Protocol for a mixed methods study to examine social workers' implementation of national guidelines with children in care who self-harm

social workers, self-harm, looked after children, children in care, NICE guidelines, mixed methods, protocol, implementation ALL Metrics - Views Downloads How to cite this article Lever G, Dowding D, Jeyasingham D and Armitage C. Protocol for a mixed methods study to examine social workers' implementation of national guidelines with children in care who self-harm [version 1; peer review: 2 approved with reservations]. NIHR Open Res 2026, 6:15 (https://doi.org/10.3310/nihropenres.14109.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Study Protocol [version 1; peer review: 2 approved with reservations] Gill Lever https://orcid.org/0009-0000-0977-9039 1, Dawn Dowding2, Dharman Jeyasingham2, Christopher Armitage https://orcid.org/0000-0003-2365-1765 1Gill Lever https://orcid.org/0009-0000-0977-9039 1, Dawn Dowding2, Dharman Jeyasingham2, Christopher Armitage https://orcid.org/0000-0003-2365-1765 1 PUBLISHED 16 Feb 2026 Author details Author details 1 The University of Manchester Division of Psychology and Mental Health, Manchester, England, UK 2 The University of Manchester Division of Nursing Midwifery and Social Work, Manchester, England, UK 2 The University of Manchester Division of Nursing Midwifery and Social Work, Manchester, England, UK Gill Lever Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation Dawn Dowding Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Dharman Jeyasingham Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Christopher Armitage Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS The National Institute for Health and Care Excellence (NICE) guidelines on self-harm (2022) aim to improve the quality of care for individuals who self-harm in all services and settings. A rapid review of the literature revealed an absence of research on social workers' implementation of the guidelines and their implementation with children. This study aims to address this gap in the literature. Children in care are at increased risk of self-harm, with risk rates between two and four-fold higher than children without care experience. However, very little is known about how this risk is assessed and managed. Although social work professionals are expected to take the NICE guidelines on self-harm fully into account, alongside the individual needs, preferences, and values of the child, it is not known if children's social workers are aware of and implement the NICE guidelines on self-harm with children in care. A mixed-methods approach will be used, consisting of two research phases. The first phase involves collecting data from a large-scale online quantitative survey, exploring children’s social workers’ knowledge of the NICE guidelines on self-harm and their opportunities, capabilities, and motivations to implement them with children in care. In the second phase, semi-structured interviews with social workers will be conducted to identify specific barriers and facilitators to NICE guideline implementation with children in care who self-harm. The study will provide important insights into the factors influencing how children’s social workers assess and manage self-harm and contribute to the literature on NICE guideline implementation. The results of this study will inform the development of interventions aimed at improving the quality of care and support of children in care who self-harm. The NICE guidelines on self-harm (2022) are designed to improve care for people who self-harm across all services and settings. A review of existing research found that there is no knowledge of how social workers use these guidelines or how the guidelines are used to support children who self-harm. This study aims to fill that gap. Children in care are at a higher risk of self-harm, with rates two to four times higher than children who are not in care. However, little is known about how this risk is assessed and managed. While social workers are expected to follow the NICE guidelines when working with children in care, it is unclear if they are aware of these guidelines or use them. The study involves two research phases. In the first phase, information will be collected through a large online survey to explore children's social workers' knowledge of the NICE guidelines and their capabilities, opportunities, and motivation to apply them to children in care. The second phase will involve interviews with social workers to identify factors that help or hinder their use of the guidelines with children in care who self-harm. This study will provide valuable insights into how social workers assess and manage self-harm in children in care and will contribute to understanding how the NICE guidelines are used. The results will help to develop ways to improve the care and support for children in care who self-harm. social workers, self-harm, looked after children, children in care, NICE guidelines, mixed methods, protocol, implementation Corresponding Author(s) Gill Lever ([email protected]) Grant information: This project is funded by the National Institute for Health Research (NIHR) under [GM-PSRC and ARC-GM (Grant Reference Number R128571*BE02, R123859 GA0701)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2026 Lever G et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Lever G, Dowding D, Jeyasingham D and Armitage C. Protocol for a mixed methods study to examine social workers' implementation of national guidelines with children in care who self-harm [version 1; peer review: 2 approved with reservations]. NIHR Open Res 2026, 6:15 (https://doi.org/10.3310/nihropenres.14109.1) First published: 16 Feb 2026, 6:15 (https://doi.org/10.3310/nihropenres.14109.1) Latest published: 16 Feb 2026, 6:15 (https://doi.org/10.3310/nihropenres.14109.1) The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Child self-harm, involving intentional self-poisoning or injury, irrespective of motivation (NICE, 2022a), in young people under the age of 18, is an increasing problem globally (Cairns et al., 2019; Griffin et al., 2018; McManus et al., 2019; Morgan et al., 2017). Care-experienced children, defined as children who have been in the care of the local authority for more than 24 hours (NSPCC, 2024) are at greater risk of self-harm (Stanley et al., 2005), with risk rates between two and four-fold higher than the general population (Evans et al., 2017; Hjern et al., 2004; Katz et al., 2011; Pilowsky & Wu, 2006; Stanley et al., 2005; Vinnerljung et al., 2006). Despite the evidence of elevated self-harm and suicide in care-experienced children, the assessment and management of self-harm in children in care is an under-researched area (Johnson et al., 2017). The National Institute for Health and Care Excellence (NICE) guidelines on self-harm: assessment, management, and preventing recurrence (NICE, 2022a) aim to improve the quality and care of individuals who self-harm in all services and settings, including children in care. Although the guidelines are advisory and are not intended to supersede other national or local processes and procedures involved in safeguarding and decision-making, they should be fully considered when making professional judgments and in consultation with individuals, their families, and carers. Most of the guidelines' recommendations reinforce best practices and do not require additional resources to implement if previous guidance has been followed (NICE, 2022a). NICE previously published guidance on self-harm in 2004 on the short-term management and prevention of recurrence (CG16) and long-term management (CG133) in 2011. The 2022 guidance, self-harm: assessment, management and preventing recurrence (NG225), updates and replaces the earlier versions. A recent rapid review of the literature, conducted by this researcher, revealed an absence of research on if and how social workers are implementing the guidelines (Lever et al., 2025). Whilst NICE guidelines purport to be evidence-based, much of the evidence derives from clinical studies and may not be generalisable to other areas (Scullard et al., 2011), such as residential children's homes. This study addresses several gaps in the literature. Adherence to NICE guidelines on self-harm is an under-researched area, and to date, no studies on awareness/implementation rates of NICE (2022a) guidance on self-harm: assessment, management, and preventing recurrence (NG225) have been identified in the literature. This study investigates adherence to the NICE (2022b) guidelines: Self-harm: assessment, management, and preventing recurrence, which replaced the 2004 guidelines. Previous research has focused on adult self-harm and the implementation of the guidelines from health professionals. This mixed methods study will provide insights into the management and prevention of self-harm in children in care. At present, it is unclear whether social workers of children in care, are aware of and implement the NICE guidelines on self-harm. Exploration of the barriers and facilitators to implementing the guidance with children in care by social workers offers a unique contribution to the knowledge base whilst addressing key limitations of the lack of diverse populations and sectors in the literature. Here, we outline a protocol to explore social workers' knowledge of the NICE guidelines on self-harm and barriers and facilitators to implementation with children in care, using a mixed methods design. The research programme consists of two phases: First, a large-scale survey of social workers’ awareness and implementation of the NICE guidelines on self-harm will be conducted. It is hypothesised that social workers will exhibit low levels of awareness and implementation rates of the NICE guidelines on self-harm. This is based on findings from the rapid review of the literature, which found that health professionals’ awareness and implementation of NICE guidelines on self-harm is low, a finding supported by the wider research literature demonstrating poor professional awareness of government policies and guidelines (Keyworth et al., 2018). Analysis of the findings will inform the second phase of research. Rich, detailed data will be collated through semi-structured interviews and analysed using a framework for behaviour change. This research involves a mixed methods study investigating children’s social workers' implementation of NICE guidelines on self-harm with children in care. Data from social workers who have worked with children in care who have actively self-harmed will be collated to gain a deep, multifaceted understanding of views and experiences and highlight potential barriers to NICE guideline implementation in this group. A trauma-informed approach to research takes account of the impact trauma has had on people's lives (Dowding, 2021). Social workers are at elevated risk of both primary and vicarious trauma. The helping professions generally attract people with significant life adversities (Newcomb et al., 2015), and "the negative effects of caring about and caring for others" (Perlman & Maclan, 1995, p.31) are well documented in the social work profession (Dykes, 2016; Esaki & Larkin, 2013; Peart, 2023; Sellers & Hunter, 2005; Thomas, 2016). The key principles of trauma-informed practice: safety, trust and transparency, choice, collaboration, and empowerment (Fallot & Harris, 2009) inform the research design, implementation, data analysis, and dissemination of the research findings. The TDF (Cane et al., 2012; Michie et al., 2005) integrates 33 theories of behaviour, incorporating 84 theoretical constructs of behaviour change and culminating in 14 distinct theoretical domains (1. knowledge, 2. skills, 3. social/professional role and identity, 4. beliefs about