Table 2 Summary of key findings
COM domain | TDF domain | Description of domain | Example quotes | Intervention function | Individual BCTs | Candidate interventions |
|---|---|---|---|---|---|---|
Psychological Capability | Knowledge | Knowledge gaps were identified pertaining to self-harm risk factors and protocols. Nurses did not perceive a need for in-depth learning about self-harm, instead wanting to improve their awareness of the self-harm guidelines | “They touch upon things like mental health and our role in searching out signs and things like that but it would, kind of, half a lecture. I don’t think it’s quite focussed on enough.” (Practice Nurse 1) | • Education | • Prompts/cues • Information about health consequences • Information about emotional consequences • Information about antecedents | Education about the positive impacts on health associated with arranging a psychosocial assessment following self-harm (IF: Education; BCT 5.1: Information about health consequences) |
Cognitive and Interpersonal Skills | Nurses were highly skilled at building trust with patients. Practical advice was needed about starting conversations about self-harm in ways that preserve patient trust and rapport | “I think it’s harder for nurses because we don’t always have the skills because we have more of a broad ranging set of skills.” (Practice Nurse 10) | • Training | • Demonstration of the behaviour • Instruction on how to perform a behaviour • Behavioural rehearsal/practice • Feedback on the behaviour | Training nurses to be able to start conversations about self-harm during appointments when it is safe and appropriate to do so (IF: Training; BCT 4.1: Instruction on how to perform the behaviour) | |
Memory, Attention, and Decision Process | Translation of the guideline content into practice- or Trust-level protocols would support decision-making. Brief reminders, akin to annual training packages, would support recall of the guidance | “There’s so much think about in general practice, and we can’t have the answers to everything, you know, so sometimes it’s good to have pathways or guidance or standards or somewhere where you can look to find some guidance really.” (Practice Nurse 5) | • Training • Environmental restructuring • Enablement | • Habit formation • Prompts/cues • Adding objects to the environment • Restructuring the physical environment | Develop an in-practice protocol for staff to follow when they encounter a patient who has self-harmed or is at risk of self-harm (IF: Environmental restructuring; BCT 12.1: Restructuring the physical environment) | |
Physical Opportunity | Environmental Context and Resources | Short appointments hampered opportunities to adequately discuss self-harm. Barriers to organising referrals consistent with the guidelines included extensive written communications with secondary mental health services, and unclear waiting times | “That’s not a ten-minute appointment, so it would take longer. It would put pressure on your other colleagues, who would maybe have to pick up on your other patients, it would make me feel bad because I know that I’ve got patients waiting, but I need to obviously concentrate on the job in hand.” (Practice Nurse 7) | • Environmental restructuring • Enablement | • Restructuring the physical environment • Restructuring the social environment • Action planning | Simplify the paperwork required to organise a mental health referral to reduce the time burden of written referrals. (IF: Environmental restructuring; BCT 12.1: Restructuring the physical environment) |
Social Opportunity | Social Influences | Support from colleagues in general practices enabled participants to implement the guidelines. ‘On-call’ systems and designated mental health staff were sought out during encounters with patients at risk of self-harm. All-staff meetings are opportunities to disseminate updated guidance | “The biggest help is having another person who I can get to come and have a conversation as well. So, being able to whip across the corridor and say to the doctor or the other practice nurse: ‘Will you just come and have a word with this patient as well and see what you think’.” (Practice Nurse 4) | • Environmental restructuring • Modelling • Enablement | • Restructuring the social environment • Demonstration of the behaviour • Social support (practical) | Designating a member of staff as the lead for mental health or safeguarding, to be contacted if a patient presents with self-harm or is believed to be at risk of self-harm. (IF: Enablement; BCT 12.2: Restructuring the social environment) |
Reflective motivation | Professional/ Social Role and Identity | Nurses and healthcare assistants are perceived to be approachable, which creates opportunities to identify and signpost patients who self-harm. While a sense of duty towards patients motivated participants to implement guidelines, some argued that their role restricted the actions they could take beyond signposting | “I think we need to keep an eye out, sort of, for any evidence or any concerns that we have and I think it’s our responsibility to either, if we feel appropriately trained to do so, or if we feel it appropriate for us to do so, to raise that issue with the patient.” (Practice Nurse 1) | • Education • Modelling | • Information about antecedents • Information about others’ approval • Demonstration of the behaviour | Provide information to nurses about how patients want to talk about self-harm; specifically what patients do and do not find helpful. (IF: Education BCT 6.2: Information about others’ approval) |