后调查自杀事件、如何探究自杀可能发生的原因以及如何产生可能改善患者安全的组织学习，我们知之甚少。这项新颖的定性研究旨在探讨参与严重事件调查过程的关键人员对后续组织学习的描述。通过区域和国家网络招募了护理人员、临床医生、调查人员和高级管理人员；通过焦点小组和个人访谈收集数据。尽管相关文献相对较少，但该分析得出的主要主题并未反映与调查过程和组织学习相关的文献主旨。反思性主题分析形成了对减轻指责恐惧的理解，这种恐惧似乎保护了所有参与者的立场，包括那些与自杀风险相关的立场。我们认为，减轻指责恐惧在成人社区精神卫生服务中成为组织学习和改善患者安全的障碍。研究结果将在组织文化、学习和更广泛的系统思维背景下进行讨论。减轻指责恐惧的概念为这个模糊且情感要求高的患者安全领域构建了新的见解。
