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Abstract

Background

Most research on appropriate, feasible, and effective suicide screening has excluded research conducted in non-Western and low-income settings. This study explores preparedness and co-designing a suicide screening and referral intervention in a Nepali emergency department (ED) using the Consolidated Framework for Implementation Research (CFIR).

Method

To assess implementation readiness and context, we conducted eight key informant interviews and four focus-group discussions with clinical staff along with 3 months of embedded ethnography. We also assessed clinical staff (n = 26) knowledge, attitudes, current practices, confidence, and institutional priorities surrounding implementing suicide screening using structured questionnaires. Qualitative analysis used CFIR to assess feasibility, acceptability, and necessary implementation strategies for a suicide screening intervention within the context of this resource-strained ED. We report descriptive statistics of quantitative findings using a convergent analytic mixed-methods approach.

Results

Qualitatively, clinicians expressed hopelessness and reservations surrounding ED programs to prevent suicide given important system and social barriers. Additionally, they doubted their ability to meaningfully overcome broader structural issues in their patients’ lives (e.g., poverty and family tension) that they believed more directly determined suicidal behavior and thwarted help seeking. They discussed practical and emotional motivators for doing suicide prevention work, which highlighted departmental leadership and deep teamwork that motivated action despite wider societal myths that suicide cannot easily be prevented. Quantitative assessments largely supported these findings, indicating shared beliefs that suicide prevention was important and supported by leadership. However, providers frequently endorsed suicide myths and noted barriers including difficult interdepartmental collaboration, limited confidence in suicide prevention communication and suicide screening.

Conclusions

In under-resourced settings, staff must contend with competing responsibilities and complex structural causes of suicide and barriers to treatment. These can impede implementation of suicide screening interventions and must be integrated into the co-design of implementation strategy selection and deployment.

Trial Registration

NCT06094959 clinicaltrials.gov

Plain Language Summary Title

Evaluating clinical preparedness for suicide screening and referral in a Nepali emergency department: An exploratory study

Plain Language Summary

This study addresses suicide detection and response in Nepal, a country with a high suicide burden but no institutionalized prevention programs. Most research on appropriate, feasible, and effective suicide screening has focused on Western settings, overlooking the unique challenges faced in low-income settings like Nepal. This mixed-methods investigation is part of a larger initiative to create culturally relevant and community-centered strategies for suicide prevention in a Nepali hospital. Findings revealed important barriers to effective suicide management, including stigma surrounding mental health that affects communication between clinicians and patients, structural and self-efficacy issues. Implementation studies are largely situated in high-income contexts, which highlights the need to understand the contextual factors that are essential for building feasible hospital-based suicide prevention approaches. We discuss how this study fills an important evidence gap as emergency department suicide management in resource-strained low- and middle-income environments.

Keywords

emergency medicine pre-implementation low- and middle-income countries suicide suicide screening Nepal mixed-methods

Introduction

Suicide is a critical public health issue, causing significant death and disability while impacting families and communities (Naghavi, 2019). Most suicide attempts and deaths occur in low- and middle-income countries (LMICs) (Gunnell et al., 2007). Despite a strong history of research examining suicide risk, prevention, and treatment, suicide as a public health problem remains intractable (Guzmán et al., 2019). Research and intervention efforts are predominantly focused on high-income contexts, deepening inequities (Franklin et al., 2017).

Educating health workers in detection and referral is a promising suicide prevention strategy an integral component of system-integrated strategies to prevent suicide (Mann et al., 2005). Western studies indicate most suicide decedents had contact with a medical professional within a year of death (Stene-Larsen & Reneflot, 2019) and face heightened risk of subsequent attempt following emergency department (ED) discharge (Simpson et al., 2022). In high-income settings, EDs play a key role in suicide screening and care transition (Stanley et al., 2016). Universal screening proponents argue that asking about suicidal thoughts, history, and intent can detect 50% more at-risk patients without harming them (Grumet & Boudreaux, 2023; Horowitz et al., 2020; LeCloux et al., 2021). Critics suggest universal screening strains needed resources and is inadequate to connect individuals to care (Bryan et al., 2023; O'Connor et al., 2013). However, little research in non-Western and low-income contexts has informed if any systematic strategy is appropriate, feasible, and effective.

This project is situated in Nepal where post-COVID suicide attempt ED visits increased 1.7 times (Risal et al., 2013; Shrestha et al., 2021). Although still limited, qualitative research into suicide (Hagaman et al., 2017; Kohrt & Harper, 2008), its risk (Jordans et al., 2017; Pradhan et al., 2011; Suvedi et al., 2009; Thapaliya et al., 2018), social meaning (Hagaman et al., 2018), and multisector response (Hagaman et al., 2016; Marahatta et al., 2016) has been well investigated in Nepal. Yet, interventional studies remain limited. Despite high suicide death rates, no research has adapted or tested universal screening approaches for suicide in LMICs. This mixed-methods study examines institutional and clinician perspectives on the feasibility, acceptability, and readiness for universal suicide screening in overburdened, under-resourced healthcare settings.

Methods

Study Setting

This study occurred in the Bagmati Province of Nepal in an eastern town along the main highway. The hospital catchment area is diverse, ranging from urban settlements along the main road, to rural hill areas only reachable by foot. Nepal is a diverse country with 125 ethnic groups (Nepal Central Bureau of Statistics, 2021). The Hindu caste system pervades the social fabric, creating entrenched discrimination for some castes (Chaudhry, 2013). Yet, more than 20% of Nepal's population is not Hindu, and indigenous janajati castes may also be marginalized in complex ways (Kohrt et al., 2009). Nepal has an abundant ethnopsychology research foundation through which scholars have documented mental health explanatory models, mind–body relationships, and impacts on traditional, allopathic, and biomedical care-seeking (Desjarlais, 1992; Kohrt & Harper, 2008; Pham et al., 2021b). Aatmahatya (suicide) is linked to distress and dysfunction in several mind–body domains including the saato (spirit), man (heart–mind), and ijjat (social status), with various gendered social scripts attributed to suicide (Canetto et al., 2023). Nepal is also a leader in implementing and scaling access to mental health services, though important gaps remain (Jordans et al., 2019; Luitel et al., 2017), particularly related to suicide prevention implementation (Hagaman et al., 2018; Jordans et al., 2017; Marahatta et al., 2016).

