Barriers and Facilitators to Using an App-Based Tool for Suicide Safety Planning in a Psychiatric Emergency Department: A Qualitative Descriptive Study Using the Theoretical Domains Framework and COM-B Model

Barriers and Facilitators to Using an App-Based Tool for Suicide Safety Planning in a Psychiatric Emergency Department: A Qualitative Descriptive Study Using the Theoretical Domains Framework and COM-B Model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Facilitators to Using an App-Based Tool for Suicide Safety Planning in a Psychiatric Emergency Department: A Qualitative Descriptive Study Using the Theoretical Domains Framework and COM-B Model Hwayeon Danielle Shin, Keri Durocher, Iman Kassam, Sridevi Kundurthi, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4390525/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Emergency departments (ED) play a crucial role in suicide prevention, with evidenced-based safety planning interventions (SPI) playing an important role. Traditional safety plans, which are often paper based, come with challenges (i.e., not easily accessible, or easy to misplace). Digital safety planning tools offer an alternative mode of intervention delivery, but clinical implementation remains limited. Using behavioural change frameworks, we aim to provide insights into the factors influencing app adoption. These insights will be used as a knowledge base to design behavior change strategies to promote the implementation of a SPI app in a psychiatric ED. Methods We used a qualitative descriptive design to conduct semi-structured interviews with clinicians in a psychiatric ED in Toronto, Canada. Participants encompassed all ED staff, irrespective of their SPI app usage. The semi-structured interview guide was developed using the Theoretical Domains Framework (TDF) and the capability (C), opportunity (O), motivation (M) and behavior (B) (COM-B) model. We then used directed content analysis, identifying findings within the TDF and COM-B domains as barriers, facilitators, or both. Findings: A total of 29 ED clinicians were interviewed, including nurses, psychiatrists, social workers, program assistants, and a pharmacist. The majority had not used the app. We observed strong motivation among clinicians across all disciplines to use the app, and they considered SPI as a high-priority ED care strategy closely linked to their professional identity and responsibility. Anticipated barriers regarding the app as a new mode of SPI delivery in routine practice included: documentation, communication, care efficiency, and patient access to smartphones. Some barriers were attributable to the lack of interoperability between the app and the electronic health record and documentation infrastructure for the app. Conclusion We identified key behavioral factors influencing the implementation of the SPI app in the psychiatric ED. We found that tailored strategies are essential to address barriers, while leveraging facilitators can sustain implementation. Additionally, ongoing monitoring and adaptation of strategies are necessary, as new barriers may arise or facilitators may weaken over time, impacting the sustained use of the app in the ED. We will use these findings to inform the next phase of this work, which involves co-designing targeted and tailored implementation strategies. Mental Health mHealth Mobile Health Technology Adoption Implementation Science Behaviour Change Background Suicide is a major public health concern that affects many people, including those living with suicidal thoughts and those grieving suicide deaths. [ 1 ] Following the definition provided by Silverman et al., the term suicide-related thoughts and behaviors (SRTB) is used herein as an umbrella term to describe a spectrum of suicidal thoughts and self-injurious behaviors, with or without intent, and with or without fatal outcomes. [ 2 ] The intent and motivation for individuals engaging in self-injurious behaviors vary and can evolve, and can fluctuate from moment to moment. [ 3 – 5 ] As such, individuals need to engage in self-management strategies, informal and formal help, and therapies to cope with SRTB. The emergency department (ED) presents a critical window of opportunity to identify those at risk and to provide suicide prevention care. [ 6 ] It may be the most important setting given recent analysis revealing that the highest prevalence (nearly 40%) of deaths from suicide occurs in individuals with physical health problems, [ 7 ] and the ED may be where those patients interact with the health system. In the ED, patients identified at risk undergo a thorough assessment and are directed to appropriate referrals and follow-up arrangements. These individuals also go home with a personalized safety plan, a central, effective intervention for suicide prevention. [ 8 , 9 ] Safety planning intervention (SPI) is an evidence-based intervention that has shown to reduce the risk of suicidal behaviour by up to 43%. [ 8 ] A safety plan is a personalized tool for patients, that is developed collaboratively with providers and helps them identify coping strategies, emergency contacts as well as strategies to keep their environment safe. [ 10 ] At our local psychiatric ED in Toronto, Canada, a paper-based SPI is a standard discharge practice. However, SPI can be improved. Patients often lose paper copies of their safety plans, and some reported feeling uncomfortable reviewing the paper copy of their safety plan in public. [ 11 , 12 ] Similar barriers, specifically regarding the inconvenience of using the paper version of the safety plan from clinicians’ perspectives, have also been reported. [ 13 ] As such, the paper modality of the safety plan implies that it may not be available “at hand” during moments of increased intensity of SRTB. Relatedly, the widespread use of mobile phones introduces a new modality for delivering interventions, which is both acceptable and convenient for many individuals. [ 14 , 15 ]. There are already numerous digital tools available to augment care and/or support individuals in managing their SRTB like apps, telehealth, and wearable monitoring devices. [ 16 – 18 ] The availability of a plethora of new digital tools does not always lead to adoption. Shin et al. identified 66 digital suicide prevention interventions implemented in clinical settings, including EDs, and found several barriers to adoption of digital technologies. [ 16 ] There are both individual and organizational barriers in clinical settings such as clinicians’ technical competence, motivation and preferences for technology, heavy workload, and limited capacity to troubleshoot technical issues promptly. [ 16 ] As such, understanding the barriers and facilitators influencing the adoption of these apps is crucial for successful implementation. Previous research has accumulated evidence on various factors impacting the adoption of digital health interventions, including patient preferences, healthcare provider attitudes, organizational support, and technological constraints. [ 19 – 21 ] However, there remains a need for more nuanced insights into the behavioral influences that shape the adoption of digital tools in clinical settings. For example, it is currently unknown how attitudes, knowledge, and the system in which clinicians practice interact to influence behavior. [ 16 ] Additionally, there is currently a lack of research on barriers and facilitators to implementing digital tools for specific psychiatric concerns, such as SRTB, particularly in acute care settings, such as the ED. [ 19 , 21 ] Additionally, in a synthesis of 81 qualitative research evidence on barriers to adopting digital technologies in mental health systems, only nine were from Canada, and none of these Canadian studies examined implementation determinants for apps. [ 19 ] To address this gap, the present study aims to identify barriers and facilitators for adopting a SPI app using behaviour change frameworks. Drawing upon the Behaviour Change Wheel (BCW)’s Capability, Opportunity, Motivation-Behavior (COM-B) model [ 22 , 23 ] and the Theoretical Domains Framework (TDF), [ 24 , 25 ] we seek to explore the behavioral influences underlying the implementation of a SPI app, called Hope By CAMH. [ 26 ] The COM-B and TDF frameworks are synthesized from 19 and 33 behavior change frameworks, respectively, to explain the complex interplay between individual capabilities, intrinsic and extrinsic motivations, and social and environmental opportunities that influence behavior change. [ 22 , 24 ] Additionally, the BCW provides guidance on how to develop behaviour change strategies based on the identified behavioural influences. [ 22 , 23 ] Although the COM-B and TDF are popular in implementation science research, [ 27 , 28 ] they have yet to be used in digital tools for suicide prevention to inform implementation strategies. By using these frameworks, we aim to provide comprehensive insights into the factors influencing app adoption that will be used as a knowledge base for the design of theory-informed behavior change strategies for promoting the implementation of SPI apps in clinical practice. Methods Design A larger, two-phased study is being conducted to develop theory-based strategies for implementing the app into routine clinical flow at a local psychiatric ED in Toronto, Canada. Complete study methods have been published elsewhere, [ 29 ] and this paper presents the results from the first phase of this study. This phase used a qualitative descriptive study design to assess clinicians’ barriers and facilitators to using the app to complete the SPI in the psychiatric ED before discharging patients to home. We used the consolidated criteria for reporting qualitative research (COREQ) checklist to prepare this manuscript. [ 30 ] Setting The study took place in a psychiatric ED in Toronto, Canada, which offers 24-hour psychiatric acute care services. This setting is unique as it is Ontario’s only stand-alone psychiatric ED, providing care to approximately 1,300-1,500 adult patients every month. About 60% of patients in the ED’s Extended Observation Unit are admitted for longer stays, while about 40% patients are discharged to home. Furthermore, there are typically between 12 and 40 patients in the ED waiting to be reassessed in the morning on any given day. This ED has a total of 12 inpatient short-stay beds, and is staffed by multidisciplinary care teams, with Registered Nurses and Registered Practical Nurses comprising the largest proportion of the team. The remaining team members include psychiatrists, program assistants, social workers, and pharmacists. Program assistants are unique in this organization; as part of the interdisciplinary team in the ED, they help the unit run smoothly under clinical staff guidance by supporting patient care, promoting safety, engaging in de-escalation, and maintaining a therapeutic environment. The ED operates with a shift-based model with 24 − 7 psychiatrist coverage. During the day shift, this typically involves a team of 6 to10 nurses, 3 program assistants, 3–4 staff psychiatrists, with up to 5 residents and medical students, 1 to 3 social workers, and 1 to 2 pharmacists. Participants and sampling All ED staff were invited to participate in the interviews, regardless of their usage of the app to support SPI. We explored actual barriers and facilitators for users of the app and explored perceived barriers and facilitators for non-users of the app. All clinicians involved in patient care in the ED were eligible to participate, irrespective of their disciplines. We used both convenience and purposive sampling methodologies. Initially, we sought voluntary participation from all ED staff, then adjusted our sampling approach based on the characteristics of the sample during data collection. Due to lower representation from psychiatrists, we issued a targeted call to them and utilized snowball sampling. We aimed to recruit interview participants to reflect the daily staffing of the ED. Additionally, we assessed our recruitment process based on data saturation, as determined by the research team involved in data analysis. We defined data saturation [ 31 , 32 ] as the point in which no additional insights emerge from the interviews and all relevant conceptual constructs within the COM-B and TDF domain have been explored, identified and completed. Recruitment After receiving ethics approval from the organization (REB# 2023/078), we circulated emails to all ED staff about the interview opportunity in September 2023. In the subsequent months, two targeted emails were sent to ED physician groups only. Additionally, we hung posters in high-traffic areas such as washrooms, ED workstations, and staff rooms, as determined by the ED Advanced Practice Nurse. To compensate for participants' time and the insights they shared, we provided them with a $ 50 e-gift card. Procedures We developed the interview guide based on the COM-B, and the TDF, as well as the previous scoping review findings (Additional file 1). [ 16 ] Interview questions were designed to identify influences of our target behaviour, which was using the app to complete SPI in the ED prior to discharging patients to home. Additional questions specific to equity considerations were added. For example, differing digital literacy skills among patients can create gaps in realizing the benefits of the app. We explored clinicians’ perspectives on their professional responsibility for providing technical support to patients. The consent form was completed using REDCap following our organization standard. Participants had a choice of in-person (i.e., ED site private office room), telephone or video-call interviews. The interviews lasted between 25 and 70 minutes and the first author conducted all interviews. Interviews were audio-recorded, transcribed verbatim, and anonymized prior to analysis. Data Analysis We analyzed interview transcripts using a directed content analysis, [ 33 ] following the established guideline to use TDF and COM-B as a codebook [ 25 ] in NVivo 12. First, four reviewers (HDS, KD, IK, SK) read and independently coded four transcripts as a calibration exercise. Then, each of the remaining transcripts were independently coded by two reviewers. Reviewers were master’s-prepared nurses and health informatics researchers with extensive experience in qualitative research. Reviewers and first author met to discuss and resolve any interpretation discrepancies. Once all codes were compared for consistency, we then generated participants’ specific beliefs within the TDF domains and indicated whether it is a barrier, facilitator, or mixture of both for influencing the target behaviour. Results A total of 29 ED clinicians were interviewed, including nurses (n = 14), psychiatrists (n = 7), social workers (n = 2), program assistants (n = 5), and a pharmacist (n = 1). Nearly half of these clinicians (n = 14) had between five and 20 years of clinical experience, while the remaining half (n = 15) had less than five years of experience. Most of the participants had not used the app. Participants identified themselves as men (n = 11), women (n = 17), and questioning (n = 1). See Table 1 for participant characteristics. Table 1 Characteristics of N = 29 clinicians Characteristics N % Clinical role Nurse 14 48.3 Psychiatrist 7 24.1 Program Assistant 5 17.2 Social Worker 2 6.9 Pharmacist 1 3.5 Gender Man 11 37.9 Woman 17 58.6 Questioning 1 3.5 Age < 30 13 44.8 30–39 9 31.0 40–49 5 17.2 50–59 1 3.5 Racial background* White 14 48.3 Racialized (examples shown below) 16 55.2 East Asian 7 24.1 South Asian 5 17.2 Other categories include Southeast Asian, Black, Latin American, Middle Eastern Prefer not to answer 1 3.4 Years of experience in the current professional role < 5 15 51.7 6–10 6 20.7 11–15 