capabilities, 5. optimism, 6. beliefs about consequences, 7. reinforcement, 8. intentions, 9. goals, 10. memory, attention, and decision processes, 11. environmental context and resources, 12. social influences, 13. emotion, and 14. behavioural regulation). Its theoretical basis promotes the elicitation of beliefs in data collection (Dyson et al., 2011) and the identification of behaviour determinants that are instrumental in behaviour change interventions (Michie et al., 2005). The TDF is recommended as a framework for interviews to identify factors influencing behaviour (Michie et al., 2014). The COM-B model consists of three interacting factors - capability, opportunity, and motivation - which must be present to generate behaviour (Michie et al., 2011). Factors influence one another, and a behaviour occurrence can result in changes to capability, motivation, and opportunity. The three key domains are further divided into six subdomains: physical and psychological capability, physical and social opportunity, and reflective and automatic motivation. The COM-B model is purposefully designed to be broad and flexible whilst being rooted in the scientific theory of behaviour implementation, ensuring its methodological rigour. The COM-B model of behaviour is widely used in public health and policy to identify which factors need to be targeted for a behaviour change intervention to be effective (West & Michie, 2020). Although the COM-B model is a distinct framework from TDF (Tomas et al., 2023), it is complementary (Fahim et al., 2020; Ojo et al., 2019), enabling the TDF to be condensed into its three key domains: capability, opportunity, and motivation. The TDF domains of knowledge, skills, memory, attention, decision processes, and behavioural regulation map onto capability. Environmental context, resources and social influences map onto opportunity, while intentions, goals, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, social/professional role, and identity, and emotion map onto motivation. The study asks four research questions based on the research objectives: Research Question 1: What proportion of children’s social workers in England are aware of the NICE guidelines on self-harm? Research Question 2: What proportion of children’s social workers in England are implementing NICE guidelines on self-harm? Research Question 3: Is there variation in social workers' implementation of NICE guidelines on self-harm according to (i) specialism, (ii) professional experience, (iii) workplace, and (iv) region? Research Question 4: What are the barriers and facilitators to social worker's implementation of NICE guidelines on self-harm with children in care? The mixed methods study will be conducted with social worker participants in England from February 2025 to April 2026. The research programme involves two phases: Phase 1: Quantitative study Research questions 1, 2, and 3 will be addressed through an online survey, in which social workers' knowledge, views, and experiences will be ascertained. Ethical approval for this study has been obtained from the University of Manchester Research and Ethics Committee (Ref: 2025-20361-39290) Purposive sampling will be used to recruit social worker participants for the survey study in phase 1 of the research. Participants will be recruited between February and December 2025. The recruitment strategy is multi-modal, comprising letter drops, advertisement on social media platforms, and the British Association of Social Workers (BASW) e-bulletin, to yield a large sample size, mitigate the margin of error, and produce meaningful results. Eligibility criteria are broad and include all children's social workers (and students of social work) practising in England. It is challenging to calculate a sample size due to the lack of available data on the number of social workers who work with children in care and how many of those children self-harm. Therefore, the assumption has been made that 10% of the 33,119 child and family social workers (FTE) practising in England (Community Care, 2024) will have worked with a child in care who has self-harmed in the past 12 months. This provides an ideal sample size of 345 with a 95% confidence interval and 5% margin of error. Inclusion criteria are occupation as a Children's Social Worker or student of social work, practising in England, and having worked with at least one child in care who has actively self-harmed, within the last 12 months. Exclusion criteria are social workers practising in the devolved nations and outside of the UK and children’s social workers who have not worked with a child in care who has actively self-harmed within the last 12 months. An online survey is an efficient data collection method with the advantage of being rapid, inexpensive, and wide-reaching, surpassing geographic boundaries. Providing the opportunity for participant anonymity, online surveys also minimise the effects of social desirability (Burruss & Johnson, 2021). However, they tend to generate low response rates, typically below 20% (Fricker et al., 2005). In this study, we address this by offering an incentive to participate for the chance to win a £50 gift voucher through a prize draw. To mitigate against participants answering the survey more than once, IP addresses will be checked, and any multiple IP addresses that contain the same demographic information will be deleted. The survey will explore children's social workers' awareness and implementation rates of NICE guidelines on self-harm in England. Children's social workers practise in diverse settings (including local authorities, NHS, charities, and the private sector) and specialties (including child and adolescent mental health services (CAMHS), child protection, fostering and adoption teams, learning disability, refugee and asylum seeker support) and have varying levels of experience within the profession, as well as of supporting children in care who self-harm. The survey consists of 19 questions (three screening questions (1-3), two assessing awareness and implementation levels (4-5), and six assessing opportunity, motivation, and capability to implement the NICE guidelines on self-harm, adapted from Keyworth et al., 2020 (6-11) based on the COM-B model (Michie et al., 2011); a free response question asking participants if anything has helped or hindered NICE guideline implementation with children in care who self-harm (12); seven questions addressing demographic information (13-19): area of social work specialism, number of years of experience, regional area of work, age, ethnicity, gender and disability status). Items 16-19 ask about personal information of protected characteristics, constructed using Diversity and Inclusion Survey (DAISY) guidance (EDIS & Wellcome, 2022) and Sex and Gender Equity in Research (SAGER) guidelines (Heidari et al., 2016). These questions contain an optional response of “prefer not to respond.” 18 of 19 items are forced-choice questions, requiring participants to insert a response, meaning items cannot be skipped. Item 12, the free response text item, is the exception. The forced response pattern is to minimise the risk of missing data. All survey items were reviewed by a trauma-informed expert and public contributors with lived experience of self-harm to ensure language sensitivity and acceptability. The survey will be implemented on the online Qualtrics system, which offers a range of accessible survey types and patterns. The Qualtrics platform provides easy-to-scan QR codes, facilitating instant access to the participant information, consent form and then survey from the advertisement (Burruss & Johnson, 2021). Qualtrics features an interactive interface so that responses to an item require completion before the delivery of the next item on the screen. This controls for skipping items and enables participant suspension and resumption of survey completion, which helps to reduce attrition rates (Couper et al., 2001; Wright, 2005). We have tried to reduce the burden on respondents, using a concise check-box fixed response survey to prevent the high attrition levels of long and time-consuming surveys (Burruss & Johnson, 2021). This design also eliminates blank and out-of-range responses (Couper et al., 2001). Another feature of Qualtrics that aids data validity is that it clarifies words and terms via pop-up information when the participant clicks on them (Burruss & Johnson, 2021). Skip patterns are also utilised in the survey design, so only questions applicable to each participant are displayed, and irrelevant items are automatically bypassed to reduce survey length and completion time. Furthermore, partial completion is minimised by using progress indicators, which enable participants to ascertain how much more of the survey remains (Burruss & Johnson, 2021; Couper et al., 2001). Information regarding partial survey completion also enables analysis of any trends at which survey abandonment occurs that could indicate a particular survey item being problematic (Couper et al., 2001). Patterns of participants' response times will also be analysed to identify items that may be unclear, as well as exceptionally rapid responses (Burruss & Johnson, 2021) that could be indicative of bots and undermine data validity. Data from the large-scale survey will be analysed using IBM SPSS Statistics (V.25). Data will be exported from the Qualtrics platform into SPSS (V.25) for data cleaning and statistical analysis. Multiple responses from the same participant will be identified using the deduplication procedure for online surveys, as described by Konstan et al., 2005. This involves screening all completed surveys for duplicate internet service provider (ISP) entries and eliminating any surveys that contain identical ISP and demographic data (region, social work specialism, etc.). All data, including from partial survey completion will be included in the analysis. A descriptive analysis of participant characteristics will be generated from the survey data to summarise participants’ self-reported awareness and implementation of the NICE guidelines on self-harm. The sample's representativeness to the base population will be cross-checked against Social Work England data, and a chi-square will be performed to assess sample representativeness. The analysis will adjust for potential demographic confounders (region, etc.). Subgroup analyses (comparing social work specialism, etc.) will be performed to identify differences between groups in reported opportunities, capabilities, and motivations to implement the guidelines. This will be assessed using analysis of variance (ANOVA) or Kruskal-Wallis (if the assumptions of ANOVA are not met). We intend to perform multiple regression analysis to examine the association of COM-B variables with NICE guideline implementation. Phase 2: Qualitative study The data obtained from the survey of children's social workers with experience working with children in care who have actively self-harmed in the past 12 months will be used to inform the second study. Phase 2 of the research addresses research question 4, exploring the barriers and facilitators to social worker's implementation of NICE guidelines on self-harm with children in care, using semi-structured interviews. Questions have been developed based on previous study semi-structured interview questions of health professionals (Leather, 2022; Leather et al., 2022; Leather et al., 2023). The semi-structured interviews comprising social work participants will be recruited during phase 1 of the research, whereby survey respondents will be asked if they are interested in taking part in a semi-structured interview. Eligible and interested participants will be contacted in January–February 2026. The sample size is determined according to