The ED we situate our study within is the region's main tertiary care hospital, with 15–17 physician-level staff and 22 nursing/paramedic level staff. As a teaching hospital, departments endure high turnover. The ED is often at its 30-bed capacity, caring for 20,000 patients annually seeing approximately three suicide/self-harm cases per week (Shrestha et al., 2021).

Study Design

The umbrella study sought to co-design and pilot test a package of suicide prevention strategies. The study includes suicidal thoughts and behaviors (attempts/death) and did not include non-suicidal self-harm. A community advisory board (CAB) of individuals with lived experience of suicidal thoughts or behaviors living in the study area was hired to oversee and collaborate from formative work through results interpretation and dissemination. Lived experience was defined as self-identified direct experiences with either personally experiencing suicidal thoughts and/or behaviors or an immediate family member (e.g., spouse, sibling, or adult child) of an individual that died by suicide or experienced suicidal thoughts and/or behaviors. The CAB met bi-monthly. This study reports on the preliminary exploration phase to assess staff and institutional readiness for suicide screening. We use a mixed-methods convergent design where we conducted quantitative and ethnographic assessments in parallel and triangulated results to form conclusions and recommendations for the next phase. We use multiple mixed-methods to allow for a richer triangulated understanding of the complex perceptions and preparedness climate across multiple clinicians working across many hospital departments (Palinkas & Cooper, 2017).

Qualitative Data Collection

We employed a suite of three qualitative methods: ethnographic observation, individual in-depth interviews, and focus-group discussions (FGDs) over a 6-month period (April to November 2022). We chose these multiple methods given our focus on sensitive topics (e.g., suicide and workplace dynamics) and aims to understand both individual experiences and group perceptions (Wutich et al., 2010). Given that no measures of institutional preparedness have been developed in LMICs and that few have been implemented in acute care settings (Weiner et al., 2020), we sought to capture various readiness domains ethnographically and triangulate with a structured quantitative assessment derived for the Nepali clinical context. Ethnographic observation: Two Nepali dual trained anthropologists/psychologists [RS and KS] and two Nepali public health trained research assistants [RB and PP] conducted 3 months of observation in the ED. Observations included attending formal activities (e.g., shift hand-offs, patient-encounters) and informal activities (e.g., tea breaks). Researchers kept daily field notes, noting observations of staff culture including hierarchy, workflows, patient care, communication, decision making, and sense making of events related to suicide and self-harm.

In-Depth Interviews

After 6 weeks of initial ethnographic observation, we purposively sampled clinicians for in-depth qualitative interviews, maximizing variation in role (nurse, resident, medical officer, etc.), gender, years in position, and leadership. The Consolidated Framework for Implementation Research 2.0 (CFIR) is an implementation determinant framework used in LMICs with an important additional domain focused on health system resources (Damschroder et al., 2022). Interviews conducted by KS and RB covered CFIR domains, including inner setting (within and across departments and roles, team effectiveness, institutional priorities, organizational context, etc.), outer setting context (e.g., social space, social place, agency, sensation, and embodiment; Mielke et al., 2022), intervention (feasibility and acceptability), and individual (e.g., experiences caring for suicide-related cases, motivation for work, personal psychosocial impacts of their work, etc.). Interviews lasted between 30 and 60 min.

Focus-Group Discussions

We stratified focus groups based on staff role (nurses and physicians) and invited all staff available. Two FGDs conducted by KS were carried out with each group focusing on different elements of screening implementation (one on overall workflows/case management of suicide and another on screening tool implementation). The facilitator used several prompts to anchor the identification of workflows, bottlenecks, barriers, and facilitators to managing suicide cases and imagining preliminary feasibility and accessibility of suicide screening. For example, clinicians drew the clinical workflow of suicide case management in the ED, including interdepartmental collaboration, and patient party facilitators and barriers to quality care. Discussions also focused on shared norms and perceptions regarding staff hierarchy, motivations, and needs to implement screening. Finally, solutions were sought to form an initial menu of possible implementation strategies to support screening/referral. FGDs lasted around 90 min. See Supplemental material for qualitative guides.

Quantitative Data Collection

We sought to survey all existing nursing- and doctor-level staff to elicit their knowledge, attitudes, confidence, and perceptions of institutional priorities and support related to suicide prevention processes. We adapted the Zero Suicide Workforce Survey to assess screening implementation within the Zero Suicide initiative (Labouliere et al., 2021). We follow cultural adaptation methods outlined by van Ommeren et al. (1999); however, we notably depart from the outdated translation–back translation method (as recommended by Colina et al. (2017)), instead using multiple independent translations by bilingual content-specific and non-content specific experts and then bringing all translations to community consensus from the CAB and the research team. We assessed five domains: suicide screening tool knowledge (five items), suicide myths (four items), individual confidence (seven items), hospital priorities (six items), and beliefs and practices about suicide prevention (seven items) derived from our formative qualitative interviews and the CAB. A key adaptation was the Likert response options, where other LMIC health worker self-efficacy measurements indicate confidence framing of Likert options may lead to more desirability bias and, instead, using frequency is more salient (Hennein et al., 2022). After cognitive interviews with scale options, we selected the time-anchored scale recommended by Hennein et al. Knowledge, attitudes, and confidence (KAC) surveys were administered in November 2022 following qualitative data collection activities.