7 24.1 16–20 1 3.5 Current working hours Full-time 20 69.0 Part-time 8 27.6 Casual 1 3.4 Years of experience working in the current ED < 5 19 65.5 6–10 5 17.2 11–15 5 17.2 *Non-mutually exclusive category The following section describes how the data maps onto the COM-B model and TDF, and a comprehensive list of barriers and facilitators along with additional quotes can be found in Table 2 . Table 2 Barriers and facilitators to using the app to complete SPI in the ED Domain TDF Theme Subtheme Barrier (B) / Facilitator (F)/ Mixed (M) Example Quotes Capability Knowledge Limited awareness of the Hope app* B "So what I know is, it's a free phone app that anyone can download. And there's some tools on it. Like suicide safety planning. And I believe there's breathing exercises, grounding exercises, and perhaps some maybe quick phone numbers for the hotlines. That's from my memory." [011] "I don’t know much about them. I think this is the first I’ve actually ever heard of an app used for safety planning, like the type of safety planning that we use in the emerg. " [012] "I didn’t know anything about it until I read your email. But I all I know is that it’s related to creating safety planning for patients. " [016] Knowledge and skills Demonstrated knowledge and skills for safety planning using the paper F "Safety planning, the purpose of that used in the emergency is to understand the client and their individual needs and what we can do to prevent further safety risks. That allows the clients to be more involved in their own care as well." [004] "What the warning signs are, coping strategies. What their support system looks like. How they can keep themselves safe, their reasons for living. What they could do, what they're in crisis, and who they can reach out to when they're in crisis" [013] Memory and decision making Decision making and prioritization of tasks including safety planning M "I'm supervising a whole bunch of residents who have urgent issues to tell me about. I also need to be available for the nurses. And then I have to also be seeing patients on top of that. I get limited in how much I can get done or what I need to prioritize." [026] "If they were willing to get the app, it'd be easier to click through the options versus sitting with them and trying to explain a physical paper making them write it out. But I think it would really depend on the population. You have a teenager that would probably be fine. I'll download an app and then just click through it. That would be faster than sitting with them with a paper, but if you had maybe somebody that's not as familiar with technology and doesn't use their phone very often that doesn't know how to even connect to Wi-Fi, then trying to download an app and explain it, wouldn’t it be practical for them? But if there was the either or option of either the app or the paper and not both, and I think depending on the client, it could be easier or harder, " [028] "It's like a tool, right, it's like a toolbox. You open your toolbox and use a special tool for whatever you need, right. It's not a universal obligation for you. As a professional you figure OK, for this individual, this might work for this individual who's probably not be able to access this app or access email if somebody, some person lives in a shelter, who has no phone, has no laptop or tablet, maybe has no email address either, probably paper copy will be better to keep on them. But majority of people probably should be able to utilise this app." [002] Remembering the app especially in the beginning phase of change B "I think, to be honest, we see so many random posters and signs everywhere, it's easy to just kind of tune them out." [003] Behavioural regulation Opting for the quickest way, and breaking habit B "I can see how, if staff is busy, if you have eight patients you need to run between, it's easier to hand the patient here, a paper form and say, “Here, do it” rather than a patient be coming back to you, “How do I do this? How do I download it? My Wi-Fi is not working.” Yeah, I can see how it can be a barrier, but with technology improving, maybe Wi-Fi gets more stable here. Because quite often, they ask you for a password and all that stuff and password expires." [002] Motivation Belief about capabilities Level of technical confidence in using the Hope app F "I don't have any problem with the technology of it. I think if I were to put in the time and the effort, then absolutely, it could work." [009] "I have helped people download it" [012] "For me very easy. I think it's not confusing at all. " [012] "Right now, if I were to a scale of zero to 10 in confidence, I'd say maybe a seven. And that's only because I don't even know what the app is. I've never seen the interface" [004] Belief about consequences* Perceived level of workload changes and difficulty in using the Hope app M "I think it might be actually easier, sometimes, because we don’t have to run back, like, physically run back and forth to, like, grab the paper, get the pencil. And we can just, hey, like, try using this. Like, it’s pretty self-explanatory – you can spend time using it and you can just click" [016] "No, I don't think that's a huge workflow increase, no. Workload increase, no." [007] "I think it requires more time to actually move from talking about the safety plan to completing it. Because you've introduced the idea of it. And then the nation is – first of all, they need to get their phones, sometimes they don't have their phones on them, then they have to connect to the Wi-Fi, and that's kind of a pain sometimes. Then they look for the app, they download the app, that can take some time. And then it's kind of like, for that whole interaction, the clinician is just kind of sitting there waiting, right. And it doesn't really make sense for the clinician to leave and then come back in a few minutes. Because that's kind of an awkward amount of time, where it doesn't really give them an opportunity to work on anything else" [003] "I think the practice change is going to be relatively easier. Because from my perspective, it just comes across, like I said, of having a tool on hand in my pocket, that will actually help me explain a safety plan better. And then I still have the option of offering the paper copy, which I generally offer anyways. The only thing is it requires more time." [003] "I think we are technology savvy enough for each team member to if they need to sit down and show the patient how to use it. But that also takes time and that’s the thing that’s in short demand in the [ED]. So everybody is just so busy. So initially, just kind of sitting down and going through with patients how to use it, I can imagine staff members will feel like that’s another burden on their time. " [017] "I think it might create new workload, in the sense of you might have people have, staff having to help patients figure out, how to download the app, how to open the app. And I think staff might see it as a more time consuming task." [009] "I think it'll be hard, just because the idea of paper safety planning is so ingrained, and I think it's been going on for so many years... ... I think just when you get down to it, it's not that much effort, I suppose to download an app and open it up. But I think in the perception of people who are very busy, nursing is always so busy in the emerge, they might see all the extra step of you have to get the patient to download the app, then you have to open me up and presumably you'd have to check the app after they're finished, to read that they've done the safety plan. Just at a glance, it would seem a lot more work. " [009] " I feel that it's a practical tool and the steps that it takes to put it on our phone and review it, it's not too heavy, it's not too intensive. It presents nicely, I don't think it would be difficult." [012] "If, let's say you're the client, you come in, your phone was never used, or you don't know how to connect to Wi-Fi. Now I have to take away maybe five, 10 minutes, sit down with you, connect it with Wi-Fi. If you're unfamiliar with Wi-Fi, I have to explain that to you. And in that situation, I think you would probably give me your phone, I would do everything and just give it back to, and you have the app and you do it. That interaction itself would be five, 10 minutes" [004] "I think – like, when it comes down to time, not everyone has the time to actually sit down for – I guess, a [unintelligible 00:08:37] amount of time to be able to – that would be a situation where I feel like you’re teaching a patient as well as trying to... maybe just assist them in filling out this information. And I feel like that could double the time that it could take to actually just fill it out if it was just paper. If that makes sense. " [025] Uncertain benefits of safety planning beyond discharge B "Or maybe their situational factors are just too overwhelming for them in the moments where they presented, to the point where they weren't really able to use the safety plans. In those kinds of cases, trying to engage patients in a pen and paper plan felt more like a formality. And it felt like I was doing it partially because of a responsibility or a checkbox, and less because I really thought it would change the trajectory of care for the patient" [003] "It’s honestly hard because if it’s successful, like, a lot of these people might not even come back to the ED. " [021] "It would be great to survey people who have actually downloaded the app, whether or not they find it useful. I don't know. Because I never been in that sort of emotional predicament where I'm needing a safety plan for myself. So I don't know whether it's useful. I mean, objectively, it looks like it should be useful. But I don't know whether we have feedback from end users" [007] Perceived benefit and disadvantages of the Hope app M "I think the other thing is, as I mentioned, having those toggles of just, oh, yes, this applies to me, this applies to me, might make it a little bit more passive." [009] " people are really excited about it. Patients are really onboard. " [024] better - at hand: " The paper you can leave in your car, in your home, in your bag and or lose it and eventually – with the app, you can always open it up and then remind yourself it's always with you, if you want it, instead of trying, OK, I left my safety plan at home. But now at my parents’ house, I don’t feel safe, I feel distressed and tried to remember what I did. And this way I have it on you. I think that's a big advantage." [002] "I do support going paperless, it's just tough, I think. Then also patients can easily lose that, there is a benefit to the app in the sense that those who have phones have their phones with them all the time. The app – I think there's obviously some people who don't have phones or can't figure out their smartphones." [009] " I feel the app is really great, because it's just easier to have in one place, especially when they're on their phone, and they can send it directly to whoever right away. And sometimes it's just helps. It's more than that. It's better than writing because sometimes they can get so stressed out that they get fed up and they don't want to write something" [010] "I think it's so great that they can carry it with them when they leave. Because people –especially people, they don't care about paper like that. They'll throw it out, but on their phone, they can take it everywhere. " [010] "when we're cleaning the rooms, we see so many safety plans left behind." [010] " it's a tool that a client can access wherever they are people, more than likely always have their phone with them. A client can access it no matter where they are and at any time, versus the paper document that probably gets shoved in a drawer. And the client will forget about and not take seriously. At least it's something that can be accessed anywhere. And that's helpful for the team to remind the person, the client that this safety plan is with them at all times. And it's instantly accessible. I think it just helps the team because it helps us reassure the client that the plan is with them at all times." [012] "I mean, when would they use it again? Only in moments of crisis, right. And in moments of crisis, they would be here. I think if this was more scheduled somehow as a weekly check in. If you guys could navigate for every so often, depending how high the safety risk, just have the app check in on them and see, hey, are these still your safety plans? Do you still feel the same way? Because if this is a one moment of the thing, it doesn't really serve too much purpose for the individual, more so for the clinician." [003] "I think it's useful, more mostly in the clinician’s perspective, as opposed to the patient's perspective. And that's only because, like I mentioned that piece of paper, once we've given it to them, more times than not, they just throw it out, it doesn't actually mean too much to them. I think out of 10 patients, maybe three or four would actually use that as the set purpose, the safety plan." [003] " I will say the biggest thing is patients really like it. And like I said, a lot more than they like the paper. Not that they ever minded the paper, but they really like it, and they really like having it on their phone and being able to open it easily and it feels like, I think, like this comforting thing that you can't lose the way that you would immediately lose the paper. And that it’s a working document and that you can change it" [024] "So the app will increase client engagement, because it allows them, it's kind of like the paper, the paper is also allowing the client to independently be the focus of the care. It's different when I tell you, “Hey, these are the resources. Use them if you want.” Versus you telling me this is my personal one, because what works for you, won’t work for the next person. So the app is just an extension of that, which allows them to do their individual unique safety plan, which is different than other persons."