Francis et al.’s framework for theoretically rooted interviewing. This framework sets an a priori minimum sample size of 10 and ceases data collection at the point when three interviews do not identify new themes (Francis et al., 2010). Inclusion criteria are participants from phase 1 of the research (social workers, including students of social work) practising in England who have experience of working with children in care in the past 12 months, who have actively self-harmed in this time, who consented to being contacted about participating in the semi-structured interviews and audio-visual recording. Participants will be purposively selected to enable the spectrum of awareness and implementation rates to be systematically explored. Exclusion criteria are social workers who did not participate in phase 1 of the research, participants who did not provide consent to be contacted about participating in semi-structured interviews in research phase 2, and participants who did not consent to audio-visual recording. Participants who match the inclusion criteria will be sent an email with the participant information sheet inviting them to participate in semi-structured interviews. Participants will be given at least seven days to consider the information and provide informed written consent to participate in audio-visual recorded interviews via Microsoft Teams. Semi-structured interviews are an effective methodology for collecting data on attitudes, perspectives, and experiences (DeJonckheere & Vaughn, 2019). They have the advantage of generating comparable data, whilst affording flexibility to probe further insights from individual responses (Knox & Burkard, 2009). The use of online semi-structured interviews has increased in recent years (Lobe et al., 2022), and lessons have been taken from some of the challenges encountered. As unfamiliar technology can present a challenge for both participants and researchers (Lobe & Morgan, 2021), we shall conduct interviews using the platform Microsoft Teams, which Local Authorities, the NHS, and the third sector widely use. Thus, participants are expected to be familiar with this platform. However, we take the precaution of offering a 5–10-minute pre-session with all participants to address technical issues and ethical considerations, as well as the provision of a software guide. Whilst the flexibility of online interviews enables participants to be interviewed in their home environment, this risks greater distraction and third-party influence/compromised confidentiality (Rahman et al., 2021; Saarijarvi & Bratt, 2021). We mitigate this challenge by following the recommendations for online interviewing described by Saarijarvi and Bratt (2021) by sending participant information a week in advance and resending it the day before the scheduled interview. This will contain the interview questions (provided in advance, in accordance with a trauma-informed and neuro-affirmative approach), a digital link to the interview, and interview preparation advice (to enable video-camera on a computer/smartphone; ensure stable wi-fi connection; ensure there is a private, quiet, and calm environment for the duration of the interview). All participants will be encouraged to wear headsets to reduce background noise and enhance audio quality, whilst also promoting privacy and confidentiality. At the start of the interview, the researcher will check with participants that they are in a safe and quiet environment with minimum distractions. Online interviews have several advantages, eliminating travel time and costs for both the researcher and participants and enabling a widely dispersed sample for inclusion (Keen et al., 2022; Lobe et al., 2022; Saarijarvi & Bratt, 2021), as well as better access for participants with disabilities (Williams et al., 2018) and caring responsibilities (Henderson & Moreau, 2020; Horrell et al., 2015). Participants also have choice over their environment, promoting psychological safety. As semi-structured interviews have time-sensitive components, the timings of each item can be effectively monitored on screen, more discreetly than in person, reducing the risk of appearing distracted (Keen et al., 2022). The duration of the semi-structured interview is 45–60 minutes. With participants’ written consent, the semi-structured interview will be audio-visually recorded. Participants are explicitly informed in advance and at the beginning of the semi-structured interviews that there are no right or wrong answers. The confidentiality statement will be read out at the beginning of the semi-structured interview and repeated at the end. Participants will be reminded of their right to withdraw at any time without needing to provide a reason. Whilst the researcher will be vigilant for signs of participant distress and will offer breaks, emotional support, and the option to cease the interview, it is acknowledged that it can be more difficult to detect and respond appropriately to signs of participant distress in the online forum (Lobe et al., 2022). However, cues can be drawn from intonation and facial expression (Saarijarvi & Bratt, 2021), and participants have more agency to withdraw than they would in physical face-to-face interviews, where there can be greater implicit demand to continue, by terminating the interview with the click of a button (Lobe et al., 2022; Thunberg & Arnell, 2021). A provisional semi-structured interview schedule is derived from the COM-B, to assess key determinants of behaviour and is informed by questions used in previous research exploring health professionals' implementation of NICE guidelines on self-harm (Leather et al., 2022; Leather et al., 2023). The interview schedule includes a range of open-ended questions to encourage social work participants to provide detailed accounts of barriers and facilitators, affecting their knowledge of, and implementation of the NICE guidelines on self-harm with children in care. As non-verbal cues are more limited in the online forum (Lobe et al., 2022), we anticipate increased use of verbal prompts. Prompts related to TDF domains have been developed, as Michie et al. (2014) recommended, which will support fluidity and aid engagement. To support the spontaneity of interaction in the online environment, participants will be instructed not to use the mute function unless they are experiencing background noise (Van Voort et al., 2023). The semi-structed interview consists of ten questions, relating to the COM-B constructs. Questions are framed in relevant language, as Atkins et al. (2017) recommended, and items are purposefully structured to facilitate logical and continuous fluidity, emulating typical conversation (Rubin & Rubin, 2005). Questions and prompts were reviewed by a trauma-informed expert and public contributors with lived experience of self-harm to ensure language sensitivity and minimise the risk of re-traumatisation. We incorporate an open final interview question, asking, “Is there anything that we have not covered that you feel is important/relevant?” to mitigate the risk of issues that are important to the participant being neglected (McGowan et al., 2020). Field notes will be made during and following the semi-structured interviews, as well as during data analysis. These are for debrief and reflexivity purposes and will not be included in the data analysis. Additional supervision will be set up during the data collection phase to reflect on and discuss researcher perceptions, experiences and reactions, to support impartiality (Holloway & Galvin, 2017) and researcher resilience (Dowding, 2021; Silverio et al., 2022). Data from the semi-structured interviews, in phase 2 of the research, will be audio-visually recorded and transcribed verbatim and analysed using framework analysis (Ritchie & Spencer, 1994) in the computer-assisted qualitative analysis software, Nvivo v.14. Participant names will be replaced with pseudonyms to protect identities. Framework analysis is a versatile method that can be adapted for use with many qualitative approaches (Gale et al., 2013). It offers a systematic and transparent approach to data analysis, encapsulating thematic analysis and describing data patterns (Ritchie & Lewis, 2003). Framework analysis identifies data similarities and differences and relationships between data, enabling both descriptive and explanatory conclusions to be drawn (Klingberg et al., 2023). The coding framework for analysis is developed using the TDF, as advised by Atkins et al. (2017). Framework analysis will facilitate the interpretation of diverse views and experiences and enable systematic identification of areas of similarities and differences within and between children's social workers, encountering children in care who self-harm. Rich insights into the influence of personal and organisational factors on the management of self-harm in children in care and its impact will be drawn. Framework analysis is well suited to semi-structured interviews since its matrix output provides a structure for analysis by participants and code. In this way, the views of each participant are connected within the matrix, and the context of individual views, patterns, and nuances is apparent (Klingberg et al., 2023). The semi-structured interview data will be analysed according to the five stages of framework analysis adapted from Gale et al., 2013, to systematically identify facilitators and barriers to NICE guideline implementation. Stage 1: Data Immersion Audio-visual recordings and verbatim transcriptions of the semi-structured interviews will be observed repeatedly for data immersion. Stage 2: Familiarisation Initial thoughts and impressions will be recorded on the transcripts. Stage 3: Coding & Indexing Predefined codes, based on the TDF, will be applied to describe interpretations of the data. Stage 4: Charting Data into the Framework Matrix Data will be charted by summarising it by category into the matrix. Illustrative quotations will be tagged in Nvivo v.14 onto the chart. Stage 5: Interpreting Researchers will journal ideas, insights, and early interpretations and discuss these regularly. Analytic memos will be used to stimulate discussion, as described by Charmaz (2006). A collaborative approach to the analysis will be endorsed. Two researchers will analyse the transcripts independently. Any disagreement will be resolved by discussion with the wider research team. Codes and themes will be documented in key domains. In this final stage, commonalities and differences will be identified, connections between categories mapped, and descriptive and/or explanatory interpretations will be generated. If the data is rich enough, predictions can be made about the extent to which the guidelines are likely to be implemented in distinct conditions. Gale et al. (2013) caution that the final phase of framework analysis, interpreting the data, is time-consuming, often taking longer than expected. Accordingly, additional sessions are set aside should they be needed for sufficient data interpretation. Researchers will be flexible and adaptive to enable the generation of rich and nuanced insights. Critical reflection is a core feature throughout the research process in recognition that how qualitative research is conducted and analysed is inevitably influenced by researcher characteristics. The researcher will keep a journal to record reflections, insights, ideas, impressions, and early interpretations about the research and analysis, as Gale et al. (2013) recommended. Academic supervision and examination of journals/field notes documenting the researcher’s perceptions of the interview process and their emotional responses will promote objectivity and help to minimise the risk of researcher bias, influencing data interpretation (Cowles, 1988) as well