Qualitative Analysis

Following interviews, interviewers completed field notes in English and debriefed with the study team. Each interviewer transcribed and translated their interview audio to produce verbatim transcripts in Nepali and English. Transcriptions and translations were quality checked, with discussions to select the most appropriate interpretation. Epistemologically, we treated the participant experiences as truth to them while simultaneously understanding they are co-constructed by their social context and our interview process (Carter & Little, 2007). Through deep readings of the field notes and interview transcripts and analytic team meetings, an inductive codebook was developed initially, with which authors attended to reaching code and meaning saturation (Hennink et al., 2017). Inductive codes were sorted into relevant CFIR domains. Regular team meetings brought forth emerging codes in conversation with research assistant who conducted the ethnography as well as CFIR (e.g., a code of staff interpersonal stress was added later). After achieving high inter-rater coding reliability, transcripts and field notes were individually coded with a codebook (see Supplemental material). Our team iteratively triangulated field notes, codes, and memos to develop analytic themes, comparing findings for contextualization. We finalized the main themes through further analytic conversations with the whole authorship team, which included co-writing sessions, and brief sharing meetings with staff within the ED.

Quantitative Analysis

Paper survey data were double-entered and discrepancies were addressed through original survey confirmation. Likert scale responses for the questions were coded as either “endorsed,” to reflect the number of survey respondents who agreed with each statement, or “unsure/not endorsed,” to reflect the number of survey respondents who disagreed with or were ambivalent about each statement. Analysis was conducted in RStudio. Descriptive results are reported as means alongside illustrative quotes in joint display tables.

Ethical Approval

Ethical approvals for all study elements were obtained from Yale University and the Nepal Health Research Council and the study hospital's ethical review board. All participants provided written informed consent.

Results

This study yielded 26 quantitative KAC surveys with all available ED clinical staff, nine individual interviews, four FGDs with 17 participants, and ethnographic observations over 3 months. Participant demographics and method participation can be found in Table 1. Of the 36 participants, most were under 34 years (91.6%) and male (72.2%). Below, we present our mixed-methods results, anchoring our findings in the analytic themes derived from the qualitative data and situating these with the quantitative data. We describe (a) the social and structural hopelessness ED providers contend with as they try to envision screening for suicidal thoughts and behaviors, (b) the emotional tolls they navigate vis-à-vis responsive and supportive clinical teams, and (c) the chaotic environment complicated further by resource constraints and the complex pay-as-you-go health system. We chose this order to demonstrate the (a) social, (b) individual/interpersonal, and (c) system level barriers and facilitators, as well as provider-identified solutions to each theme. We then discuss these findings using the CFIR to target salient determinant domains and strategies to address barriers.

Table 1.

Participant Demographic Characteristics.

Characteristics	Total ( N = 36)	% or average (range)
Age (years)
18–24	5	13.9
25–34	28	77.7
35+	3	8.3
Gender
Male	26	72.2
Female	10	27.8
Clinical profession
Physician (including interns and faculty)	19	52.8
Nurse/paramedical	17	47.2
Years in practice	36	4.41 (2.5 months to 20 years)
Interview participant	9	25.0
FGD participant	17	47.2
KAC participant	26	72.2
Both qualitative and KAC participant	11	30.6

Note. FGD = focus-group discussion; KAC = knowledge, attitudes, and confidence.

Theme 1 (Outer Setting): ED Providers Contend With Larger Social Hopelessness as They Try to Envision Their Own Capacity and Confidence to Screen and Respond to Suicide Risk

Stigma and Mistrust

Providers described hopelessness overwhelmingly related to larger social stigma surrounding suicide: that they struggled to trust patients or families to accurately report suicide attempt. One doctor expressed this frustration: “It's not possible in the ED. They don’t speak. They are not comfortable with [talking about suicide]” (2066, Doctor). Similarly, providers explained that they could not trust patients’ families to provide critical information regarding why a patient presented in the ED, which could delay care. Furthermore, some providers feared negative patient reactions to a suicide-risk assessment, “the patient might hit us and leave for asking such questions! They will think we are calling them ‘pagal’ [mad/crazy]” (2038, Nurse Manager). These sentiments reflect broader, more pervasive stigmas about suicide that preclude clinical engagement. Provider hesitance to trust patients and families to disclose suicidal thoughts or behaviors is reflected in the myth statements endorsed (Table 2). For example, 42% of surveyed providers believed suicidal individuals, “would not tell anyone.” Moreover, 35% of providers stated they did not feel confident getting patients to talk about their suicide honestly. These data reflect how providers felt helpless on both the interpersonal and community levels.

Table 2.

Theme 1 Joint Display.