[004] Anticipation of patients' reactions for checking the phone (Reading over patient's phone may not be well-received) B "Looking over somebody's phone is invasive a little bit? Yeah, a little bit. And not everyone might be comfortable to do that or to hold the phone itself or with COVID, germs." [012] "I think it makes it a little bit difficult in the sense that I'd have to go back in and see the patient and read their phone. Whereas in this scenario, it's usually nursing brings me back the worksheet that the patient has completed. And then I just review it, copy it, give the original back to nursing so they can give back to the patient or give back to the patient myself." [009] "Yeah, for me, the only thing I don't like is it sometimes I'd like to write, like, I'll write like, somebody will write the safety plan with a person. So they'll tell me and I'll write it up for them. So I don't know if I would grab a person's phone and tech, like start typing on their phone, necessarily." [027] Beliefs about equity with regard to the Hope app M "My grandfather has a cell phone, but he'd rather write something down and type it into a phone. He doesn't even probably know how to type a text message. So it's nice to have it accessible. So, I mean, the phone helps for younger folks or people that are interested in technology. But that's not the majority, right, unfortunately. Well yeah, we see a lot of homeless people, impoverished people come in with police, they don't have cell phones." [005] "There might be some people who are not very good with English, they might need extra help. And also I’m just assuming this, but the app is probably just in English, right?" [006] "if that patient then decides to come in and use our tablet, because they don't have a phone. And now it's out in the ether in the internet on a server, but they don't have access to technology. If they wanted to send that, where do they go to access technology, when they send it, to access their email? I've met a lot of people that have emails, but no means to access it. Interviewer: So that's why we can't replace paper." [005] "I think using cellphone for the population out there is feasible just because smartphone are so – they are everywhere." [020] Goal Safety planning is high priority for ED care F "the purpose of [safety plan] used in the emergency is to understand the client and their individual needs and what we can do to prevent further safety risks. That allows the clients to be more involved in their own care as well." [004] "I just think that at the end of the day, it's promoting safety, right. So we promote mental health in a way that is not like this daunting cloud? It’s something that you can work towards? Yeah, you're having a rough day, but at the same time, there are ways that you can work towards having a better day tomorrow and the safety plan, is that" [010] "Safety planning in the emergency department. It is always at kind of like top" [018] "Usually it's a requirement for somebody that has depression or suicide. For some sort of history of self harming. Then for sure that they require, a complete safety plan, they can’t even be discharged. So, can't really think of instances that I've seen where it's been absolutely missed" [028] "If there's anything particular – if it's chaotic, sure, it might get missed. But when it's determined by the doctors that a safety plan is required, we have to complete it. ...I don't see the doctors not using it when they clinically determine, OK, we're going to need to do a safety plan for the patient, then that has to be done" [012] Professional responsibility* Professional responsibility for safety planning F "I think it comes from discussions with your team, and the feedback that you get from each other. And reminding each other of opportunities to have a safety plan be discussed. I know that's a little bit vague, but I think it comes with a cultural shift, where we eventually start thinking of safety planning as a therapeutic tool and incorporate that as a focus of our plan for a patient, as opposed to just something that we do before discharge." [003] "I think it’s very important. Like it’s one of our – it should be one of our key assessments that we do as nurses here. Because even though the doctor, you know, is mainly the one who makes the decision about a disposition for a patient, our value as nurses is most of the time like taken into account by the doctors." [012] "Yeah, I think it's – I don't think it should be just a nursing task. I think the psychiatrists could mention [the Hope app]. The social workers could mention it. Nurses could mention it. And even the program assisted staff could mention it. I don't think this is strictly nursing tasks." [014] "I think safety is all of our responsibility. And the Hope app supports patient safety." [015] "I think it's very feasible. Just about making sure that we do it. And how to you make sure well, we have team meetings, social work team meeting. So if we say that this is a goal, we have, seasonal meetings. So at that next meeting, if we say, let's make sure we do this for each client, it's going to be on our to do list." [012] Medical legal M "I don't know if I if they did the hope app. I probably would just say they complete the hope app. And I eyeballed it looks good. And then if there was an adverse outcome, that's all the information we would have, but I think that would be enough for the safety committee. And they would know they could pull up what is the Hope app? The recent version was that look like what would the client have filled? I think that would have been enough medical legally." [027] Shared responsibility to support the Hope app implementation including tech support F "[Tech support is] something that we can all do. Because if we are familiar with the app, and we know how to use it, we should be OK" [010] "we also have other people that can help with some of those things like PAs can help with, with setting up the Internet, they can help them to open the app. And then if they need any more help, they can ask the nurses, so it's not solely on the nursing staff." [013] Variability in how clinicians approach safety planning related to time spent with patients M "Yeah, there are definitely certain days where there's no time, but I think you have to make time. Especially for these vulnerable patients, right. And for me, personally, my practice, I don't – especially these patients that are going through depressive episodes or have suicidal ideation, I never want them to think that I kind of abandon them. So for – the safety planning takes 10 minutes of your time, right, maybe a little bit more. But I don't know, I think it's, I think this is a nurse to nurse question. And everyone's practice is different. But I personally, even if I'm really, really busy, I will try to make time for these people." [014] SPI is important professional role for all disciplines in the ED F "So my role is to help people safety plan, but also to give them some sort of independence to safety plan. I'm not going to give them the answers, I will work with them to get the answers. But yeah ultimately, I really try to encourage people to safety plan by themselves, because nurses aren't going to be there with you forever, right. Patients also have to be self-sufficient, right. And one of the things that's really important about safety planning is that you don't coddle patients, you let them have their independence and do it themselves. I think that's really important." [ 14 ] "I think emergency nurses are special because, you know, they work with patients for a brief period of time but they have to build the relationship really quickly and probably spend more time with patients than the physicians do. So nurses are really well positioned to take the lead on supporting patients with the Hope app. " [015] " I’m working here, like an ED, I feel like anyone that comes to seek for help, like, I feel obligated to do my best to, like, keep them safe. And just because they come at the lowest moment of their life and, like, I’m able to help – that’s great. But if I don’t do enough then, like, I question myself, like, you could have done better. Like, you could have spent more time with that person. Or just because I was preoccupied with something else and I couldn’t spend more time with that person, that person could have gotten better care. So I feel like safety planning is part of me doing my obligation in by sitting with them and just go through the questions with them. " [016] "Not to stop using paper for people who prefer it or don't have another option. And to still provide that. Like again, the process of the safety plan and the mental process of working through it is a lot of the intervention, so even if they do lose it, I do believe that a lot of people that way at least can generate it again. So, it still was helpful. "[024] "Safety planning in general. I mean, I think that that's part of our assessments, that's really the sort of bread and butter of what we do in the emergency department" [007] "Yeah, I just – I mean, safety planning is really important, right? We don't like to leave – we don't like to let people leave hospital if they're not really to safety plan. And as a nurse, especially as a mental health nurse, I feel it's my due diligence to safety plan, and the Hope app is something that they'll always have with them. So yeah, it's a really good way to Safety Plan." [014] Optimism/ pessimism Personal preference towards digitizing healthcare services including safety planning M "if it’s not integrated with the health record it’s – like, we would prefer paper because paper gets stand in." [015] "I even myself, like, prefer writing, like, on the paper." [016 "Yeah, for me, the only thing I don't like is it sometimes I'd like to write, like, I'll write like, somebody will write the safety plan with a person" [027] "I'm getting kind of tired with technology. And so maybe like what resistance do I have as a, I think my biggest resistance is probably paper to me feels a bit more therapeutic than a computer screen. Also, given the documentation doesn't get into the charts. So it doesn't feel as it might be more worthwhile for the patient. But from a clinician perspective, having a in the chart to me is very important." [027] Opportunity Social opportunity Communication for safety planning B "There's suicide risk assessment and suicide evaluation. But there's no checkbox for was a safety plan administered? Or should we do it? It's just case by case? We feel in the moment that clinically it's a necessary tool, then we'll, the doctor will say let's do a safety plan or the social worker would say let's do a safety plan. Then we do it and then review it." [012] "I was just saying sometimes, I guess, we – like in my experience, every time a safety plan needs to be done the doctor has told me, “Can you just make sure they fill out a safety plan before they leave?” Other than that time I think I – well I guess it would be based on the nurse’s judgement whether or whether or not the safety plan should be filled out. That’s actually a grey area for me. I'm actually not too sure if it’s every time the doctor says to do one, or if it's based on also if we think that the patient needs to do one. That's a grey area for me." [025] Team culture in the ED F I found the team is really cohesive in the emerge. It’s a really great team to work with. [024] "Communication is important. And our team does that well. And we support each other outside of our roles, because we're family, so. And we try to pass that on to the patients for sure. And once we acclimate ourselves, I don't see any problems rolling it out." [005] "With this new practice change, we have to do, take some time, people get used to it, but then once you're used to it, it's fine." [028] Physical opportunity Lack of access to smart devices among subgroup of ED patient population B "What I'm saying if that patient then decides to come in and use our tablet, because they don't have a phone. And now it's out in the ether in the internet on a server, but they don't have access to technology. If they wanted to send that, where do they go to access technology, when they send it, to access their email? I've met a lot of people that have emails, but no means to access it." [005] "I think a lot of our clients who are homeless, living in shelter, they're chronically getting their items stolen because of the culture in shelters so many of our clients might get one phone and it's gone in a week. Or with people with chronic addiction, they're selling their phones. " [012] "I think the barrier, from my perspective, is that is that is that people need to have a smart, smart device. Yeah. Or phone. I think that's, I know that probably most people do now, but we also do work with people who are experiencing homelessness or poverty. So not everybody has access to that. And then and then like, like, you know, and like I said earlier, like people can have technological challenges, which again, we can help problem solve. But sometimes people just don't like to use apps and that's a preference thing" [029] Busy ED setting and being understaffed, need for prioritizing multiple tasks B "But I think during very peak periods of busyness, they won't use it, because they forget, or it will just be too though they'll opt for like the quickest thing to do, which would be like grabbing a piece of paper." [001] "And I feel like it’s something that shouldn’t be rushed but it ends up being rushed because we – like, even today we have, like, five, six discharges happening at the same time. And if that’s the only thing that’s holding them back then, like, hey, as long as we have something on the paper then, like, you can go." [016] Lack of documentation infrastructure in the EHR for the Hope app B "I think downloading an app should be fairly simple. I think most people in emerge would be fine with that. One other issue that I'm just now thinking about is that, as I mentioned, we like having the safety plan to put in the file. We like having – before I discharged someone, I like seeing that they filled out the safety plan. And if it's on their phone, I kind of wonder how I would be able to see that? Would I have to go and look on their phone in order to see that they filled things out? Because that sounds like it would be – it's a lot easier then for the patient to say they'll do it, and then not fill it out." [009] "I think tools like a pop up reminder or a tab can be added to our multidisciplinary assessment." [011] "But if it does become placed into the multidisciplinary assessment, which is the tool that we do for every emerge visit, if it's part of that standard checklist of things to do, then it's part of what we have to do so then it's not, it won't be overlooked." [012] Wi-Fi connection in the ED B "I think the most challenging part is getting access to the Wi-Fi, because it’s like a long code to type. And then some patients, they can't see properly so then we’ll have to take their phones and then we’ll type it in for them. " [023] “Yes, like I said, so if the patient was really eager to get discharged, telling they can stay safe. But I want to see a safety plan before they go. But now they're telling me, “Well, I can't seem to download it. The internet’s really spotty.” Then we're kind of at, like, a difficult situation where I technically, I don't have grounds to keep them. I can't really imprison them in the hospital to do this app. To finish this.”[026] Organization culture - Alignment of the Hope app's purpose with the organizational value and goal F "I think it fits with the organisation in the sense that [the organization] is continually striving to innovate the way that care is provided. So as I mentioned, it makes sense as generations change and things become more digital." [009] App-specific Layout, usability, resources, F "It's pretty straightforward, I think that's what matters. And like I said before, it's, multiple choice is always easier than to come up with something, less time consuming" [002] "Yeah, it's pretty user friendly," [007] Lack of translation function in the app B "The multi language could be useful. Because that eliminates the needs of getting it translated and all that stuff." [020] "I noticed there are a lot of language barriers as well. So, maybe just having an option to translate the page or the app. Or I don't know if that's a feature that will be with the phone. Like, if the phone is set to French will the app be installed with French language built into it?" [023] Toggle options in the safety plan M "I think one of the challenges that I've encountered is, depending on how engaged the patient is with the process of coming up with a safety plan, and what their mental status is, they may have difficulty coming up with items that they can put on the list. For example, someone presenting in crisis might say something like, “Oh, I have no one supportive in my life.” And they would have a really hard time coming up with resources or people or clinical team members who would be able to support them if they were ever in crisis in the future. So in a way, I think having options that are presented to them, can be really valuable." [003] "The one other thing that I was just thinking of, I like that you have the little toggles to decide, if that applies to them, and then at the end, it's optional to write in. Actually kind of feel like it's sometimes beneficial that on the worksheet, it's totally blank. And they have to think and write it in. Whereas they feel like there might be a passive kind of just, yeah, sure, sure, like checking off a bunch of ones. And it's hard to tell then if the safety planning was really thought through." [009] "I think the other thing that actually is a con of the app, in my opinion, is actually having the choices there may make the clients, it might be easier for them to not really actually think about it, if that makes sense. Like we're actually doing a paper form, even though because there's no options, they have to come up with them. So it's more spontaneous, they actually have to think about it. Whereas this app, there is a small risk. I think it's small, but a risk that like you, or I could just click on the thing, and then just toggle whatever we think and even if we're not really processing, like, do we actually mean that? Does that actually apply for us? You know, yeah, so that's the only other risk I see."