as supporting researcher resilience and wellbeing (Dowding, 2021). We are mindful that qualitative explorations of behavioural determinants, influences, and experiences should be flexible and open to identifying all emergent ideas and themes (Layder, 1993; McGowan et al., 2020). Although we use a predominantly deductive approach, whereby data is coded into TDF domains, inductive content analysis will be applied to emergent sub-themes within each TDF domain as per guidance from Atkins et al. (2017). We will apply the coding, as described in Arden et al. (2019), whereby two researchers independently code under the TDF domain that best matches the data, and instances where data relates strongly to multiple TDF domains will be coded in all that apply. As the evidence indicates that some TDF domains measure an amalgamation of factors rather than distinct behaviour (Huijg et al., 2014), double coding should enhance the identification of related themes and domains. Data under each domain will then be subjected to inductive content analysis to create sub-themes, identified according to the procedure outlined by Atkins et al. (2017) when: mentioned by several participants; participants report conflicting beliefs and experiences; or there is strong importance expressed that may affect the target behaviour. Any discrepancies in coding will be discussed and resolved using the wider research team. A Social Worker Advisory Panel (SWAP) comprising three children and family social workers was formed to guide the research process. They reviewed the research materials, provided feedback on the recruitment strategy, advised on trauma-informed practices, and promoted the study within their networks. Public Contributors with lived experience of self-harm at the National Institute of Health and Care Research (NIHR) Patient Safety Research Collaboration (PSRC) Greater Manchester (GM) provided feedback on the equality impact assessment, reviewed the research materials, and advised on trauma-informed processes. Ethical approval for the online survey study was granted by the University of Manchester Research Ethics Committee on 29 January 2025 (Ref: 2025-20361-39290). Participants provide implied consent. Participants are required to provide full, informed written consent to data collection for the semi-structured interviews. Initial approval from the Research Ethics Committee (REC) is currently being sought. Manuscripts with the results of the survey and semi-structured interviews will be submitted for publication in peer-reviewed journals. Findings will also be showcased at conferences and public engagement events. This mixed methods study of social workers’ implementation of the NICE guidelines on self-harm with children in care will provide information about the proportion of social workers who are presently aware of and/or implementing the guidelines, as well as insights into social workers’ opportunities, capabilities, and motivation for doing so. The findings will add to the evidence base on NICE guidance on self-harm implementation, extending knowledge to the social care sector and vulnerable groups. The results of this study will inform the development of interventions aimed at improving the quality of care and support of children in care who self-harm. 1. Figshare: A mixed methods study to examine social worker’s implementation of national guidelines with children in care who self-harm. https://doi.org/10.48420/30069739 (Lever et al., 2025a) This project contains the following extended data: Gatekeeper letter Recruitment flyer Participant Consent Form – Survey study Participant Information – Survey study Debrief – Survey study Interview Schedule Participant Consent Form – Interview study Participant Information – Interview study Distress Protocol Debrief – Interview study Guide for participants – online interviews Step by step guide to joining your online interview Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). 2. Figshare. https://doi.org/10.48420/29605634 (Lever, 2025a) This project contains the following extended data: Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). 1. Figshare. https://doi.org/10.48420/30192934 (Lever, 2025b) This project contains the following extended data: Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Faculty Opinions recommendedReferences - Arden MA, Drabble S, O’Cathain A, et al.: Adherence to medication in adults with cystic fibrosis: an investigation using objective adherence data and the theoretical domains framework. Br J Health Psychol. 2019; 24(2): 357–380. PubMed Abstract | Publisher Full Text | Free Full Text - Atkins L, Francis J, Islam R, et al.: A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci. 2017; 12(1): 77. PubMed Abstract | Publisher Full Text | Free Full Text - Burruss GW, Johnson A: Online survey research. In: Barnes, J.C. and Forde, D. R., eds. The Encyclopedia of Research Methods in Criminology and Criminal Justice. Wiley-Blackwell, 2021. Publisher Full Text - Cairns R, Karanges EA, Wong A, et al.: Trends in self-poisoning and psychotropic drug use in people aged 5-19 years: a population-based retrospective cohort study in Australia. BMJ Open. 2019; 9(2): e026001. PubMed Abstract | Publisher Full Text | Free Full Text - Cane J, O’Connor D, Michie S: Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012; 7(1): 37. PubMed Abstract | Publisher Full Text | Free Full Text - Charmaz K: Constructing grounded theory: a practical guide through qualitative analysis. London: Sage, 2006. Reference Source - Community Care: Councils employing record number of children’s social workers on back of 25% recruitment boost. 2024; (Accessed: 22 April 2025). Reference Source - Couper MP, Traugott MW, Lamias MJ: Web survey design and administration. Public Opin Q. 2001; 65(2): 230–253. PubMed Abstract | Publisher Full Text - Cowles KV: Issues in qualitative research on sensitive topics. West J Nurs Res. 1988; 10(2): 163–179. PubMed Abstract | Publisher Full Text - DeJonckheere M, Vaughn LM: Semi-structured interviewing in primary care research: a balance of relationship and rigour. Fam Med Community Health. 2019; 7(2): e000057. PubMed Abstract | Publisher Full Text | Free Full Text - Dowding K: Trauma-informed social research – a practical guide. 2021; (Accessed: 8 April 2025). Reference Source - Dykes G: Coping, resilience and posttraumatic growth: adverse childhood experiences and social work students. Southern African Journal of Social Work and Social Development. 2016; 28(1): 18–35. Publisher Full Text - Dyson J, Lawton R, Jackson C, et al.: Does the use of a theoretical approach tell us more about hand hygiene behaviour? The barriers and levers to hand hygiene. J Infect Prev. 2011; 12(1): 17–24. Publisher Full Text - EDIS & Wellcome: The DAISY guidance version 2. 2022; (Accessed: 15 April 2025). Reference Source - Esaki N, Larkin H: Prevalence of adverse childhood experiences (aces) among child service providers. Families in Society. 2013; 94(1): 31–37. Publisher Full Text - Evans R, White J, Turley R, et al.: Comparison of suicidal ideation, suicide attempt and suicide in children and young people in care and non-care populations: systematic review and meta-analysis of prevalence. Child Youth Serv Rev. 2017; 82: 122–129. Publisher Full Text - Fahim C, Acai A, McConnell MM: Use of the theoretical domains framework and behaviour change wheel to develop a novel intervention to improve the quality of multidisciplinary cancer conference decision-making. BMC Health Serv Res. 2020; 20(1): 578. PubMed Abstract | Publisher Full Text | Free Full Text - Fallot RD, Harris M: Creating Cultures of Trauma-Informed Care (CCTIC): A self assessment and planning protocol. Community Connections, 2009. Reference Source - Francis JJ, Johnston M, Robertson C, et al.: What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010; 25(10): 1229–1245. PubMed Abstract | Publisher Full Text - Fricker S, Galesic M, Tourangeau R, et al.: An experimental comparison of web and telephone surveys. Public Opin Q. 2005; 69(3): 370–392. Publisher Full Text - Gale NK, Heath G, Cameron E, et al.: Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013; 13: 117. PubMed Abstract | Publisher Full Text | Free Full Text - Griffin E, McMahon E, McNicholas F, et al.: Increasing rates of self-harm among children, adolescents and young adults: a 10-year national registry study 2007–2016. Soc Psychiatry Psychiatr Epidemiol. 2018; 53(7): 663–671. PubMed Abstract | Publisher Full Text - Heidari S, Babor TF, De Castro P, et al.: Sex and gender equity in research: rationale for the sager guidelines and recommended use. Res Integr Peer Rev. 2016; 1: 2. PubMed Abstract | Publisher Full Text | Free Full Text - Henderson EF, Moreau MP: Carefree conferences? Academics with caring responsibilities performing mobile academic subjectivities. Gend Educ. 2020; 32(1): 70–85. Publisher Full Text - Hjern A, Vinnerljung B, Lindblad F: Avoidable mortality among child welfare recipients and intercountry adoptees: a national cohort study. J Epidemiol Community Health. 2004; 58(5): 412–417. PubMed Abstract | Publisher Full Text | Free Full Text - Holloway I, Galvin K: Qualitative research in nursing and healthcare. 4th ed. West-Sussex, UK: Wiley Blackwell, 2017. Reference Source - Horrell B, Stephens C, Breheny M: Online research with informal caregivers: opportunities and challenges. Qual Res Psychol. 2015; 12(3): 258–271. Publisher Full Text - Huijg JM, Gebhardt WA, Dusseldorp E, et al.: Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework. Implement Sci. 2014; 9: 33. PubMed Abstract | Publisher Full Text | Free Full Text - Johnson DR, Ferguson K, Copley J: Residential staff responses to adolescent self-harm: the helpful and unhelpful. Clin Child Psychol Psychiatry. 2017; 22(3): 443–454. PubMed Abstract | Publisher Full Text - Katz LY, Au W, Singal D, et al.: Suicide and suicide attempts in children and adolescents in the child welfare system. CMAJ. 2011; 183(17): 1977–1981. PubMed Abstract | Publisher Full Text | Free Full Text - Keen S, Lomeli-Rodriguez M, Joffe H: From challenge to opportunity: virtual qualitative research during COVID-19 and beyond. Int J Qual Methods. 2022; 21: 16094069221105075. PubMed Abstract | Publisher Full Text | Free Full Text - Keyworth C, Epton T, Goldthorpe J, et al.: Are healthcare professionals delivering opportunistic behaviour change interventions? A multi-professional survey of engagement with public health policy. Implement Sci. 2018; 13(1): 122. PubMed Abstract | Publisher Full Text | Free Full Text - Keyworth C, Epton T, Goldthorpe J, et al.: Acceptability, reliability, and validity of a brief measure of capabilities, opportunities, and motivations (“COM-B”). Br J Health Psychol. 2020; 25(3): 474–501. PubMed Abstract | Publisher Full Text - Klingberg S, Stalmeijer RE, Varpio L: Using framework analysis methods for qualitative research: AMEE Guide No. 164. Med Teach. 2023; 46(5): 603–610. PubMed Abstract | Publisher Full Text - Knox S, Burkard AW: Qualitative research interviews. Psychother Res. 2009; 19(4–5): 566–575. Publisher Full Text - Konstan JA, Rosser BRS, Ross MW, et al.: The story of subject naught: a cautionary but optimistic tale of Internet survey research. J Comput Mediat Commun. 2005; 10(2): JCMC1029. Publisher Full Text - Layder D: New strategies in social research: an introduction and guide. Cambridge, UK: Polity Press, 1993. Reference Source - Leather JZ: Developing an intervention to improve implementation of national guidance for self-harm. Student thesis: Phd, June 15, 2022. Reference Source - Leather JZ, Keyworth C, Kapur N, et al.: Examining drivers of self-harm guideline implementation by general practitioners: a qualitative analysis using the theoretical domains framework. Br J Health Psychol. 