KAC domain	KAC item	Endorsed	Unsure/not endorsed	Illustrative quote
Beliefs and practices about suicide prevention	I currently screen patients for suicide risk (screening refers to asking a set of questions about suicide to patients)	14 (53.58)	12 (46.15)	“I look after the emergency. Since I don’t stay in the OPD, I am not like that. In case there is a patient, I don’t think I can do screening.” (PID 2009)
Individual confidence	I have the knowledge and skills needed to screen individuals for suicide risk	16 (61.54)	10 (38.46)	"Maybe, if we have skills and expertise according to that, then it would be easier to do. But in the emergency as well, there isn't much training in doing therapy or counseling. We don’t have training on how to approach [suicide with patients]. I think it is difficult because of that.” (PID 2006, 30, female, nurse)
	I am confident that I can identify if a patient is at risk for suicide	17 (65.38)	9 (34.62)
	I feel confident in my ability to get patients to talk about their suicidality honestly	17 (65.38)	9 (34.62)
	I know what procedures to follow when I suspect that an individual may be at risk for suicide	18 (69.23)	8 (30.76)
	I feel confident in my ability to talk to families about how they can help their family member if they are at risk for suicide	17 (65.38)	9 (34.62)
Suicide myths	If I talk to someone about suicide, I might unintentionally “put the idea in their head” or trigger them to consider it.	12 (46.16)	14 (53.85)	The young people tend to take a little reactive decision. It is seen in teenagers as well, nowadays. In teenagers plus with people in their 20s, it is very reactive. If there is even a fight with someone, with friends, or with boyfriend girlfriend. They eat out of anger because of something their parents said. Another one is, in older aged people, in their 30–40s, I see depressive patients usually around the age of 40s. There is a little domestic violence, a little depression in people around 60s. It is mixed in old age.” (PID 2008, 31, male, resident doctor)
	People who really want to kill themselves wouldn’t tell someone they are thinking about suicide	15 (57.7)	11 (42.31)
	If someone wants to kill themselves, there is not much anyone can do about it	10 (38.47)	16 (61.54)
	Most suicides occur with little or no warning signs	19 (73.08)	7 (26.93)
Suicide tool knowledge	Suicide screening tools can identify more than half of patients with suicidal thoughts and behaviors more than informal methods	16 (61.54)	10 (38.46)	"In this question, it says, ‘do you wish you were dead?’. Some people might get angry when we ask them this. When they are a little hyper or they might feel ‘they are dominating me by looking at my condition’. Instead, maybe we can ask them, ‘in the past 2 weeks, have you had any negative thoughts?’. They might think badly when we ask them, ‘do you wish you were dead?.’” (PID 2047, 34, male, health assistant)
	Suicide screening tools can ensure that all clinicians ask every patient the same questions, giving each at-risk client the same opportunity to be identified	17 (65.38)	9 (34.62)
	Suicide screening tools can negatively affect rapport and trust with clients	14 (53.58)	12 (46.15)
	Suicide screening tools allow different clinicians to communicate more clearly and have a uniform vocabulary for documentation	22 (84.62)	4 (15.38)

Note. Theme 1: ED providers contend with larger social and structural hopelessness as they try to envision their own capacity and confidence to screen and respond to suicide risk. KAC = = knowledge, attitudes, and confidence; ED = emergency department; OPD = out patient department; PID = participant Identification number.

Dismissing Possibility

The intensity of their hopelessness caused providers to dismiss possibilities for improving screening and prevention. Suicidal attempts often presented with desperate social situations (e.g., abuse, extreme poverty, social failure) that emergency providers saw limited ability to help, along with a health system ill equipped to address any psychiatric needs (see more in theme 3). They highlighted lack of privacy barriers, beds too close together, lack of private rooms, which did not allow for providers and patients to talk at length. Observations underscored waves of crowded activity, infrequent use of privacy curtains (and many that were broken/absent), and constant interruptions by family and others seeking answers to their care. A doctor explained that speaking with “uncooperative” patients placed an extra burden on the staff to draw out more information and wasted critical time that they could have been using helping another patient. He gave an example: “We spoke with the patient for 4 hours. They didn’t say anything!” (2068, Doctor). This underscores the hopelessness providers expressed and how collective despair obscured treatment possibilities. Because providers were so discouraged that patients were not forthcoming, they did not give them a real opportunity to talk. This hopelessness is reflected in the quantitative findings where 61.5% of providers believed, “If someone wants to kill themselves, there is not much anyone can do about it.”

Impulsivity Cannot Be Screened Nor Prevented

Most providers commented that attempting suicide was caused by extreme impulsive responses to adolescent, family, and financial stressors. A doctor explained, “Especially in adults, whatever we have seen, we always see impulsivity. We have seen someone not accepting whatever it is (chitta nabhujhera) and attempting it as he couldn’t control the impulse. It's not planned, its impulsive” (2007, Doctor). Providers shared numerous stories of spousal/romantic fights, largely for attention seeking. Some providers gestured toward larger societal taboos that kept patients and their families from sharing, and themselves from seeing possibility in prevention. These perspectives are reflected in the quantitative survey where 38.5% believed that screening tools could not accurately identify someone at risk for suicide.

Staff Recommendations

Providers need more time to build appropriate patient trust in the chaotic ED to engage in a topic that, as yet was neglected. Providers recommended private space, suicide-specific ED training to manage address stigma and fear, and an available psychological expert for as needed consultation. For example, an ED nurse expressed the importance of her leadership and recognition for staff, “If they get recognition from the whole hospital, that could build their confidence. Everyone will know what they are doing…That's important” (2003, Nurse). This quote underscores staff willingness to engage new strategies. Despite larger stigma and hesitation, nearly all providers expressed a medical duty to support suicide prevention.

Theme 2 (Inner/Outer: Structural Conditions/Policies): Hospital Systems Create Persistent Structural Challenges, Reifying Clinician Helplessness

Hospital systems played a crucial role in how patients, their families, and staff navigate complex patient care. Providers expressed that the ED environment precludes proper suicide prevention activities due to excessive noise, overcrowding, hectic discharge procedures, rapid ED bed turnover goals, incomplete record keeping, and challenging patient tracking. The unavailability of complete patient data and an unregulated medical record system add to existing challenges of managing and tracking patient information and care within and outside the hospital. The hospital's complex “pay-as-you-go” service model, requiring constant family member presence at every step of treatment, propelled families to seek fast discharge to limit necessary time and financial resources. Such family moments were consistently observed and discussed in detail by clinicians informally. Providers’ work was inhibited by patients demanding early discharge (typically due to financial expenses). Furthermore, providers were frustrated by the unreliability of and communication gap between various departments, resulting in delayed care and patients leaving early (Table 3).

Table 3.

Theme 2 Joint Display.