[029] Social opportunity Leadership support for change management F "I think that people, if you make it mandatory, and you make all of us attend, I think that'll be easier than a sticker on – you can still have the poster on the wall."[010] "it’s called ED Communications. And then in that email, there’s always like a section about, you know, this is a change in practice and then she kind of types it out, describes it. For example, if it was for the safety plan it would be like, you know, “Usually we do safety plan by paper but now we’re doing something new using the app.” "[012] "I don't really have anything to add to that, because our team is pretty good. And if [leadership team] asks us to implement something in our practice, I think everyone is pretty good about it." [014] "I think if we can, you know, get people on board with it through leadership, like, endorsing it, through physician leadership endorsing it, some champions, maybe, or whatever we want to call them, then yeah, I think it could work well. But it will take time. Practice change takes a lot of time." [015] Patients' readiness for safety planning B pretty much sometimes patients who don't want to be discharged, they will sabotage the discharge by refusing to participate in the safety plan or so on. I think that's the biggest challenge sometimes, if someone doesn't want to leave, and the doctor insists on leaving, and a part of the discharge, conditional being discharged, completing a safety plan. So that could be a challenge. [002] " And there’s been instances where they, for example, just say that there’s nothing. Like they can't fill it out at all, they have nothing to write. And that becomes a little bit tricky to kind of persuade them. Especially when we're really rushed in the emerge and there’s so many other clients to be seen. It can be difficult to kind of engage them meaningfully." [024] Patients characteristics including age, preference, mental health conditions M ". So, I mean, the phone helps for younger folks or people that are interested in technology. But that's not the majority, right, unfortunately." [005] " I got to say, even elderly people with cognitive impairment, if they have a smart phone, this is not a problematic app to use. It is a short download, people find it, they find it easy to use. If they have a smart phone." [024] "I think it depends on the age range. I found with younger clients that are in their teenage years or maybe a bit more reluctant to fill out a physical paper or early twenties they don't want to do it. I'd rather scroll on their phone. So I think the app might actually be a solution to that. It'd be easier to kind of click through the questions and type it versus writing on a physical paper that they're going to lose right away." [028] Alignment of the app's purpose and ED and organizational goal/vision F "I think [the organization] is, is really great like that we were always sort of ahead of the curve, I think. And when people come here, they're always very impressed by all the technology and all the new things that we do. Everything like that. So that's pretty cool."[013] * Means salient themes Capability The COM-B defines psychological capability as the skills, knowledge, and ability to engage in the necessary reasoning and decision-making processes. [ 22 ] Related TDF domains under capability include knowledge, skills, memory, decision making, and behavioural regulation, such as intentional habit breaking. [ 24 ] Clinician’s psychological capabilities influenced their use and non-use of the SPI app. Limited awareness about the app Most notably, reasons for clinicians having not used the app was due to unawareness, even though the app has been available since 2020 and was developed by the organization. This could potentially be attributable to staff turnover in the ED, especially during the pandemic; there are occasional new staff members, and residents rotate throughout the health institutions. Even if clinicians had heard about it through organizational emails, they lacked knowledge about the app’s features and contents. Few clinicians knew that the app included wellness activities such as journaling and boxed breathing, as well as community resources tailored to users’ locations, to better support them in managing their SRTB. "So what I know is, it's a free phone app that anyone can download. And there's some tools on it. Like suicide safety planning. And I believe there's breathing exercises, grounding exercises, and perhaps some maybe quick phone numbers for the hotlines. That's from my memory." [011, social worker] "I don’t know much about them. I think this is the first I’ve actually ever heard of an app used for safety planning, like the type of safety planning that we use in the emerg." [012, nurse] "I didn’t know anything about it until I read your email. But I all I know is that it’s related to creating safety planning for patients. " [016, nurse] Memory and decision making Clinicians mentioned that information (i.e., posters, flyers, etc.) about new innovations, like the app, often goes unnoticed due to the abundance of other posters. For this reason, clinicians have expressed concerns that it may be difficult to remember to use the app to complete safety planning, especially during the early phase of implementation and when clinicians are managing multiple priorities simultaneously. "I think, to be honest, we see so many random posters and signs everywhere, it's easy to just kind of tune them out." [003, psychiatrist] Behavioural regulation and habit breaking Clinicians emphasized that in order to transition away from using paper SPI in the busy ED setting, the value proposition must be clear. In other words, the app implementation and use must be easy and more efficient than the current method of delivering safety planning. This also relates to both the physical environment and clinicians' anticipation of future outcomes. Due to the nature of the busy ED setting, clinicians tend to gravitate towards the quickest way to complete assigned tasks, including safety planning. Since the app is not replacing the paper method entirely, this option will always be available. Thus, if instructing patients to download the app or providing technical support to patients proves to be time consuming, clinicians will likely opt for the quicker method, which is using paper. "I can see how, if staff is busy, if you have eight patients you need to run between, it's easier to hand the patient here, a paper form and say, “Here, do it” rather than a patient be coming back to you, “How do I do this? How do I download it? My Wi-Fi is not working.” Yeah, I can see how it can be a barrier, but with technology improving, maybe Wi-Fi gets more stable here. Because quite often, they ask you for a password and all that stuff and password expires." [002, nurse] Demonstrated knowledge and skills for safety planning Since safety planning is a standard discharge practice in the ED, the majority of interviewed clinicians demonstrated knowledge and skills for completing safety planning using paper. Often, nurses, social workers and psychiatrists are directly involved in safety planning. Program assistants, who are not directly involved in safety planning process, also seem to have a good understanding of safety planning and its purpose. “What the warning signs are, coping strategies. What their support system looks like. How they can keep themselves safe, their reasons for living. What they could do when they're in crisis, and who they can reach out to when they're in crisis" [013, nurse] Opportunity Barriers and facilitators within the social and physical ED environment can shape the opportunities for clinicians to use the app to deliver SPI. Physical opportunity is determined by environmental factors such as time, location, and physical and human resources in the ED. [ 24 ] Social opportunity refers to social factors such as cultural and social norms, peer pressure, relationships, and social cues that influence behaviors. [ 24 ] Communication about safety planning in the ED amongst clinical team There is currently no standard method of communicating about safety planning in the ED. Safety planning is not included in order forms in the electronic health record (EHR). Moreover, safety plans can be initiated by psychiatrists, social workers, or nurses. When safety planning is initiated by a psychiatrist and completed by a nurse, communication primarily takes place verbally. Alternatively, nurses sometimes discover that a safety planning paper was provided to the patient by a psychiatrist. This barrier is not specific to app-based safety planning but rather applies to safety planning in general, which may impact the adoption of the app and add an additional layer of socio-technical complexity in routine practice. "There's suicide risk assessment and suicide evaluation. But there's no checkbox for was a safety plan administered? Or should we do it? It's just case by case? We feel in the moment that clinically it's a necessary tool, then we'll, the doctor will say let's do a safety plan or the social worker would say let's do a safety plan. Then we do it and then review it." [012, nurse] "In my experience, every time a safety plan needs to be done the doctor has told me, “Can you just make sure they fill out a safety plan before they leave?” Other than that time I think I – well I guess it would be based on the nurse’s judgement whether or whether or not the safety plan should be filled out. That’s actually a grey area for me. I'm actually not too sure if it’s every time the doctor says to do one, or if it's based on also if we think that the patient needs to do one. That's a grey area for me." [025, nurse] Lack of documentation infrastructure in the EHR for the app Another barrier was related to the current documentation infrastructure in the EHR. Currently, the patient’s paper safety plan is photocopied and scanned into the EHR. If the app-based safety plan were to be used, clinicians were uncertain about how they would document or keep record of the completed digital safety plan in the EHR. Clinicians also discussed the medical-legal responsibilities and the importance of documenting the safety plan. This documentation provides them with an idea of whether patients can be safely discharged to home and allows for the assessment of patients' insights to manage their symptoms. As such, clinicians discussed the opportunity to change or add in a new form within the EHR to document completion of a safety plan. "One other issue that I'm just now thinking about is that, as I mentioned, we like having the safety plan to put in the file. We like having – before I discharged someone, I like seeing that they filled out the safety plan. And if it's on their phone, I kind of wonder how I would be able to see that? Would I have to go and look on their phone in order to see that they filled things out? Because that sounds like it would be – it's a lot easier then for the patient to say they'll do it, and then not fill it out." [009, psychiatrist] Patient populations in the ED Patient population characteristics tend to influence clinicians’ decisions regarding the use of the app for safety planning. Clinicians often mentioned that younger patients who visit the ED would benefit the most from the app due to their widespread use of smartphones and familiarity with apps. Conversely, clinicians assumed that older patients, particularly those who may not be as tech-savvy or reliant on smartphones, might face challenges in engaging with the app for safety planning. This assumption may influence clinicians' decisions to offer the paper version rather than the app. " So, I mean, the phone helps for younger folks or people that are interested in technology. But that's not the majority, right, unfortunately." [005, program assistant] " I got to say, even elderly people with cognitive impairment, if they have a smartphone, this is not a problematic app to use. It is a short download, people find it, they find it easy to use. If they have a smartphone." [024, program assistant] "I think it depends on the age range. I found with younger clients that are in their teenage years or maybe a bit more reluctant to fill out a physical paper or early twenties they don't want to do it. I'd rather scroll on their phone. So I think the app might actually be a solution to that. It'd be easier to kind of click through the questions and type it versus writing on a physical paper that they're going to lose right away." [028, nurse] Lack of access to smart devices among subgroup of ED patient population In addition to patient characteristics and preferences, clinicians also discussed physical access to devices for downloading the app. They mentioned that individuals experiencing homelessness tend to misplace their belongings, but this barrier applies to both modes of SPI. Additionally, there are patients who do not have smart devices (i.e., flip phones) and will require a paper copy of the safety plan. "I think a lot of our clients who are homeless, living in shelter, they're chronically getting their items stolen because of the culture in shelters so many of our clients might get one phone and it's gone in a week. Or with people with chronic addiction, they're selling their phones. " [012, nurse] "I think the barrier, from my perspective, is that people need to have a smart device. Yeah. Or phone… I know that probably most people do now, but we also do work with people who are experiencing homelessness or poverty. So not everybody has access to that… like I said earlier, like people can have technological challenges, which again, we can help problem solve. But sometimes people just don't like to use apps and that's a preference thing" [029, psychiatrist] Wi-Fi and other technical resources in the ED Although the ED has public Wi-Fi for patients' use, clinicians expressed concerns about its speed, noting this as a potential barrier for using the app. Additionally, during night hours, access to the ED Wi-Fi requires a password. This concern is also linked to clinicians' anticipated changes in workload. The current process for accessing public Wi-Fi in the ED is not simple. Therefore, if patients awaiting discharge are delayed due to app downloads, this would not be ideal, especially considering the nature of the ED. “We shut [Wi-Fi] off at night and you need weird passwords, like it's – I'm sure from a security standpoint, it's quite adequate. But in terms of accessibility for patients that are stuck here, the internet is not very good here.” [005, program assistant] "I think the most challenging part is getting access to the Wi-Fi, because it’s like a long code to type. And then some patients, they can't see properly so then we’ll have to take their phones and then we’ll type it in for them. " [023, program assistant] “If the patient was really eager to get discharged, telling [me] they can stay safe. But I want to see a safety plan before they go. But now they're telling me, “Well, I can't seem to download it. The internet’s really spotty.” Then we're kind of at, like, a difficult situation where I technically, I don't have grounds to keep them. I can't really imprison them in the hospital to do this app. To finish this.”