2022; 27(4): 1275–1295. PubMed Abstract | Publisher Full Text | Free Full Text - Leather JZ, Keyworth C, Kapur N, et al.: Implementation of national guidance for self-harm among general practice nurses: a qualitative exploration using the capabilities, opportunities, and motivations model of behaviour change (COM-B) and the theoretical domains framework. BMC Nurs. 2023; 22(1): 452. PubMed Abstract | Publisher Full Text | Free Full Text - Lever G, Dowding D, Jeyasingham D, et al.: A mixed methods study to examine social workers implementation of national guidelines with children in care who self-harm. [Dataset]. figshare. 2025a. http://www.doi.org/10.48420/30069739 - Lever G: Survey. University of Manchester, Dataset. 2025a. http://www.doi.org/10.48420/29605634.v1 - Lever G: Study protocol reporting checklist for novice researchers (ObsQual Checklist). University of Manchester, Dataset. 2025b. http://www.doi.org/10.48420/30192934.v1 - Lever G, Dowding D, Jeyasingham D, et al.: Health and social care professionals’ awareness and implementation of NICE guidelines on self-harm: a rapid review of the literature. BMJ Open. 2025; 15(8): e093883. PubMed Abstract | Publisher Full Text | Free Full Text - Lobe B, Morgan DL: Assessing the effectiveness of video-based interviewing: a systematic comparison of video-conferencing based dyadic interviews and focus groups. Int J Soc Res Methodol. 2021; 24(3): 301–312. Publisher Full Text - Lobe B, Morgan DL, Hoffman K: A systematic comparison of in-person and video-based online interviewing. Int J Qual Methods. 2022; 21: 160940692211270. Publisher Full Text - McGowan LJ, Powell R, French DP: How can use of the theoretical domains framework be optimized in qualitative research? A rapid systematic review. Br J Health Psychol. 2020; 25(3): 677–694. PubMed Abstract | Publisher Full Text - McManus S, Gunnell D, Cooper C, et al.: Prevalence of non-suicidal self-harm and service contact in England, 2000–14: repeated cross-sectional surveys of the general population. Lancet Psychiatry. 2019; 6(7): 573–581. PubMed Abstract | Publisher Full Text | Free Full Text - Michie S, Johnston M, Abraham C, et al.: Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005; 14(1): 26–33. PubMed Abstract | Publisher Full Text | Free Full Text - Michie S, van Stralen MM, West R: The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011; 6: 42. PubMed Abstract | Publisher Full Text | Free Full Text - Michie S, Atkins L, West R: The behaviour change wheel: a guide to designing interventions. London: Silverback Publishing, 2014. Reference Source - Morgan C, Webb RT, Carr MJ, et al.: Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care. BMJ. 2017; 359: j4351. PubMed Abstract | Publisher Full Text | Free Full Text - National Institute for Health and Care Excellence: Self-harm: assessment, management and preventing recurrence. GID-NG10148, 2022a; (Accessed: 2 April 2025). Reference Source - National Institute for Health and Care Excellence: Membership of self-harm: assessment, management and preventing recurrence guideline committee. 2022b; (Accessed: 2 April 2025). Reference Source - National Society for the Protection of Cruelty to Children (NSPCC): Statistics briefing: children in care. 2024; (Accessed: 2 April 2025). Reference Source - Newcomb M, Burton J, Edwards N, et al.: How Jung’s concept of the wounded healer can guide learning and teaching in social work and human services. Advances in Social Work and Welfare Education. 2015; 17(2): 55–69. Reference Source - Ojo SO, Bailey DP, Hewson DJ, et al.: Perceived barriers and facilitators to breaking up sitting time among desk-based office workers: a qualitative investigation using the TDF and COM-B. Int J Environ Res Public Health. 2019; 16(16): 2903. PubMed Abstract | Publisher Full Text | Free Full Text - Peart V: There is a wounded healer inside every social worker. Social Work News, 2023; (Accessed: 4 April 2025). Reference Source - Perlman LA, Maclan PS: Vicarious traumatization: an empirical study of the effects of trauma work on trauma therapists. Prof Psychol Res Pr. 1995; 26(6): 558–565. Publisher Full Text - Pilowsky DJ, Wu LT: Psychiatric symptoms and substance use disorders in a nationally representative sample of American adolescents involved with foster care. J Adolesc Health. 2006; 38(4): 351–358. PubMed Abstract | Publisher Full Text | Free Full Text - Rahman SA, Tuckerman L, Vorley T, et al.: Resilient research in the field: insights and lessons from adapting qualitative research projects during the COVID-19 pandemic. Int J Qual Methods. 2021; 20: 1–16. Publisher Full Text - Ritchie J, Spencer L: Qualitative data analysis for applied policy research. In: Bryman, A. and Burgess, R.G., eds. Analyzing qualitative data. London: Routledge, London, 1994; 173–194. Publisher Full Text - Ritchie J, Lewis J: Qualitative research practice: a guide for social science students and researchers. Sage, 2003. Reference Source - Rubin HJ, Rubin IS: Qualitative interviewing: the art of hearing data. (2nd ed.). Thousand Oaks, CA: SAGE Publications, 2005. Publisher Full Text - Saarijarvi M, Bratt EL: When face-to-face interviews are not possible: tips and tricks for video, telephone, online chat, and email interviews in qualitative research. Eur J Cardiovasc Nurs. 2021; 20(4): 392–396. PubMed Abstract | Publisher Full Text | Free Full Text - Scullard P, Abdelhamid A, Steel N, et al.: Does the evidence referenced in NICE guidelines reflect a primary care population? Br J Gen Pract. 2011; 61(584): e112–e117. PubMed Abstract | Publisher Full Text | Free Full Text - Sellers SL, Hunter AG: Private pain, public choices: influence of problems in the family origin on career choices among a cohort of MSW students. Soc Work Educ. 2005; 24(8): 869–881. Publisher Full Text - Silverio SA, Sheen KS, Bramante A, et al.: Sensitive, challenging, and difficult topics: experiences and practical considerations for qualitative researchers. Int J Qual Methods. 2022; 21: 16094069221124739. Publisher Full Text - Stanley N, Riordan D, Alaszewski H: The mental health of looked after children: matching response to need. Health Soc Care Community. 2005; 13(3): 239–248. PubMed Abstract | Publisher Full Text - Thomas JT: Adverse childhood experiences among MSW students. J Teach Soc Work. 2016; 36(3): 235–255. Publisher Full Text - Thunberg S, Arnell L: Pioneering the use of technologies in qualitative research – A research review of the use of digital interviews. Int J Soc Res Methodol. 2021; 25(6): 757–768. Publisher Full Text - Tomas V, Kingsnorth S, Kirsh B, et al.: Using the COM-B model and theoretical domains framework to understand workplace disclosure experiences, influencers, and needs among autistic young adults. J Autism Dev Disord. 2023; 53(12): 4772–4786. PubMed Abstract | Publisher Full Text | Free Full Text - Van der Voort A, Tessensohn LM, de Jonge MV: Studying voices of middle childhood online: conducting online video-based focus groups with children. Int J Qual Methods. 2023; 22. Publisher Full Text - Vinnerljung B, Hjern A, Lindblad F: Suicide attempts and severe psychiatric morbidity among former child welfare clients – a national cohort study. J Child Psychol Psychiatry. 2006; 47(7): 723–733. PubMed Abstract | Publisher Full Text - West R, Michie S: A brief introduction to the COM-B model of behaviour and the PRIME theory of motivation. Qeios. 2020; 1–6. Publisher Full Text - Williams V, Tarleton B, Heslop P, et al.: Understanding disabling barriers: a fruitful partnership between disability studies and social practices? Disabil Soc. 2018; 33(2): 157–174. Publisher Full Text - Wright KB: Researching internet-based populations: advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services. J Comput Mediat Commun. 2005; 10(3): JCMC1034. Publisher Full Text Author details Author details 1 The University of Manchester Division of Psychology and Mental Health, Manchester, England, UK 2 The University of Manchester Division of Nursing Midwifery and Social Work, Manchester, England, UK 2 The University of Manchester Division of Nursing Midwifery and Social Work, Manchester, England, UK Gill Lever Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation Dawn Dowding Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Dharman Jeyasingham Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Christopher Armitage Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This project is funded by the National Institute for Health Research (NIHR) under [GM-PSRC and ARC-GM (Grant Reference Number R128571*BE02, R123859 GA0701)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright © 2026 Lever G et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. metrics VIEWS $counts.viewCount downloads Citations CITE how to cite this article Lever G, Dowding D, Jeyasingham D and Armitage C. Protocol for a mixed methods study to examine social workers' implementation of national guidelines with children in care who self-harm [version 1; peer review: 2 approved with reservations]. NIHR Open Res 2026, 6:15 (https://doi.org/10.3310/nihropenres.14109.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 16 Feb 2026 Views 0 How to cite this report: Huber RS. Reviewer Report For: Protocol for a mixed methods study to examine social workers' implementation of national guidelines with children in care who self-harm [version 1; peer review: 2 approved with reservations]. NIHR Open Res 2026, 6:15 (https://doi.org/10.3310/nihropenres.15342.r39725) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/6-15/v1#referee-response-39725 https://openresearch.nihr.ac.uk/articles/6-15/v1#referee-response-39725 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 01 Apr 2026 Rebekah S. Huber, Oregon Health & Science University, Portland, Oregon, USA Approved with Reservations VIEWS 0 Summary This is an interesting and important proposed study. The focus on self-harm of children while they are in care is very important, however, this focus was not always clear in the abstract and introduction, and the breadth ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close This is an interesting and important proposed study. The focus on self-harm of children while they are in care is very important, however, this focus was not always clear in the abstract and introduction, and the breadth ... Continue reading Summary This is an interesting and important proposed study. The focus on self-harm of children while they are in care is very important, however, this focus was not always clear in the abstract and introduction, and the breadth of the population ("children with and without care experience") would benefit from further clarification. The background literature cited to support the elevated self-harm risk also requires clarification, as it is ambiguous whether the findings apply specifically to children during care placements. A persistent gap throughout is the lack of explanation of the NICE guidelines. It is never made clear what they are or how social workers are expected to implement them. Importantly, the research questions will not be answered by the protocol and cannot be answered unless there is a change to the inclusion criteria. Restricting the sample to social workers who have already supported a child who actively self-harmed excludes a large portion of the workforce and introduces significant sampling bias, preventing any conclusions about awareness or implementation at a population level; including all social workers and stratifying by experience would be a stronger approach. Finally, sharing the survey questions would help determine whether the instrument is sufficiently aligned with the research questions, though the mixed-methods approach is a notable strength of the protocol. Below are considerations for each section of the protocol.