KAC domain	KAC item	Endorsed	Unsure/not endorsed	Illustrative quote
Beliefs and practices about suicide prevention	I have the time to dedicate to screening patients for suicide risk given all of my other responsibilities	17 (65.34)	9 (34.62)	“One of the barrier is time. Even if we inform in time, the treatment doesn’t start right away. Sometimes, it might be because there are no empty beds. Another one is, we can’t transfer the patients on time because we can’t find ICUs in other hospitals. Because of that we have to keep the patients in the ER for a long duration. Anything can happen at that time. That is one of the barriers.” (PID 2038)
Hospital priorities	This hospital has policies and procedures in place that clearly define each employee's role in preventing suicide	12 (46.16)	14 (53.85)	“While talking with the patients first of all, we have to talk about the patient's condition. How critical it is. What is there. Other than that, in our emergency department, we are mostly scared if there is going to be enough beds or not. It comes down to saving the patient's life. How to save them? More than the counseling approach in the emergency, we mostly only have time to treat them physically, whether there is bed or not.” (PID 2009, 25, male, Medical officer)
Hospital priorities	The psychiatry department is easy to collaborate with when there is a suicide case	14 (53.85)	12 (46.16)
Hospital priorities	Is there a belief in the hospital that universal screening is possible in their every day work?	9 (34.62)	17 (65.38)
Individual confidence	I feel confident in my ability to help suicidal patients connect with mental health services that are accessible and affordable for them	21 (80.77)	5 (19.23)	“We might have to think about that in case it affects our workload. We have to evaluate, clinically judge patients so we can identify the candidate for screening. Even though the screen is one and a half minutes long, it takes time to build rapport with the patient. We have to spend time with the patient. That means increasing our workload.” (PID 2007)

Note. Theme 2: Hospital systems and healthcare structure will create persistent challenges. KAC = knowledge, attitudes, and confidence. ICUs = intensive care units; ER = emergency room; PID = participant identification number.

Maximum ED Capacity Intensifies Competing Priorities

The perceived endless work, unpredictable patient flow (such as high patient influx due to bus accidents), limited time, and resources precluded staff from imagining meaningful engagement in suicide screening, particularly universal screening. A doctor explained, “it gets so chaotic. The patient in-flow is so much…The manpower is so low, addressing every case is difficult. These kinds of emotional questions must be done in peaceful and private environment, we don’t have that kind of room. We don’t even have room for just basic patient conversations…On top of that, the ED is constant chaos. It's hard to get a patient discharged before they LAMA (leave-against-medical-advice)” (2006, Doctor). Providers felt strain at every phase of treatment, helpless vis-à-vis patient load, poverty, and pressures to return home quickly. The “chaos” of the ED also diminished provider autonomy, which increased immediate task demands to stabilize patients and coordinate patient transfers and decreased freedom to engage in more emotional conversations and suicide risk assessments. The perceived barriers to universal screening are reflected quantitatively where only 35% of staff believed universal screening was possible in everyday work (Table 3).

Competing Outside Department Priorities and Interdepartmental Collaboration Are Challenging to Effectively Manage Suicide

The unpredictable consultation and often unreliable coordination with other departments impeded the ability of ED providers to connect suicide patients with necessary care. Observations commonly revealed ED staff requested consultations over and over without response, eager to try to get someone bedside before the patient left, with infrequent success. An ED doctor illustrated the gap in inter-departmental collaboration for suicidal injury management, “The main thing we look after is to give any suicide patient a psychiatry consult and intensive care unit (ICU) preference. But none of that happens. We manage them in emergency. We wait. We call for consults. We wait” (2008, ED resident). The quantitative survey indicated 54% of clinicians believed psychiatric referrals were easy to coordinate. Moreover, frustrating referral procedures impacted timely patient care as the ED had no authority to refer or transfer a patient to another department until they received a consultation from the respective department. One doctor explained, “There is a lot of hierarchy here. This person must call that person and another person. Time is wasted” (KII 2009, Medical Officer). ED doctors communicated frustration as they worked to get suicide attempt patients admitted, underscoring institutional tensions in departmental capacities and added complications of where suicide patients “belonged.” Issues of hierarchy and communication were perceived as making effective care for suicide patients particularly frustrating.

Reliance on Family Members to Facilitate Care Amplifies Challenges for Patients Presenting With Suicide Risk and Attempts

The healthcare system requires a visitor (often family member) to be present to administer the patient's care (buy medication, necessary equipment, etc.). Limited family presence leaves patients vulnerable and staff desperate for replaced resources, “If visitors don’t come, our ED loses medicines. … They bring the poisoning cases and just abandon them. We use all the medicine that we have” (2047, Health Assistant). Staff reported additional challenges with suicidal attempt patient's families, indicating complex abuse, manipulation, and difficult communication, which left staff frustrated. Furthermore, the paper-based medical record system posed challenges for both visitors and providers to keep track of patient treatment progress. The administrative structure of the ED added burdens to patients and providers, as well as to their families, who had to keep track of care and fill gaps that the health system could not meet. This is reflected in quantitative findings where 46% of clinicians believed policies were in place that defined suicide management roles (Table 3).

ED Patients Are Assessed by Physical Severity, Propelling ED Doctors to Ignore the “Suicide Risk” and Focus on the Physical Problems

Doctors emphasized that all critical cases are top priority, regardless of cause. Unless the family or police officially reports a case as attempted suicide, the healthcare providers treated it as a standard case of physical injury. A doctor explained how difficult it is to do much about suicide screening given ED priorities, “In our emergency department there is a fear of whether there are beds or not. It comes down to saving the patient's life. How to save them? More than screening and counseling, we have to focus on treatment” (2009, Medical Officer). While the ED priority was to physically stabilize patients, treating suicidal attempts and ideations also required managing hospital beds, distributing necessary medicines, and communicating with family members. “We have to manage everything. From medicines to money” (2016, Medical Officer). Increasing system demands added to provider strain, creating hesitance toward integrating suicide prevention into their everyday work.

Theme 3 (Inner Setting/Individuals): Staff Believe Suicide Prevention Work Is Important but Need More Support to Make It Possible

Despite larger social barriers limiting perceived efficacy of suicide prevention work in the ED, staff agreed it was important (nearly 85% reported “suicide management was a part of their regular clinical work” and 62% reported it is an important part of everyone's job). They cite, however, a need for strengthened vital interpersonal and interdepartmental relationships and psychosocial support to implement such work. Staff said the “impossibility” of preventing suicide creates “impossible” demands on the ED health staff, which included reckoning with their own exposures to suicide in their personal lives while engaging in emotionally taxing care. On the contrary, they noted that more support could help facilitate the implementation of suicide prevention care.