[026, psychiatrist] Clinicians also discussed access to computers in the same building for public use, as well as available tablets in the ED. Since the app has an email function to share the safety plan, clinicians talked about alternative ways for patients to access a digital version of the safety plan, particularly for individuals who do not own smart devices but would still like to have a digital copy of the safety plan. “So some do have emails and the access to a computer can be sometimes arranged. They can even come here… …We can do it with them. Or we have some tablets. And we can do that with them so I can leave it with them to do here and email it to me and I could print it out for them. But then I’m not sure if that’s – depending on – it may be better than the one we have now because they can put their own options in and I think that would be the benefit of it.” [018, social worker] Busy ED setting and being understaffed, need for prioritizing multiple tasks The ED is busy most of the time, with clinicians having multiple priorities depending on patient acuity, turnover and staffing levels. While the busy nature of the ED is not an issue specific to the app, it may serve as a barrier due to the added layer of complexity if the implementation process does not streamline the existing procedures. "And I feel like [safety planning is] something that shouldn’t be rushed but it ends up being rushed because we – like, even today we have, like, five, six discharges happening at the same time. And if that’s the only thing that’s holding them back then, like, hey, as long as we have something on the paper then, like, you can go." [016, nurse] “All the little things add to each other. And in the ED, nurses have to be available for the patients, all of the patients they have in case of emergency because code whites and code blues can happen very frequently. So a nurse cannot stay with a patient for a long time to go do all this because they’re expected to do the initial assessment as well” [006, nurse] Team culture in the ED A strong culture of team-based interdisciplinary collaboration is present in the ED. This culture is a significant facilitating factor for implementing new initiatives, including the adoption of the app. Clinicians mentioned how technical tasks, such as assisting patients with accessing Wi-Fi, is often a shared task amongst the team. "Communication is important. And our team does that well. And we support each other outside of our roles, because we're family, so. And we try to pass that on to the patients for sure. And once we acclimate ourselves, I don't see any problems rolling it out." [005, program assistant] “I think it’ll take some change management, for sure. But I think the team is very strong and, like, very open to trying new things.” [015, nurse] “I found the team is really cohesive in the emerge. It’s a really great team to work with”[024, psychiatrist] Leadership support for change management Clinicians spoke about leadership support and how they are aligned with the leadership’s decisions. Clinicians often mentioned that if the app adoption is made mandatory by the leadership team, it will be well accepted by the ED team. “I think the leadership should promote this behaviour because we are not asked to do this with the patient, so we just don’t do it.” [006, nurse] "If [leadership team] asks us to implement something in our practice, I think everyone is pretty good about it." [014, nurse] "I think if we can, you know, get people on board with it through leadership, like, endorsing it, through physician leadership endorsing it, some champions, maybe, or whatever we want to call them, then yeah, I think it could work well. But it will take time. Practice change takes a lot of time." [015, nurse] Alignment of the app's purpose and ED and organizational goal and vision Clinicians unanimously spoke about the alignment of the app’s purpose with the organizational vision. As Canada’s largest academic mental health hospital, clinicians view the organization's vision as leading innovation and staying ahead of innovative trends, including the use of apps. "I think [the organization] is really great like that we were always sort of ahead of the curve, I think. And when people come here, they're always very impressed by all the technology and all the new things that we do. Everything like that. So that's pretty cool." [013, nurse] Motivation Motivation encompasses the brain processes that guide our decisions and behaviors. [ 24 ] The COM-B distinguishes between automatic, such as emotions and impulses, and reflective motivations, including beliefs, values, evaluations, and plans for a target behavior. [ 22 ] Several barriers and facilitators for using the app for safety planning were found to be associated with clinicians’ motivations. Professional role and identity related to safety planning The interviewed clinicians unanimously emphasized SPI as a priority care goal in the ED, closely connected to their professional role and identity in ensuring patients’ safety. Safety planning is already integrated into standard discharge practice and is considered fundamental to the care provided in the ED, described as the “bread and butter” of their work. For such reasons, the introduction of a new modality to improve the portability of safety plans was mostly well-received by clinicians. “Safety planning in general. I mean, I think that that's part of our assessments, that's really the sort of bread and butter of what we do in the emergency department. And safety assessments to some degree, are sort of incorporated into every assessment and discharge that we do… … I think there's a variety, I think there's sort of a spectrum of different safety assessments, as I said, depending on the patient, the provider, the risk threshold, all of these things. But I do think they're incorporated into most if not all of the assessments.” [007, psychiatrist] “I almost feel obligated to – like, it’s not my responsibility to keep people safe at all times. But at least while I’m working here, like an ED, I feel like anyone that comes to seek for help, I feel obligated to do my best to keep them safe. And just because they come at the lowest moment of their life and, I’m able to help – that’s great. But if I don’t do enough then, I question myself, you could have done better. You could have spent more time with that person. Or just because I was preoccupied with something else and I couldn’t spend more time with that person, that person could have gotten better care. So I feel like safety planning is part of me doing my obligation in by sitting with them and just go through the questions with them.” [016, nurse] Despite the importance of safety planning in the ED, variability in its delivery has been identified. Although crucial for all clinicians, the level of interaction provided to patients regarding safety plans differs. There is no prescribed time or amount of time that clinicians need to spend; it varies based on the clinician's discretion, whether the patient requires extra support when completing the safety plan for the first time or is already familiar with it. Therefore, when considering the app version of the safety plan, the amount of time that clinicians feel they need to allocate to each patient may vary. Although this is related to the busy nature of the ED, clinicians view safety planning as an important role regardless of the time allocated to this task. "Yeah, there are definitely certain days where there's no time, but I think you have to make time. Especially for these vulnerable patients, right. And for me, personally, my practice, I don't – especially these patients that are going through depressive episodes or have suicidal ideation, I never want them to think that I kind of abandon them. So for – the safety planning takes 10 minutes of your time, right, maybe a little bit more. But I don't know, I think it's, I think this is a nurse to nurse question. And everyone's practice is different. But I personally, even if I'm really, really busy, I will try to make time for these people." [014, nurse] Considering the new modality, clinicians discussed how they saw technical support as part of their role. Technical support includes, but not limited to, assisting patients with Wi-Fi connection, downloading the app, or orienting patients with the app features. Although these tasks are not traditional 'clinical' roles, clinicians have been providing such support to patients already in the ED due to the ubiquitous use of technologies in healthcare. However, they talked about how important it is to share this responsibility among the team. "[Tech support is] something that we can all do. Because if we are familiar with the app, and we know how to use it, we should be OK" [010, program assistant] "We also have other people that can help with some of those things like [program assistants] can help with, with setting up the Internet, they can help them to open the app. And then if they need any more help, they can ask the nurses, so it's not solely on the nursing staff." [013, nurse] Perceived benefits and disadvantages of the app Clinicians discussed anticipated benefits of the app. Some talked about some patients currently leaving the ED without their paper safety plan, so the portability aspect of carrying it with them via a phone was highly valued. “The paper you can leave in your car, in your home, in your bag and or lose it and eventually – with the app, you can always open it up and then remind yourself it's always with you, if you want it, instead of trying, OK, I left my safety plan at home. But now at my parents’ house, I don’t feel safe, I feel distressed and tried to remember what I did. And this way I have it on you. I think that's a big advantage." [002, nurse] "I do support going paperless, it's just tough, I think. Then also patients can easily lose that, there is a benefit to the app in the sense that those who have phones have their phones with them all the time." [009, psychiatrist] "I think it's so great that they can carry it with them when they leave. Because people –especially people, they don't care about paper like that. They'll throw it out, but on their phone, they can take it everywhere… When we're cleaning the rooms, we see so many safety plans left behind." [010, program assistant] A few clinicians commented on the layout of the safety plan in the app, suggesting that it prevents genuine reflection compared to the paper copy of the safety plan, which requires patients to come up with their own answers. Conversely, some mentioned that the app is more helpful and reduces time because it offers prompts to stimulate patients' thinking. “I just like to know that they've really thought about what responsibility they have in their own safety and what resources are available to them. It's kind of passive versus active learning. Like in the process of them writing out what resources are available to them, they're kind of actively participating in their own safety.” [009, psychiatrist] “I'd say list the strategies and as you come up with those strategies, and sometimes you have to sort of brainstorm with the patients, or often solutions tailored to them. Because if you say to one individual that, “Well, you do this”, “Well, I don't have access to my family, I'm alone in this universe” type of thing. So it can be triggering to some people. But if it's just a select few options, that'll probably limit that, so it’ll be easier, you just tick, tick, tick.”[002, nurse] Perceived impact of safety planning Additionally, there were discussions regarding the anticipated impacts of safety plans in general. As SRTB exist on a spectrum, patients' engagement with their personalized safety plans to manage their daily lives extends beyond the control of the ED team. There appears to be some disbelief or skepticism towards the effectiveness of safety plans, which needs to be addressed despite the existing evidence. "I think it's useful, more mostly in the clinician’s perspective, as opposed to the patient's perspective. And that's only because, like I mentioned that piece of paper, once we've given it to them, more times than not, they just throw it out, it doesn't actually mean too much to them. I think out of 10 patients, maybe three or four would actually use that as the set purpose, the safety plan." [003, psychiatrist] "I will say the biggest thing is patients really like it. And like I said, a lot more than they like the paper. Not that they ever minded the paper, but they really like it, and they really like having it on their phone and being able to open it easily and it feels like, I think, like this comforting thing that you can't lose the way that you would immediately lose the paper. And that it’s a working document and that you can change it" [024, psychiatrist] “I mean, they'll always be the person that thinks that it's rubbish. I mean, patient wise, right. Where they're just like, this isn't going to do anything. I'm going to scribble a couple answers that you like, down on a piece of paper, and you're going to discharge me now. It's like a check mark on the chart. But then there are some people that it's a good point of reflection, and then they rely on those new coping mechanisms when they're struggling in the future.” [005, program assistant] Perceived level of workload changes and difficulty in using the app Clinicians discussed workload changes regarding the implementation of the app. Some believed the app modality would decrease workload by minimizing time to retrieve and scan the paper forms, while others expressed concerns that it would increase their workload due to providing technical support to patients, potentially delaying the discharge process. Uncertainty regarding workload changes was an important consideration to address for future implementation efforts. "I think it might create new workload, in the sense of you might have people, staff having to help patients figure out, how to download the app, how to open the app. And I think staff might see it as a more time consuming task." [009, psychiatrist] “I just think that it would be kind of a little bit time consuming. Of course, we don’t mind, but it’s just that there’s not always going to be that chance to – it might not be even often, but you know, but it would all come down to how the day is going and how busy is that day.” [025, nurse] "I think the practice change is going to be relatively easier. Because from my perspective, it just comes across, like I said, of having a tool on hand in my pocket, that will actually help me explain a safety plan better. And then I still have the option of offering the paper copy, which I generally offer anyways. The only thing is it requires more time." [003, psychiatrist] "I think we are technology savvy enough for each team member to if they need to sit down and show the patient how to use it. But that also takes time and that’s the thing that’s in short demand in the [ED]. So, everybody is just so busy. So initially, just kind of sitting down and going through with patients how to use it, I can imagine staff members will feel like that’s another burden on their time." [017, pharmacist] Anticipation of patients' reactions to checking the phone Another barrier discussed was concerns about patient’s reactions to clinician’s viewing the safety plan on the patient’s personal device. Although it is the clinicians’ responsibility to support