Background -There are many different research questions that are introduced in this section, and the aim is a little unclear -Children with and without care experience is quite broad and more information would be helpful to understand the type of care they are engaged in -What are the NICE guidelines?

-Based on the research questions, I would expect the results of this study will inform implementation efforts of the NICE guidelines and not the development of new interventions, however it is unclear what the NICE guidelines are.

-Since this study is looking at self-harm that occurs while being in the care of local authorities for more than 24 hours, it would be important to cite background literature that supports self-harm during care. Based on what was cited, it is unclear if the 2-4-fold higher risk is for self-harm is during care or children that have been involved with the care system. -It is still unclear what the NICE guidelines are, suggest including a summary of them in the introduction. Could it be possible that hospitals and clinics base their protocols on the NICE guidelines, but are unaware of the NICE guidelines? Research Questions -Unless they are able to survey all the social works in England, then they will not be able to determine the proportion that are aware and implementing, only what proportion of the survey respondents. Inclusion criteria -Based on the requirement that the social worker had to have at least on child in care that has actively self-harmed does not allow for the research questions 1 & 2 to be answered, as this excludes many social workers -This inclusion criteria will significantly limit the survey sample and will not provide information about all social workers. Suggest including all social workers and then stratifying results by whether they have had a child in care that has actively self-harmed Data collection -It would be helpful to see the survey questions in order to determine if they will answer the research questions -Qualitative data collection and analyses strengthen the protocol and will provide in-depth qualitative information; however, some of the barrier and facilitator information could be collected during the first survey. This is an interesting and important proposed study. The focus on self-harm of children while they are in care is very important, however, this focus was not always clear in the abstract and introduction, and the breadth of the population ("children with and without care experience") would benefit from further clarification. The background literature cited to support the elevated self-harm risk also requires clarification, as it is ambiguous whether the findings apply specifically to children during care placements. A persistent gap throughout is the lack of explanation of the NICE guidelines. It is never made clear what they are or how social workers are expected to implement them. Importantly, the research questions will not be answered by the protocol and cannot be answered unless there is a change to the inclusion criteria. Restricting the sample to social workers who have already supported a child who actively self-harmed excludes a large portion of the workforce and introduces significant sampling bias, preventing any conclusions about awareness or implementation at a population level; including all social workers and stratifying by experience would be a stronger approach. Finally, sharing the survey questions would help determine whether the instrument is sufficiently aligned with the research questions, though the mixed-methods approach is a notable strength of the protocol. Below are considerations for each section of the protocol.