Implementing Suicide Prevention Can Overburden Individual Staff With Limited Hierarchical Support

In the ED, staff are constantly busy, and their efforts are frequently stretched thin. Added responsibilities like screening for suicide threaten to overburden individual staff, particularly nurses who often receive top-down orders. A nurse explained the interpersonal and individual impacts of added work, “when we ask her [the ED nurse] to do psychosocial work […], she will either do her nursing tasks properly or counseling properly. If she starts doing counseling, other staff say ‘don’t give me duty with her. She's not able to do her nursing work’” (2003, Nurse). While the nurses navigate multiple additional duties, they lack support from senior doctors and other medical staff to protect their time, which impedes their ability to effectively carry out suicide prevention work. Notably, a medical officer noted feeling supported by the department after witnessing patient suicide deaths (Table 4). While doctors indicated the presence of supportive administration, nurses had far fewer comments on a supportive subculture. Indeed, while most providers reported they were comfortable asking for help managing suicidal attempt and ideation cases (85%) and that their supervisor supported them spending more time to support suicidal patients (73%), only 58% believed that they had enough support to effectively assist suicidal patients. Hierarchies of expertise and power are further underscored by 73% reporting that senior clinicians do not need to use standardized psychometric tools.

Table 4.

Theme 3 Joint Display.

KAC domain	KAC item	Endorsed	Unsure/not endorsed	Illustrative quote
Beliefs and practices about suicide prevention	3. I believe suicide prevention is a part of my regular clinical work	22 (84.62)	4 (15.38)	Team Psychosocial Traits: I did not enter the red zone for many years. When I moved to work in the ER, I cannot say that I won’t enter that zone. If such a case comes, I have to be the first to attend to them. (PID 2003)
	16. I receive enough supportive supervision to effectively assist patients with suicidal thoughts and behaviors, especially if I am unsure on what to do	15 (57.7)	11 (42.31)
	28. Is there a belief in the hospital that suicide prevention is an important part of everyone's job?	16 (61.54)	10 (38.46)
Hospital priorities	10. Leadership in my department makes suicide prevention a priority	17 (65.34)	9 (34.62)	“When we ask her [the ED nurse] to do psychosocial work […], she will either do her duty properly or just the counseling properly. If she starts doing other counseling work, the staff who work with her come say ‘I dont want duty with her. She is doing that other work.’” (PID 2007)
Suicide tool knowledge	25. Suicide screening tools are not necessary for senior clinicians who have experience and expertise with mental health assessment	19 (73.08)	7 (26.92)
Individual confidence	17. I am comfortable asking my colleagues for help in managing suicidal patients without feeling embarrassed or burdensome	22 (84.62)	4 (15.38)	"I was traumatized for almost 15 days, (smiling) seeing patients die [from suicide]. Later, we become numb. The department is supportive. more than just support, you feel it from your heart.” (PID 2009)
Individual confidence	18. If I need to spend more time to support suicidal patients, my supervisor is supportive to manage my other responsibilities	19 (73.08)	7 (26.92)

Note. Theme 3: Staff believe suicide prevention work is important, but need more psychosocial and team support to make it possible. KAC = knowledge, attitudes, and confidence; ER = emergency room; PID = participant identification number; ED = emergency department.

Frequent Exposure to Suicide Compromises Motivation and Highlights Needs for More Psychosocial Support

Health staff are empathetic toward the needs and plight of their suicidal patients but demand additional psychosocial support to offer comprehensive care. A nurse noted that after a suicide attempt in her family and ED suicide exposures, “I dreaded entering the critical care room for many years. I can’t tell my team that I can’t go in there. If a suicide attempt comes, I have to be the first to attend to them” (2003, Nurse). Staff frequently echoed that there were limited supports to cope with high intensity situations. While they relied on peers for support, they noted exhaustion, limited time off, and minimal psychosocial support to cope with daily trauma. Vis-à-vis the infrastructure-strained hospital, following a 60-year-old poisoning death, a nurse shared her guilt, lamenting that she “couldn’t even do that much” (2003). She felt helpless given her limited agency in a “frustrating system.” Exposures to suicide attempts inside the hospital, compounded with personal exposures, engendered unresolved guilt that deeply impacted the health staff's ability to engage with their patients.

Staff Recommendations

Table 5 highlights barriers and facilitators to care mapped onto CFIR and implementation strategy taxonomies. Possible implementation strategies brainstormed by staff and CAB in consultation with study team are also included.

Table 5.

Barriers, Facilitators, and Implementation Strategies.