patients in developing and going over the safety plan, they were unsure whether it would be appropriate to ask patients to hand over their phone or turn the screen towards clinicians. In either case, clinicians were concerned about how patients would react. Some mentioned that it would be 'invasive', potentially impacting the therapeutic relationship. "I think it makes it a little bit difficult in the sense that I'd have to go back in and see the patient and read their phone. Whereas in this scenario, it's usually nursing brings me back the worksheet that the patient has completed. And then I just review it, copy it, give the original back to nursing so they can give back to the patient or give back to the patient myself." [009, psychiatrist] "Looking over somebody's phone is invasive a little bit? Yeah, a little bit. And not everyone might be comfortable to do that or to hold the phone itself or with COVID germs." [012, nurse] Identifying potential solutions to behavioral change using the BCW Grounded in behavior change theory, the COM-B and TDF facilitated a comprehensive analysis of clinicians’ capability, opportunity, and motivation for app use, shedding light on how these factors interact to influence behavior. We also discovered barriers and facilitators for safety planning itself, identifying important areas for improvement in the ED. It was important to note that barriers and facilitators within the COM-B and TDF domains can interact with each other. In other words, individuals' capability influenced aspects of their motivation, like the level of confidence, and factors related to opportunity, like the social environment or team culture, also influenced motivation to perform the target behavior. For example, physical resources such as slow Wi-Fi in the ED influenced clinicians’ beliefs about anticipated changes in workload, creating a negative emotional response, which influenced the likelihood of performing the target behavior – using the app to deliver SPI. As such, when designing implementation strategies, it is important to think comprehensively about the possible behaviour change solutions to target multiple COM-B domains. [ 23 ] One major gap in implementation science is the absence of theoretical grounding in strategy development, alongside a discrepancy between context and implementation strategies, which frequently leads to inadequacy and unsustainability in implementation. [ 34 ] To understand how the barriers can be addressed and facilitators can be leveraged, we examined suggested intervention functions (i.e., solutions) for the target determinants of behavioral change. Table 3 is informed by the work of Michie et al. [ 23 ] and displays the matrix of intervention functions deemed most relevant to target the COM-B barriers, colored in green. These connections between intervention functions and COM-B domains have been previously established through expert consensus and reliability testing. [ 23 ] We mapped our study findings to the left column according to the COM-B. By using this matrix, we identified appropriate implementation strategies to target the barriers and leverage facilitators to support clinicians’ behavior change. This aligns with evidence-based practice for designing rigorous implementation strategies to make the process of tailoring more effective. [ 35 ] Table 3. COM-B matrix and intervention functions Barriers and facilitators identified from the current study COM-B BCW Intervention Functions Education Persuasion Incentivization Coercion Training Restriction Environmental Restructuring Modelling Enablement Awareness, knowledge, skills, memory, decision making, behavioural regulation and habit breaking Psychological capability Wi-Fi and technical resources, documentation infrastructure, access to smart devices, busy ED, short staffing, patient population Physical opportunity Communication about SPI, team culture, leadership support, organizational vision Social opportunity Professional role and identify, preferences for technology, technical competence Autonomic motivation Professional role and identify, beliefs about consequences for using the app, perceived impact of SPI, goal Reflective motivation The matrix confirms that to address limited awareness of the app, education and training is necessary to support the implementation. Web-based training and informational resources about the app are available within the organization, but these educational tools may require updating and active dissemination efforts in the ED. Training and education are popular implementation strategies for suicide prevention [ 16 , 36 ]; however, it is important to note that addressing limited awareness and promoting familiarization of the app alone cannot lead to successful implementation. There are other barriers we identified that require more attention, such as motivation and opportunity, which are often not adequately addressed and lead to ineffective implementation in ED related to suicide prevention care. [ 37 ] To address concerns related to the busy ED and workload challenges, environmental restructuring may be necessary. Environmental restructuring refers to making changes in social or physical environment. [ 23 ] Possible ideas include making EHR form changes to streamline the SPI documentation process and standardizing communication process that clinicians are concerned about. Additionally, to address skepticism towards the effectiveness of SPI, persuasion may be necessary. Persuasion-type interventions can be particularly helpful in mitigating negative emotions or attitudes. [ 23 ] For example, referring staff to systematic reviews on the effectiveness of SPI and patient testimonials for the app and its impact on their SRTB management can help increase their awareness of the positive impacts that SPIs can have on suicide prevention. Discussion This study involved interviews with 29 ED clinicians, comprising nurses, psychiatrists, social workers, program assistants, and a pharmacist, with varying levels of clinical experience. Most participants had not used the app, highlighting a lack of awareness despite its availability since 2020. Clinicians mentioned staff turnover rate, busy schedules, and an overflow of information as contributing factors to their limited awareness for the app. The study revealed key barriers such as the absence of standard communication methods for safety planning, limitations in EHR documentation infrastructure, and concerns regarding patient access to smart devices and Wi-Fi connectivity in the ED. In addition, clinicians discussed the anticipated consequences of workload changes in an already busy ED setting. Despite the perceived barriers, clinicians expressed positivity to adopt the app, emphasizing its potential benefits in enhancing safety planning portability and patient engagement. Notably, strong team culture, leadership support, and alignment with organizational goals emerged as facilitators for the app use in routine care. These findings underscore the need for tailored strategies addressing clinicians' capabilities, opportunities, and motivations to promote successful implementation of the app in the routine clinical care. Anticipated concern for workload changes associated with the app implementation was one major concern that we heard from many clinicians. This finding is corroborated by a previous qualitative systematic review, which suggests that the integration of new technology can be perceived as creating an additional burden of care, including administrative tasks related to technology. [ 19 , 38 ] Lack of time and additional tasks for a newly introduced technology was also discussed, similar to the current study findings. Additionally, limited infrastructures for supporting new technology implementation in clinical settings [ 19 ] were also similarly identified in the current study. Integrating apps into the EHR is one effective way to support sustainable integration of these interventions. [ 39 ] Various interoperability standards exist to support the linkage of apps with the EHR, such as the Health Level 7 Fast Healthcare Interoperability Resources (HL7 FHIR). [ 40 ] However, this is not always feasible within the healthcare organization, especially as FHIR itself faces its own implementation challenges. [ 40 ] We also identified several facilitators, which represent strengths that can be leveraged for future implementation efforts for the app. Notably, within this ED, we observed a strong sense of professional responsibility, a cohesive team culture, and strong leadership support. While targeted implementation strategies are often customized to tackle identified barriers, as recommended in implementation practice, it is also equally important to capitalize on existing facilitators when supporting implementation. One critical facilitator for technology implementation in healthcare is leadership and team culture. [ 16 , 38 , 41 ] The current study setting is in an advantageous position due the robust leadership support and positive team dynamics. While the lack of leadership support and the absence of positive team dynamics have been barriers in previous mental health app implementations, [ 42 ] in this setting, these factors can be capitalized as strengths to sustain the app implementation and adoption. Despite this strength, it is also essential to consider the non-static and iterative nature of healthcare systems. Sustainability (i.e., long-term use and maintaining benefits) remains to be one major gap for implementation of evidence-based interventions in healthcare. [ 43 – 45 ] Team culture and leadership may evolve over time and new barriers may arise during the implementation process. Therefore, while we can capitalize on and sustain these existing strengths, it is imperative that we continue to monitor them. This includes making necessary adaptations [ 46 ] to the deployed implementation strategies and considering the introduction of new strategies [ 44 ] to ensure the sustainability of the app use for SPI. As more innovative technologies are integrated to augment care, clinicians are increasingly assuming non-traditional clinical roles, such as supporting patients in connecting to Wi-Fi and troubleshooting technical glitches. Although these roles are not traditionally considered clinical, clinicians in the current study reported that they undertake these tasks, nonetheless. This was identified as a facilitator in the current study; clinicians were already providing this technical support to patients in the ED, primarily with Wi-Fi connection. Additionally, there may be added tasks with the app implementation, such as introducing and orienting the app to patients. To ensure the sustainability of the app implementation, further exploration is necessary, as technical support cannot always be guaranteed due to human resource challenges and increasing patient volumes, [ 47 ] potentially limiting clinicians' availability to provide such support to patients. Digital navigators are an emerging area to support the adoption and integration of technologies into care. [ 48 , 49 ] Major roles of digital navigators include technical assistance, [ 48 ] workflow optimization, [ 50 , 51 ] and providing support for digital literacy, [ 52 ] among others. Similarly, in the current study, program assistants were more frequently involved in tasks resembling those of digital navigators compared to other clinical disciplines. To ensure the sustainable implementation of technologies in healthcare, formalizing digital navigator roles could offer potential solutions to address human resource challenges. Clinicians were concerned about potentially infringing upon their patient’s privacy by having to view their patients’ personal device, despite clinical responsibility for assessing the completeness of the safety plan. As SPI is inherently collaborative, even with changes in modality, it is expected to maintain its collaborative nature. As such, the use of apps and other digital tools in healthcare raises questions about how it can be therapeutic and collaborative. [ 53 , 54 ] Additionally, SPI is one critical aspect of discharge planning. Discharge communication is crucial in all healthcare settings, including the ED. Despite this, ED clinicians face unique challenges due to the busy environment. For instance, the discharge process may be rushed, which can contribute to poor discharge communication, [ 55 ] leading to insufficient instructions, [ 56 ] impacting patients' post-discharge health outcomes and increasing return visits to the ED. [ 57 ] Considering the nature of SRTB and the critical window of opportunity for healthcare contact by patients living with SRTB, [ 58 – 60 ] the discharge process must not be rushed. Further exploration is needed to determine how the app can be integrated into clinical workflows. There is a specific need to determine how the app can be introduced in the ED, to maintain the collaborative nature of SPI, and there is a need to determine when to introduce the app during the patient’s stay in the ED. As outlined in the next phase of the study, [ 29 ] such details will be explored and discussed with a team of patient partners, families, and clinicians. Prior implementation studies of SPI apps in European countries have highlighted limited uptake and sustained use of these apps over time, despite their high ratings for usability and acceptability. [ 61 ] Recent research in New Zealand has also shown a positive attitude towards digital tools among mental health clinicians, with smartphone apps being frequently utilized alongside other types of digital tools. [ 62 ] Similarly, clinicians in the current study expressed openness to the app because of its ease of use and their perceived digital literacy skills. Our study explored factors beyond usability and acceptability (i.e., motivation, opportunity) and their relationships, shedding light on potential explanations for the limited uptake and sustained use, and highlighting the importance of considering the dynamic nature of the healthcare system and the individuals involved when implementing new innovations. Additionally, previous research has used the BCW and TDF to investigate behavior change strategies aimed at encouraging primary clinicians to prescribe apps. [ 63 ] Similar to our findings, education and training were identified as necessary strategies to support clinicians in improving knowledge, self-confidence, and skills for using apps. However, none of the behavior change strategies identified in the current literature used rules or restrictions to increase app prescriptions or decrease competing behaviors. [ 63 ] In line with recommendations for behavior change solutions [ 63 ] and the findings presented in Table 3 , our future work will involve design sessions with clinicians, families, and ED services users to identify feasible behavioral strategies. We will ensure that these strategies maintain the theoretical backbone of the solution's design while establishing mutually agreed-upon expectations. [ 29 ] Limitations This study's findings are limited to one ED context, which is unique, compared to other EDs that provide both medical and psychiatric emergency care services. As such, some findings may not be applicable, or there may be additional barriers unexplored due to the nature of the study context. For example, EDs are often described as having a biomedical focus, leading to hesitance and uncertainty from the ED team towards psychiatric care. [ 64 ] There also tends to be a dichotomy of care between psychiatry and medical/physical health care, which needs to be further challenged to promote holistic healthcare. [ 64 ] However, since the ED in this study provides psychiatric emergency health care exclusively, this could lead to a different culture, different