Background -There are many different research questions that are introduced in this section, and the aim is a little unclear -Children with and without care experience is quite broad and more information would be helpful to understand the type of care they are engaged in -What are the NICE guidelines?

-Based on the research questions, I would expect the results of this study will inform implementation efforts of the NICE guidelines and not the development of new interventions, however it is unclear what the NICE guidelines are.

-Since this study is looking at self-harm that occurs while being in the care of local authorities for more than 24 hours, it would be important to cite background literature that supports self-harm during care. Based on what was cited, it is unclear if the 2-4-fold higher risk is for self-harm is during care or children that have been involved with the care system. -It is still unclear what the NICE guidelines are, suggest including a summary of them in the introduction. Could it be possible that hospitals and clinics base their protocols on the NICE guidelines, but are unaware of the NICE guidelines? Research Questions -Unless they are able to survey all the social works in England, then they will not be able to determine the proportion that are aware and implementing, only what proportion of the survey respondents. Inclusion criteria -Based on the requirement that the social worker had to have at least on child in care that has actively self-harmed does not allow for the research questions 1 & 2 to be answered, as this excludes many social workers -This inclusion criteria will significantly limit the survey sample and will not provide information about all social workers. Suggest including all social workers and then stratifying results by whether they have had a child in care that has actively self-harmed Data collection -It would be helpful to see the survey questions in order to determine if they will answer the research questions -Qualitative data collection and analyses strengthen the protocol and will provide in-depth qualitative information; however, some of the barrier and facilitator information could be collected during the first survey. - Is the rationale for, and objectives of, the study clearly described? Partly - Is the study design appropriate for the research question? Partly - Are sufficient details of the methods provided to allow replication by others? Partly - Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Suicide Prevention CITE HOW TO CITE THIS REPORT Huber RS. Reviewer Report For: Protocol for a mixed methods study to examine social workers' implementation of national guidelines with children in care who self-harm [version 1; peer review: 2 approved with reservations]. NIHR Open Res 2026, 6:15 (https://doi.org/10.3310/nihropenres.15342.r39725) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/6-15/v1#referee-response-39725 https://openresearch.nihr.ac.uk/articles/6-15/v1#referee-response-39725 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Views 0 How to cite this report: Russell AE. Reviewer Report For: Protocol for a mixed methods study to examine social workers' implementation of national guidelines with children in care who self-harm [version 1; peer review: 2 approved with reservations]. NIHR Open Res 2026, 6:15 (https://doi.org/10.3310/nihropenres.15342.r39724) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/6-15/v1#referee-response-39724 https://openresearch.nihr.ac.uk/articles/6-15/v1#referee-response-39724 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 13 Mar 2026 Abigail Emma Russell, University of Exeter, Exeter, England, UK Approved with Reservations VIEWS 0 This is a protocol for a mixed methods study that aims to assess implementation of self-harm guidelines by social workers, and with care-experienced children, from the point of view of social workers. The overall plan is good, but there ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close This is a protocol for a mixed methods study that aims to assess implementation of self-harm guidelines by social workers, and with care-experienced children, from the point of view of social workers. The overall plan is good, but there are a number of methodological details that require clarification, and repetition that could be removed.

Consider moving the aim to the end of the background, rather than in the middle, and explain the rationale before the study aim. Is there space to briefly outline analysis methods in the abstract? Will these be separate for the two phases or integrated?

The term ‘children’ is used to describe those age 18 and under, consider using children and adolescents, or children and young people to define your population.

third paragraph- it is unclear whether you mean if the 2004 and 2011 guidance were followed, or if you mean other relevant guidance followed- if the latter, do cite the guidance you are referring to or clarify your meaning. “conducted by this researcher”- there are several researchers in the author list, please use initials to indicate who this refers to. Was this rapid review systematic or ad hoc? This section is confusing- the NICE 2022b reference is to the membership of the guidelines group, I think you are referring to the same thing twice and only need to do so once: “… to date, no studies on awareness/implementation rates of NICE (2022a) guidance on self-harm: assessment, management, and preventing recurrence (NG225) have been identified in the literature. This study investigates adherence to the NICE (2022b) guidelines: Self-harm: assessment, management, and preventing recurrence, which replaced the 2004 guidelines.” Can you add citations to support the assertion that previous research has focused on adult self-harm and health professional implementation? Can you be clear about whether there is any research on child/adolescent populations in relation to health professionals implementing the guidelines? The introduction would benefit from a clear description of why implementation is important to study. Objectives- is the 12-month timeframe in relation to children having care experience, or social workers’ experiences working with children? Please remove “protocol” from above the objectives

There is a lot more information presented for the first phase of research than the second at the start of the methods. Could more be added to the second phase so that the level of detail is similar? Will the study be reported in line with a reporting guideline? Which one? Is the protocol written in line with a reporting guideline? Following one would remove repetition and add clarity. There is a lot of repetition across the objectives, the first sentence of the methods and the first sentence of the study design that could be removed. What do you mean by ‘actively’ self-harmed in the study design section? Presumably facilitators are also of interest (study design section) Perhaps have a subheading for the sections on trauma informed approach, theoretical domains framework and COM-B model of behaviour such as “Theoretical frameworks” or similar to orientate the reader to what these sections are. It is not clear how the COM-B model is being used in the study at this point. Protocols would more typically be design, participants, recruitment, process, analysis etc so clearer headings are needed. It would make sense to have objectives and research questions both at the start of the methods RQs 1 and 2 imply that you are surveying all children’s social workers in England- is this correct? I assume the dates for the study are wrong, otherwise it must have already been conducted. Phase 1: The sample size calculation suggests that the target sample represents all social workers who have relevant experience, essentially 100% of the eligible study population. Is this realistic? The recruitment strategy does not include systematically contacting all social workers and I expect you will have a much lower response rate than the total eligible population. What is the rationale for excluding those working across the devolved nations? Data collection- I do not think an incentive of a prize draw realistically will increase your response rate (and your acknowledgement of low response rate conflicts with your assertion about sample size target above). The incentive is appropriate but I think unlikely to be linked to better response rates. Has the survey been piloted with social workers? How long does it take to complete? There is an unnecessary amount of detail included about the Qualtrics platform, it reads a bit like an advert for Qualtrics. What is essential to know that relates to the study design? I am confused as to why skip patterns are relevant as you say above that all questions apart from item 12 must be responded to. Are you planning to analyse these data? “Information regarding partial survey completion also enables analysis of any trends at which survey abandonment occurs that could indicate a particular survey item being problematic (Couper et al., 2001). Patterns of participants' response times will also be analysed to identify items that may be unclear, as well as exceptionally rapid responses (Burruss & Johnson, 2021) that could be indicative of bots and undermine data validity.” They are not mentioned in the analysis section and you have not proposed removing responses, nor do you have an aim about identifying unclear items. These seem surplus to requirements, although you may wish to delete responses that are completed in a very short timeframe- if so, please include this information. If Qualtrics has a feature where you resume the survey at the point you left off, presumably it is not possible for one individual to submit multiple responses? I am confused as to how you plan to compare the sample to the base population, as in the recruitment section you say you are unable to ascertain the size of the base population- those with experience working with children who self-harm. Comparing to all social workers seems to not be a direct comparison, as there may be particular characteristics that predict working with this population that would not be identified in the whole social work population data? Will an analysis plan be written and followed? I would expect to see precise detail about what the demographic confounders will be, and what the subgroup analyses will be. Will NICE guideline implementation be measured as a binary yes/no indicator? What if participants report implementing this sometimes but not always? Phase 2. How will phase 1 findings inform phase 2, beyond being a recruitment route? This sentence is unclear and needs re-phrasing – “The semi-structured interviews comprising social work participants will be recruited during phase 1 of the research, whereby survey respondents will be asked if they are interested in taking part in a semi-structured interview.” The timeline suggests this study has already been conducted. Why is visual recording needed rather than audio-only? This may be offputting to potential participants. Will participants be purposively selected based on their phase 1 survey answers? Do you have a back-up plan for if you have insufficient numbers of phase 1 respondents willing to be interviewed, or no variation in their awareness and implementation? E.g. recruiting more widely? ill they be reimbursed for their time doing the interview? Add to “at the start of the interview” that the researcher will check they have read the information they were sent. When will written consent be obtained? I recommend that audio-only recording is offered as an option to participants also. Is the researcher experienced in interviewing about emotionally-challenging topics and in identifying distress? If a social worker discloses a safeguarding risk, how will this be managed? Analysis- participant names and any other identifying information should be replaced, not only names. How is the framework approach described going to work with the plan to continue interviews until 3 have generated no new themes? Will analysis start immediately upon completion of the first interview? How will the findings of phases 1 and 2 be synthesized together? Or will they form separate and discrete publications?