Level/context	Barriers	Facilitators	Possible implementation strategies	ERIC construct
Outer setting: sociocultural context	Hospital infrastructure does not enable privacy for patients to discuss their suicidality openly	Patient deference to clinician expertise and instructions	Install curtains and other hard and soft barriers to preserve patient privacy	Change physical structure and equipment
	Providers and patients are kept from understanding each other by social context of stigma and shame that makes patient/family hesitant to disclose suicide cases; providers become hopeless because they expect that patients and families will not be forthcoming	Patients believing in power of providers to fix and give solutions to problems	Suicide-specific trainings with lived experience integration; universal suicide screening	Conduct ongoing training
	Providers anticipate that patients’ dire socioeconomic circumstances will make effective follow-up care impossible; families may not be able to pay for (?)follow-up care and will simply leave the hospital with the patient; families could also express their anger toward providers	Patient and family deference to clinician expertise and instructions	Educating providers on referral sources for social determinants of health	Develop resource sharing agreements
	Pervasive notions that suicide is “impulsive” and attention seeking		Suicide-specific trainings with lived experience integration	Conduct ongoing training
Inner setting: interpersonal and individual context	Staffs’ prior traumatic exposures to suicide, stress, and unmet psychosocial needs	Exposure to suicide motivates staff to provide empathetic care	Access to mental health and other psychosocial support services; mental health leave; debriefing after traumatic events	N/A
	Inconsistent support from hierarchical structures for nurses	Leadership buy in to suicide management; some clinicians super motivated/eager to learn	Leadership training to effectively and feasibly provide supportive supervision and consultation, improve staff self-efficacy, understand secondary trauma, and support accessing support services	Provide clinical supervision
	Families and patient party are not always supportive of suicide care, making staff feel guilty	Staff rapport and ability to confide in peers	Improving team morale through data driven insights on the impacts of suicide prevention in daily work	Tailor strategies
Inner setting/outer setting (structural policies and shortcomings)	The inconsistent documentation of suicide incidents impedes providers’ comprehension of the burden and obstructs subsequent monitoring efforts to address them		Improve medical record systems	Change record systems
	Difficult for providers to coordinate patient care with other departments	If there is strong provider relationships across departments, can speed up care and trust across departments	Streamline referral procedures with transparent tracking, create a psychiatric ED rotation/round, track and report referral receipt times	Centralize technical assistance
	Limited staff, constrained space, the pay-as-you-go service, and absence or engagement of families contributes to a chaotic environment in ED
	Suicide is treated as a standard physical injury	Family abuse combined with necessary family facilitation of care precludes disclosure	ED training in suicide risk screening, brief interventions, and referral/care options	Conduct ongoing training

Note. ERIC = expert recommendations for implementing change; ED = emergency department.

Discussion

This mixed multimethod formative investigation was a larger part of a co-designing process to create a culturally appropriate suicide prevention and management strategy in a Nepali hospital co-designed by clinicians and community members with lived experience. Our data highlighted important barriers to hospital-based suicide prevention that we coupled with strategies to optimize implementation. Findings highlighted how various “outer setting” domains are inextricably linked to determinants identified at inner setting and individual levels, particularly suicide stigma that manifests in structural communication and self-efficacy barriers. We discuss how this study fills an important evidence gap in literature on ED suicide management implementation studies that are largely situated in high-income contexts. We highlight how important contextual factors are essential for building feasible hospital-based suicide prevention approaches in resource-strained LMIC environments.

Clinician Perceived Barriers to ED-Based Suicide Prevention

Our study found that ED clinicians prioritized the physical impact of suicide attempts, shaping perceptions that reduced suicidal behaviors to interpersonal problems or physical harm. This limited opportunities to connect with patients. Providers cited time constraints and the chaotic ED environment as barriers to suicide screening, similar to findings in Petrik et al. (2015). Our study furthers this finding by contextualizing how and why providers prioritize their time given resource constraints. It also contextualizes provider interpretation and assumptions that might shape patient self-reports. Specifically, salient social drivers and a broader milieu of suicide stigma in Nepal shaped provider dismissal of their ability to respond to suicide. More than half of providers in our study also perceived that standardized questions related to suicide risk may negatively affect rapport and trust with patients. Stigma among health providers globally hinders identification and response to mental health concerns (Gurung et al., 2022; Kohrt et al., 2018; Thornicroft et al., 2022). Designing interventions that involve individuals with lived experience of suicide is a promising avenue to reduce provider stigma and improve care quality.

Privacy and patient disclosure were also key concerns. Similar barriers are noted in high-income settings (Allison et al., 2022; Petrik et al., 2015). Patients may withhold suicidal thoughts, particularly if they mistrust the system (Podlogar et al., 2022; Richards et al., 2019). Suicide-prevention care must continue to focus on developing quality relationships anchored in trust to create possibility for open communication. Vandewalle found through qualitative inquiry that hospital psychiatric nurses perceived their role to create conditions for open and genuine communication. Work cultures that value communication may be important facilitators for successful suicide-related communication (Vandewalle et al., 2019).

Over one-third of providers in our study reported limited self-efficacy to screen, refer, and navigate patient suicide-related conversations. In contrast, studies in the USA found higher provider self-efficacy (Allison et al., 2022; Labouliere et al., 2021). This may be expected as ED environments in Nepal and other LMICs have not historically focused on serving suicide patients beyond stabilization and referral. Cultural-disclosure practices for sensitive topics such as suicide are also not well-elucidated. Indeed, before suicide management practices can be implemented, thoughtful approaches to training and supporting providers’ skills and confidence must be established.

Clinician Needs to Support Suicide Prevention

Clinicians in our study reported stress, burnout, and countertransference from previous traumatic exposures, aligning with findings in high-income EDs (Michaud et al., 2023; Roden-Foreman et al., 2017). Burnout is common in high-stress settings (Pooja et al., 2021; Zheng et al., 2022) and stems from excessive job demands, long hours, and moral injury (Dean et al., 2019). Mental illness and suicide are also salient problems experienced among clinicians (Harvey et al., 2021). In our study, several respondents noted past suicides among colleagues, yet few support services exist. Mental health systems must be integrated into the healthcare system itself. Moreover, organizational and systems resources must create policies and structures that prevent burnout and acknowledge and treat moral injury, particularly among clinicians asked to engage in trauma-heavy topics. In implementation research contexts, study teams also have important responsibility to create and enable model systems of appropriate care (Burgess et al., 2022; Memish et al., 2017). Exposure to patient suicide may also affect clinician self-efficacy. Mental health specialists who lost a patient to suicide reported inadequate suicide-specific training, despite having more experience than those without such loss (Spruch-Feiner et al., 2022).