Consider moving the aim to the end of the background, rather than in the middle, and explain the rationale before the study aim. Is there space to briefly outline analysis methods in the abstract? Will these be separate for the two phases or integrated?

The term ‘children’ is used to describe those age 18 and under, consider using children and adolescents, or children and young people to define your population.

third paragraph- it is unclear whether you mean if the 2004 and 2011 guidance were followed, or if you mean other relevant guidance followed- if the latter, do cite the guidance you are referring to or clarify your meaning. “conducted by this researcher”- there are several researchers in the author list, please use initials to indicate who this refers to. Was this rapid review systematic or ad hoc? This section is confusing- the NICE 2022b reference is to the membership of the guidelines group, I think you are referring to the same thing twice and only need to do so once: “… to date, no studies on awareness/implementation rates of NICE (2022a) guidance on self-harm: assessment, management, and preventing recurrence (NG225) have been identified in the literature. This study investigates adherence to the NICE (2022b) guidelines: Self-harm: assessment, management, and preventing recurrence, which replaced the 2004 guidelines.” Can you add citations to support the assertion that previous research has focused on adult self-harm and health professional implementation? Can you be clear about whether there is any research on child/adolescent populations in relation to health professionals implementing the guidelines? The introduction would benefit from a clear description of why implementation is important to study. Objectives- is the 12-month timeframe in relation to children having care experience, or social workers’ experiences working with children? Please remove “protocol” from above the objectives

There is a lot more information presented for the first phase of research than the second at the start of the methods. Could more be added to the second phase so that the level of detail is similar? Will the study be reported in line with a reporting guideline? Which one? Is the protocol written in line with a reporting guideline? Following one would remove repetition and add clarity. There is a lot of repetition across the objectives, the first sentence of the methods and the first sentence of the study design that could be removed. What do you mean by ‘actively’ self-harmed in the study design section? Presumably facilitators are also of interest (study design section) Perhaps have a subheading for the sections on trauma informed approach, theoretical domains framework and COM-B model of behaviour such as “Theoretical frameworks” or similar to orientate the reader to what these sections are. It is not clear how the COM-B model is being used in the study at this point. Protocols would more typically be design, participants, recruitment, process, analysis etc so clearer headings are needed. It would make sense to have objectives and research questions both at the start of the methods RQs 1 and 2 imply that you are surveying all children’s social workers in England- is this correct? I assume the dates for the study are wrong, otherwise it must have already been conducted. Phase 1: The sample size calculation suggests that the target sample represents all social workers who have relevant experience, essentially 100% of the eligible study population. Is this realistic? The recruitment strategy does not include systematically contacting all social workers and I expect you will have a much lower response rate than the total eligible population. What is the rationale for excluding those working across the devolved nations? Data collection- I do not think an incentive of a prize draw realistically will increase your response rate (and your acknowledgement of low response rate conflicts with your assertion about sample size target above). The incentive is appropriate but I think unlikely to be linked to better response rates. Has the survey been piloted with social workers? How long does it take to complete? There is an unnecessary amount of detail included about the Qualtrics platform, it reads a bit like an advert for Qualtrics. What is essential to know that relates to the study design? I am confused as to why skip patterns are relevant as you say above that all questions apart from item 12 must be responded to. Are you planning to analyse these data? “Information regarding partial survey completion also enables analysis of any trends at which survey abandonment occurs that could indicate a particular survey item being problematic (Couper et al., 2001). Patterns of participants' response times will also be analysed to identify items that may be unclear, as well as exceptionally rapid responses (Burruss & Johnson, 2021) that could be indicative of bots and undermine data validity.” They are not mentioned in the analysis section and you have not proposed removing responses, nor do you have an aim about identifying unclear items. These seem surplus to requirements, although you may wish to delete responses that are completed in a very short timeframe- if so, please include this information. If Qualtrics has a feature where you resume the survey at the point you left off, presumably it is not possible for one individual to submit multiple responses? I am confused as to how you plan to compare the sample to the base population, as in the recruitment section you say you are unable to ascertain the size of the base population- those with experience working with children who self-harm. Comparing to all social workers seems to not be a direct comparison, as there may be particular characteristics that predict working with this population that would not be identified in the whole social work population data? Will an analysis plan be written and followed? I would expect to see precise detail about what the demographic confounders will be, and what the subgroup analyses will be. Will NICE guideline implementation be measured as a binary yes/no indicator? What if participants report implementing this sometimes but not always? Phase 2. How will phase 1 findings inform phase 2, beyond being a recruitment route? This sentence is unclear and needs re-phrasing – “The semi-structured interviews comprising social work participants will be recruited during phase 1 of the research, whereby survey respondents will be asked if they are interested in taking part in a semi-structured interview.” The timeline suggests this study has already been conducted. Why is visual recording needed rather than audio-only? This may be offputting to potential participants. Will participants be purposively selected based on their phase 1 survey answers? Do you have a back-up plan for if you have insufficient numbers of phase 1 respondents willing to be interviewed, or no variation in their awareness and implementation? E.g. recruiting more widely? ill they be reimbursed for their time doing the interview? Add to “at the start of the interview” that the researcher will check they have read the information they were sent. When will written consent be obtained? I recommend that audio-only recording is offered as an option to participants also. Is the researcher experienced in interviewing about emotionally-challenging topics and in identifying distress? If a social worker discloses a safeguarding risk, how will this be managed? Analysis- participant names and any other identifying information should be replaced, not only names. How is the framework approach described going to work with the plan to continue interviews until 3 have generated no new themes? Will analysis start immediately upon completion of the first interview? How will the findings of phases 1 and 2 be synthesized together? Or will they form separate and discrete publications? - Is the rationale for, and objectives of, the study clearly described? Partly - Is the study design appropriate for the research question? Partly - Are sufficient details of the methods provided to allow replication by others? Yes - Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Child and adolescent mental health, self-harm and suicide, health research, public health CITE HOW TO CITE THIS REPORT Russell AE. Reviewer Report For: Protocol for a mixed methods study to examine social workers' implementation of national guidelines with children in care who self-harm [version 1; peer review: 2 approved with reservations]. NIHR Open Res 2026, 6:15 (https://doi.org/10.3310/nihropenres.15342.r39724) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/6-15/v1#referee-response-39724 https://openresearch.nihr.ac.uk/articles/6-15/v1#referee-response-39724 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | || |---|---|---| | 1 | 2 | | | Version 1 16 Feb 26 | read | read | - Abigail Emma Russell, University of Exeter, Exeter, UK - Rebekah S. 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