System Barriers to Suicide Prevention Implementation

Our study found interdepartmental collaboration as a key system barrier. Clinicians reported confidence in referral knowledge but struggled with psychiatric consults and care coordination, similar to findings in high-income settings (Allison et al., 2022; Labouliere et al., 2021). Departmental collaboration is particularly difficult in lower resource settings where electronic medical records and complex system software are limited. In Nepal, staff relied on on-call phone lines and personal cell phone communication. Patient wait times are difficult to log and easily share across the health system. Communication and logistics infrastructure are important developments to consider particularly in suicide prevention work where efficient linkage to care is deeply important for patient safety (Asarnow et al., 2017; Ayer et al., 2022; O'Connor et al., 2013). Notably, aside from departmental referral difficulties within the hospital, providers in our study did not highlight the lack of referral resources as a barrier to them screening, as has been found in other related studies (Allison et al., 2022; Labouliere et al., 2021; LeCloux et al., 2021; Petrik et al., 2015). Indeed, in LMICs, mental health services are only available to 1 in 10 of individuals in need (Thornicroft et al., 2017). The disconnect between providers believing they know where to send a patient for care vis-à-vis what is available in the community can be addressed through implementation strategies and workflows for safe patient linkage.

Another system barrier not highlighted in high-income suicide-screening literature is the reliance on families to facilitate healthcare. The Nepali family-reliant pay-as-you-go model distances patient-centered care in several ways, particularly for suicide-related problems. While strong family support can be a valuable resource for providers to leverage in patient care, the inherent reliance on families within the Nepali healthcare system can inadvertently distance individuals at risk of suicide from receiving necessary care. This is particularly true when individuals are living within unhealthy family systems or experiencing abuse. However, it is crucial to acknowledge that family and social support can also act as significant protective factors for these vulnerable individuals. A nuanced approach is necessary to harness the potential benefits of family involvement while simultaneously mitigating the risks associated with over-reliance on family support. Providers must adeptly navigate family communication not only to provide efficient and high-quality care, but also often must communicate about suicide with family members present. Patient disclosure and care decisions may be influenced, highlighting the need for clinician training on communication and systems capability to support confidentiality and safe spaces to report (Banfield et al., 2022). Such strategies can facilitate improved patient-provider trust and ability to provide high-quality suicide prevention care (Shin et al., 2022).

Strengths and Limitations

Our study has multiple strengths, particularly our use of embedded ethnography. Our work is informed by strong ethnopsychological theories of mental health and suicide in Nepal (Hagaman et al., 2018; Kohrt & Harper, 2008), and is responsive to recent advancements in access to mental health services (Jordans et al., 2019; Kohrt et al., 2022). We analyze our data in the language it was collected, Nepali. We use multiple methods for eliciting implementation preparedness information including ethnography, FGDs, individual interviews, and an anonymous survey. There are of course limitations to consider in the interpretation of our results including the convenience sample of ED providers and natural limitations of eliciting information through spoken communication, which requires individuals to be able to articulate what behaviors they do, what norms they perceive, and why they think conditions are the way they are. We report our results in English, despite the language of data collection and analysis, limiting true representation to the words and meanings of the data. We believe that our epistemological and methodological orientation allowing for deep triangulation limits these weaknesses, but our findings should be interpreted in light of them.

Conclusion

Success in suicide prevention implementation is contingent on a prepared, confident, and well-supported clinical workforce. Nepali ED clinicians note important perceived barriers in their own ability, their system's ability, and their workplace's culture and priorities. They also note deep moral commitments to providing high-quality care to their patients and desire to engage in suicide prevention work. Implementation strategies to bring the system and workplace toward readiness must be designed to match the noted barriers and facilitators. We believe the information provided from this study will be useful in the design of future research and ED protocols for suicide prevention work globally.

Supplemental Material

sj-pdf-1-irp-10.1177_26334895251343644 - Supplemental material for Evaluating implementation preparedness for suicide screening and referral in a Nepali emergency department: A mixed-methods study

Supplemental material, sj-pdf-1-irp-10.1177_26334895251343644 for Evaluating implementation preparedness for suicide screening and referral in a Nepali emergency department: A mixed-methods study by Anmol P Shrestha, Roshana Shrestha, Ajay Risal, Renu Shakya, Kripa Sigdel, Riya Bajracharya, Pratiksha Paudel, Divya Gumudavelly, Emilie Egger, Sophia Zhuang, Lakshmi Vijayakumar and Ashley Hagaman in Implementation Research and Practice

Supplemental Material

sj-pdf-2-irp-10.1177_26334895251343644 - Supplemental material for Evaluating implementation preparedness for suicide screening and referral in a Nepali emergency department: A mixed-methods study

Supplemental material, sj-pdf-2-irp-10.1177_26334895251343644 for Evaluating implementation preparedness for suicide screening and referral in a Nepali emergency department: A mixed-methods study by Anmol P Shrestha, Roshana Shrestha, Ajay Risal, Renu Shakya, Kripa Sigdel, Riya Bajracharya, Pratiksha Paudel, Divya Gumudavelly, Emilie Egger, Sophia Zhuang, Lakshmi Vijayakumar and Ashley Hagaman in Implementation Research and Practice

Footnotes

Acknowledgments

The study team is deeply grateful for the invaluable contributions of the Community Advisory Board who have guided it throughout the various phases of the study. We acknowledge the helpful clinical and administrative staff that participated in the research and its complex logistics.

Authors’ contributions

AH conceptualized the study, led the mixed-method components, and drafted the manuscript. APS and RoS led the recruitment, management, and interpretation of the findings. KS, ReS, RB, PP, DG, and EE contributed to writing the manuscript and APS, RoS, LV, and AR provided substantive critiques and edits. ReS, KS, PP, and RB collected the data. DG and EE contributed to data management. All authors have read and approved the final manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by the American Foundation for Suicide Prevention (YIG-0-076-19). AH is funded by the National Institute of Mental Health (K01MH125142). The content is solely the responsibility of the authors and does not necessarily represent the view of the funder.

Ethics approval and consent to participate

All participants signed the informed consent form. Ethical approval for the study was obtained from Yale University and the Nepal Health Research Council.

Availability of data and materials

Data are available upon reasonable request after the close of the umbrella trial.

ORCID iDs

Pratiksha Paudel

Sophia Zhuang

Ashley Hagaman

Supplemental Material

Supplemental material for this article is available online.

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