attitudes and levels of professional role and identity related to SPI. To accommodate for these contextual differences and to support transferability of our study findings, we have attempted to provide contextual details where appropriate. Conclusion Our study, grounded in behavioral change theory, identified key behavioral factors influencing the implementation of an app to support SPI in the psychiatric ED. These factors encompassed barriers and facilitators that collectively impacted clinicians' capability, opportunity, and motivation. It was evident that tailored strategies were essential to address these barriers, while leveraging facilitators could help support and sustain future implementation efforts. In addition to the identified behavioral barriers and facilitators, our study highlighted the importance of ongoing monitoring and being open to adaptation of implementation strategies. By remaining attentive to evolving clinician needs and organizational dynamics, new barriers could arise, or facilitators might weaken, thus impacting the sustained use of the app in the ED. Declarations Availability of data and materials The raw data supporting the findings of the manuscript can be requested to the corresponding author. The anonymity of the participants must be secured; in the raw data, it is possible to identify the participants, and therefore restrictions will be applied to the availability of these data. Reasonable requests concerning the data can be sent to the corresponding author. Ethics approval and consent to participate The research complies with all the relevant national regulations and institutional policies Ethics approval for the study was obtained from the Research Ethics Board at the Centre for Addiction and Mental Health (REB# 2023/078) and the University of Toronto (REB # 45110). All participants signed an informed consent form after having received written information to enable them to make an informed choice regarding participation. Consent for publication Participants consented to have the findings shared through publications and presentations. Competing interests Authors have no competing interests to declare with this submission. Funding As a Doctor of Philosophy candidate in health services research at the University of Toronto, HDS is supported by the Canadian Institutes of Health Research Doctoral Research Award, the Canadian Behavioural Intervention and Trials Network Doctoral Studentship, and the Registered Nurses’ Foundation of Ontario Research in Mental Health Award. Funding agencies did not have any role in content development. Authors’ contributions HDS, JZ, JT, GS conceived the study design. HDS designed and led data collection, analysis and interpretation. HDS, KD, IK, SK participated in data analysis. HDS wrote the first draft of the manuscript and worked on revisions. JZ, JT, GS provided guidance on all phases of the work. 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Clinical technology specialists. Bmj. 2015;350. Offodile AC, Seitz AJ, Peterson SK. Digital health navigation: an enabling infrastructure for optimizing and integrating virtual care into oncology practice. JCO Clinical Cancer Informatics. 2021;5. Rodriguez JA, Charles J-P, Bates DW, Lyles C, Southworth B, Samal L. Digital healthcare equity in primary care: implementing an integrated digital health navigator. Journal of the American Medical Informatics Association. 2023;30:965–70. Gratzer D, Goldbloom D. Therapy and e-therapy—preparing future psychiatrists in the era of apps and chatbots. Academic Psychiatry. 2020;44:231–4. Cavanagh R, Gerson SM, Gleason A, Mackey R, Ciulla R. Competencies Needed for Behavioral Health Professionals to Integrate Digital Health Technologies into Clinical Care: a Rapid Review. Journal of Technology in Behavioral Science. 2023;8:446–59. Hutchinson C, Curtis K, McCloughen A. Patients’ experiences and reasons for unplanned return visits to the emergency department: A qualitative study. Journal of advanced nursing. 2023;79:2597–609. Hoek AE, Anker SCP, van Beeck EF, Burdorf A, Rood PPM, Haagsma JA. Patient Discharge Instructions in the Emergency Department and Their Effects on Comprehension and Recall of Discharge Instructions: A Systematic Review and Meta-analysis. Annals of Emergency Medicine. 2020;75:435–44. Hutchinson CL, Curtis K, McCloughen A. Characteristics of patients who return unplanned to the ED, and factors that contribute to their decision to return: Integrated results from an explanatory sequential mixed methods inquiry. Australasian Emergency Care. 2024;27:71–7. Stene-Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019;47:9–17. John A, DelPozo-Banos M, Gunnell D, Dennis M, Scourfield J, Ford DV, et al. Contacts with primary and secondary healthcare prior to suicide: Case-control whole-population-based study using person-level linked routine data in Wales, UK, 2000–2017. The British Journal of Psychiatry. 2020;217:717–24. Bergqvist E, Probert-Lindström S, Fröding E, Palmqvist-Öberg N, Ehnvall A, Sunnqvist C, et al. Health care utilisation two years prior to suicide in Sweden: a retrospective explorative study based on medical records. BMC health services research. 2022;22:664. Gryglewicz K, Orr VL, McNeil MJ, Taliaferro LA, Hines S, Duffy TL, et al. Translating Suicide Safety Planning Components Into the Design of mHealth App Features: Systematic Review. JMIR Ment Health. 2024;11:e52763. Rawnsley C, Stasiak K. Unlocking the Digital Toolbox — A Mixed Methods Survey of New Zealand Mental Health Clinicians’ Knowledge, Use and Attitudes Towards Digital Mental Health Interventions. Journal of Technology in Behavioral Science. 2024. https://doi.org/10.1007/s41347-024-00403-z . Alkhaldi O, McMillan B, Maddah N, Ainsworth J. Interventions Aimed at Enhancing Health Care Providers’ Behavior Toward the Prescription of Mobile Health Apps: Systematic Review. JMIR Mhealth Uhealth. 2023;11:e43561. Shin HD, Price S, Aston M. A poststructural analysis: Current practices for suicide prevention by nurses in the emergency department and areas of improvement. Journal of Clinical Nursing. 2020;n/a n/a. Additional Declarations No competing interests reported. Supplementary Files AdditionalFileInterviewGuide.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4390525","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":304440548,"identity":"e85d2e3b-93a1-4a43-b1d7-a3e6ec8ac155","order_by":0,"name":"Hwayeon Danielle Shin","email":"data:image/png;base64,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","orcid":"","institution":"University of Toronto","correspondingAuthor":true,"prefix":"","firstName":"Hwayeon","middleName":"Danielle","lastName":"Shin","suffix":""},{"id":304440549,"identity":"34288509-290d-4d4f-8b64-72702a9da760","order_by":1,"name":"Keri Durocher","email":"","orcid":"","institution":"Western University","correspondingAuthor":false,"prefix":"","firstName":"Keri","middleName":"","lastName":"Durocher","suffix":""},{"id":304440550,"identity":"afae3ad6-b4a1-419a-af13-c5fcafb4a9f7","order_by":2,"name":"Iman Kassam","email":"","orcid":"","institution":"Centre for Addiction and Mental Health","correspondingAuthor":false,"prefix":"","firstName":"Iman","middleName":"","lastName":"Kassam","suffix":""},{"id":304440551,"identity":"0acc8a54-ec18-49f3-90dd-35e0a4464a78","order_by":3,"name":"Sridevi Kundurthi","email":"","orcid":"","institution":"Centre for Addiction and Mental Health","correspondingAuthor":false,"prefix":"","firstName":"Sridevi","middleName":"","lastName":"Kundurthi","suffix":""},{"id":304440552,"identity":"88d11fec-58c1-4d1f-9280-748871b60b45","order_by":4,"name":"John Torous","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center, Harvard Medical School","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"","lastName":"Torous","suffix":""},{"id":304440555,"identity":"520ced33-761b-4f05-87ef-23a732147d58","order_by":5,"name":"Gillian Strudwick","email":"","orcid":"","institution":"Centre for Addiction and Mental Health","correspondingAuthor":false,"prefix":"","firstName":"Gillian","middleName":"","lastName":"Strudwick","suffix":""},{"id":304440556,"identity":"52231082-b30e-4f4e-a93f-30ebf32543d7","order_by":6,"name":"Juveria Zaheer","email":"","orcid":"","institution":"Centre for Addiction and Mental Health","correspondingAuthor":false,"prefix":"","firstName":"Juveria","middleName":"","lastName":"Zaheer","suffix":""}],"badges":[],"createdAt":"2024-05-08 16:09:28","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4390525/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4390525/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90526596,"identity":"006b3131-fbe7-461a-b380-e848e8e016d4","added_by":"auto","created_at":"2025-09-03 17:08:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1628798,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4390525/v1/9d0b3856-3c75-4f6f-a15a-e584778affde.pdf"},{"id":56886102,"identity":"61782d4a-dd3b-4a11-b9ed-ab0ed853e063","added_by":"auto","created_at":"2024-05-21 18:51:48","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19401,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFileInterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-4390525/v1/6adfec89cd53fbd3315e3e77.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and Facilitators to Using an App-Based Tool for Suicide Safety Planning in a Psychiatric Emergency Department: A Qualitative Descriptive Study Using the Theoretical Domains Framework and COM-B Model","fulltext":[{"header":"Background","content":"\u003cp\u003eSuicide is a major public health concern that affects many people, including those living with suicidal thoughts and those grieving suicide deaths. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Following the definition provided by Silverman et al., the term suicide-related thoughts and behaviors (SRTB) is used herein as an umbrella term to describe a spectrum of suicidal thoughts and self-injurious behaviors, with or without intent, and with or without fatal outcomes. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] The intent and motivation for individuals engaging in self-injurious behaviors vary and can evolve, and can fluctuate from moment to moment. [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] As such, individuals need to engage in self-management strategies, informal and formal help, and therapies to cope with SRTB.\u003c/p\u003e \u003cp\u003eThe emergency department (ED) presents a critical window of opportunity to identify those at risk and to provide suicide prevention care. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] It may be the most important setting given recent analysis revealing that the highest prevalence (nearly 40%) of deaths from suicide occurs in individuals with physical health problems, [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and the ED may be where those patients interact with the health system. In the ED, patients identified at risk undergo a thorough assessment and are directed to appropriate referrals and follow-up arrangements. These individuals also go home with a personalized safety plan, a central, effective intervention for suicide prevention. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Safety planning intervention (SPI) is an evidence-based intervention that has shown to reduce the risk of suicidal behaviour by up to 43%. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] A safety plan is a personalized tool for patients, that is developed collaboratively with providers and helps them identify coping strategies, emergency contacts as well as strategies to keep their environment safe. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] At our local psychiatric ED in Toronto, Canada, a paper-based SPI is a standard discharge practice.\u003c/p\u003e \u003cp\u003eHowever, SPI can be improved. Patients often lose paper copies of their safety plans, and some reported feeling uncomfortable reviewing the paper copy of their safety plan in public. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Similar barriers, specifically regarding the inconvenience of using the paper version of the safety plan from clinicians\u0026rsquo; perspectives, have also been reported. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] As such, the paper modality of the safety plan implies that it may not be available \u0026ldquo;at hand\u0026rdquo; during moments of increased intensity of SRTB. Relatedly, the widespread use of mobile phones introduces a new modality for delivering interventions, which is both acceptable and convenient for many individuals. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. There are already numerous digital tools available to augment care and/or support individuals in managing their SRTB like apps, telehealth, and wearable monitoring devices. [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe availability of a plethora of new digital tools does not always lead to adoption. Shin et al. identified 66 digital suicide prevention interventions implemented in clinical settings, including EDs, and found several barriers to adoption of digital technologies. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] There are both individual and organizational barriers in clinical settings such as clinicians\u0026rsquo; technical competence, motivation and preferences for technology, heavy workload, and limited capacity to troubleshoot technical issues promptly. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] As such, understanding the barriers and facilitators influencing the adoption of these apps is crucial for successful implementation. Previous research has accumulated evidence on various factors impacting the adoption of digital health interventions, including patient preferences, healthcare provider attitudes, organizational support, and technological constraints. [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] However, there remains a need for more nuanced insights into the behavioral influences that shape the adoption of digital tools in clinical settings. For example, it is currently unknown how attitudes, knowledge, and the system in which clinicians practice interact to influence behavior. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Additionally, there is currently a lack of research on barriers and facilitators to implementing digital tools for specific psychiatric concerns, such as SRTB, particularly in acute care settings, such as the ED. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Additionally, in a synthesis of 81 qualitative research evidence on barriers to adopting digital technologies in mental health systems, only nine were from Canada, and none of these Canadian studies examined implementation determinants for apps. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] To address this gap, the present study aims to identify barriers and facilitators for adopting a SPI app using behaviour change frameworks.\u003c/p\u003e \u003cp\u003eDrawing upon the Behaviour Change Wheel (BCW)\u0026rsquo;s Capability, Opportunity, Motivation-Behavior (COM-B) model [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and the Theoretical Domains Framework (TDF), [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] we seek to explore the behavioral influences underlying the implementation of a SPI app, called Hope By CAMH. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] The COM-B and TDF frameworks are synthesized from 19 and 33 behavior change frameworks, respectively, to explain the complex interplay between individual capabilities, intrinsic and extrinsic motivations, and social and environmental opportunities that influence behavior change. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Additionally, the BCW provides guidance on how to develop behaviour change strategies based on the identified behavioural influences. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Although the COM-B and TDF are popular in implementation science research, [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] they have yet to be used in digital tools for suicide prevention to inform implementation strategies. By using these frameworks, we aim to provide comprehensive insights into the factors influencing app adoption that will be used as a knowledge base for the design of theory-informed behavior change strategies for promoting the implementation of SPI apps in clinical practice.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eA larger, two-phased study is being conducted to develop theory-based strategies for implementing the app into routine clinical flow at a local psychiatric ED in Toronto, Canada. Complete study methods have been published elsewhere, [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and this paper presents the results from the first phase of this study. This phase used a qualitative descriptive study design to assess clinicians\u0026rsquo; barriers and facilitators to using the app to complete the SPI in the psychiatric ED before discharging patients to home. We used the consolidated criteria for reporting qualitative research (COREQ) checklist to prepare this manuscript. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThe study took place in a psychiatric ED in Toronto, Canada, which offers 24-hour psychiatric acute care services. This setting is unique as it is Ontario\u0026rsquo;s only stand-alone psychiatric ED, providing care to approximately 1,300-1,500 adult patients every month. About 60% of patients in the ED\u0026rsquo;s Extended Observation Unit are admitted for longer stays, while about 40% patients are discharged to home. Furthermore, there are typically between 12 and 40 patients in the ED waiting to be reassessed in the morning on any given day. This ED has a total of 12 inpatient short-stay beds, and is staffed by multidisciplinary care teams, with Registered Nurses and Registered Practical Nurses comprising the largest proportion of the team. The remaining team members include psychiatrists, program assistants, social workers, and pharmacists. Program assistants are unique in this organization; as part of the interdisciplinary team in the ED, they help the unit run smoothly under clinical staff guidance by supporting patient care, promoting safety, engaging in de-escalation, and maintaining a therapeutic environment. The ED operates with a shift-based model with 24\u0026thinsp;\u0026minus;\u0026thinsp;7 psychiatrist coverage. During the day shift, this typically involves a team of 6 to10 nurses, 3 program assistants, 3\u0026ndash;4 staff psychiatrists, with up to 5 residents and medical students, 1 to 3 social workers, and 1 to 2 pharmacists.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and sampling\u003c/h2\u003e \u003cp\u003eAll ED staff were invited to participate in the interviews, regardless of their usage of the app to support SPI. We explored actual barriers and facilitators for users of the app and explored perceived barriers and facilitators for non-users of the app. All clinicians involved in patient care in the ED were eligible to participate, irrespective of their disciplines. We used both convenience and purposive sampling methodologies. Initially, we sought voluntary participation from all ED staff, then adjusted our sampling approach based on the characteristics of the sample during data collection. Due to lower representation from psychiatrists, we issued a targeted call to them and utilized snowball sampling. We aimed to recruit interview participants to reflect the daily staffing of the ED. Additionally, we assessed our recruitment process based on data saturation, as determined by the research team involved in data analysis. We defined data saturation [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] as the point in which no additional insights emerge from the interviews and all relevant conceptual constructs within the COM-B and TDF domain have been explored, identified and completed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment\u003c/h2\u003e \u003cp\u003eAfter receiving ethics approval from the organization (REB# 2023/078), we circulated emails to all ED staff about the interview opportunity in September 2023. In the subsequent months, two targeted emails were sent to ED physician groups only. Additionally, we hung posters in high-traffic areas such as washrooms, ED workstations, and staff rooms, as determined by the ED Advanced Practice Nurse. To compensate for participants' time and the insights they shared, we provided them with a \u003cspan\u003e$\u003c/span\u003e50 e-gift card.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eWe developed the interview guide based on the COM-B, and the TDF, as well as the previous scoping review findings (Additional file 1). [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Interview questions were designed to identify influences of our target behaviour, which was using the app to complete SPI in the ED prior to discharging patients to home. Additional questions specific to equity considerations were added. For example, differing digital literacy skills among patients can create gaps in realizing the benefits of the app. We explored clinicians\u0026rsquo; perspectives on their professional responsibility for providing technical support to patients. The consent form was completed using REDCap following our organization standard. Participants had a choice of in-person (i.e., ED site private office room), telephone or video-call interviews. The interviews lasted between 25 and 70 minutes and the first author conducted all interviews. Interviews were audio-recorded, transcribed verbatim, and anonymized prior to analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eWe analyzed interview transcripts using a directed content analysis, [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] following the established guideline to use TDF and COM-B as a codebook [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] in NVivo 12. First, four reviewers (HDS, KD, IK, SK) read and independently coded four transcripts as a calibration exercise. Then, each of the remaining transcripts were independently coded by two reviewers. Reviewers were master\u0026rsquo;s-prepared nurses and health informatics researchers with extensive experience in qualitative research. Reviewers and first author met to discuss and resolve any interpretation discrepancies. Once all codes were compared for consistency, we then generated participants\u0026rsquo; specific beliefs within the TDF domains and indicated whether it is a barrier, facilitator, or mixture of both for influencing the target behaviour.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 29 ED clinicians were interviewed, including nurses (n\u0026thinsp;=\u0026thinsp;14), psychiatrists (n\u0026thinsp;=\u0026thinsp;7), social workers (n\u0026thinsp;=\u0026thinsp;2), program assistants (n\u0026thinsp;=\u0026thinsp;5), and a pharmacist (n\u0026thinsp;=\u0026thinsp;1). Nearly half of these clinicians (n\u0026thinsp;=\u0026thinsp;14) had between five and 20 years of clinical experience, while the remaining half (n\u0026thinsp;=\u0026thinsp;15) had less than five years of experience. Most of the participants had not used the app. Participants identified themselves as men (n\u0026thinsp;=\u0026thinsp;11), women (n\u0026thinsp;=\u0026thinsp;17), and questioning (n\u0026thinsp;=\u0026thinsp;1). See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for participant characteristics.\u003c/p\u003e \u003cp\u003e\u0026lt;Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026gt;\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of N\u0026thinsp;=\u0026thinsp;29 clinicians\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eClinical role\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychiatrist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgram Assistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eRacial background*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRacialized (examples shown below)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEast Asian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth Asian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eOther categories include Southeast Asian, Black, Latin American, Middle Eastern\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer not to answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eYears of experience in the current professional role\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eCurrent working hours\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCasual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eYears of experience working in the current ED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e*Non-mutually exclusive category\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe following section describes how the data maps onto the COM-B model and TDF, and a comprehensive list of barriers and facilitators along with additional quotes can be found in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBarriers and facilitators to using the app to complete SPI in the ED\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTDF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarrier (B) / Facilitator (F)/ Mixed (M)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExample Quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eCapability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimited awareness of the Hope app*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"So what I know is, it's a free phone app that anyone can download. And there's some tools on it. Like suicide safety planning. And I believe there's breathing exercises, grounding exercises, and perhaps some maybe quick phone numbers for the hotlines. That's from my memory.\" [011]\u003c/p\u003e \u003cp\u003e\"I don\u0026rsquo;t know much about them. I think this is the first I\u0026rsquo;ve actually ever heard of an app used for safety planning, like the type of safety planning that we use in the emerg. \" [012]\u003c/p\u003e \u003cp\u003e\"I didn\u0026rsquo;t know anything about it until I read your email. But I all I know is that it\u0026rsquo;s related to creating safety planning for patients. \" [016]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge and skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDemonstrated knowledge and skills for safety planning using the paper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"Safety planning, the purpose of that used in the emergency is to understand the client and their individual needs and what we can do to prevent further safety risks. That allows the clients to be more involved in their own care as well.\" [004]\u003c/p\u003e \u003cp\u003e\"What the warning signs are, coping strategies. What their support system looks like. How they can keep themselves safe, their reasons for living. What they could do, what they're in crisis, and who they can reach out to when they're in crisis\" [013]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMemory and decision making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDecision making and prioritization of tasks including safety planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I'm supervising a whole bunch of residents who have urgent issues to tell me about. I also need to be available for the nurses. And then I have to also be seeing patients on top of that. I get limited in how much I can get done or what I need to prioritize.\" [026]\u003c/p\u003e \u003cp\u003e\"If they were willing to get the app, it'd be easier to click through the options versus sitting with them and trying to explain a physical paper making them write it out. But I think it would really depend on the population. You have a teenager that would probably be fine. I'll download an app and then just click through it. That would be faster than sitting with them with a paper, but if you had maybe somebody that's not as familiar with technology and doesn't use their phone very often that doesn't know how to even connect to Wi-Fi, then trying to download an app and explain it, wouldn\u0026rsquo;t it be practical for them? But if there was the either or option of either the app or the paper and not both, and I think depending on the client, it could be easier or harder, \" [028]\u003c/p\u003e \u003cp\u003e\"It's like a tool, right, it's like a toolbox. You open your toolbox and use a special tool for whatever you need, right. It's not a universal obligation for you. As a professional you figure OK, for this individual, this might work for this individual who's probably not be able to access this app or access email if somebody, some person lives in a shelter, who has no phone, has no laptop or tablet, maybe has no email address either, probably paper copy will be better to keep on them. But majority of people probably should be able to utilise this app.\" [002]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRemembering the app especially in the beginning phase of change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think, to be honest, we see so many random posters and signs everywhere, it's easy to just kind of tune them out.\" [003]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBehavioural regulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpting for the quickest way, and breaking habit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I can see how, if staff is busy, if you have eight patients you need to run between, it's easier to hand the patient here, a paper form and say, \u0026ldquo;Here, do it\u0026rdquo; rather than a patient be coming back to you, \u0026ldquo;How do I do this? How do I download it? My Wi-Fi is not working.\u0026rdquo; Yeah, I can see how it can be a barrier, but with technology improving, maybe Wi-Fi gets more stable here. Because quite often, they ask you for a password and all that stuff and password expires.\" [002]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"12\" rowspan=\"13\"\u003e \u003cp\u003eMotivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelief about capabilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLevel of technical confidence in using the Hope app\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I don't have any problem with the technology of it. I think if I were to put in the time and the effort, then absolutely, it could work.\" [009]\u003c/p\u003e \u003cp\u003e\"I have helped people download it\" [012] \"For me very easy. I think it's not confusing at all. \" [012]\u003c/p\u003e \u003cp\u003e\"Right now, if I were to a scale of zero to 10 in confidence, I'd say maybe a seven. And that's only because I don't even know what the app is. I've never seen the interface\" [004]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eBelief about consequences*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerceived level of workload changes and difficulty in using the Hope app\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think it might be actually easier, sometimes, because we don\u0026rsquo;t have to run back, like, physically run back and forth to, like, grab the paper, get the pencil. And we can just, hey, like, try using this. Like, it\u0026rsquo;s pretty self-explanatory \u0026ndash; you can spend time using it and you can just click\" [016]\u003c/p\u003e \u003cp\u003e\"No, I don't think that's a huge workflow increase, no. Workload increase, no.\" [007]\u003c/p\u003e \u003cp\u003e\"I think it requires more time to actually move from talking about the safety plan to completing it. Because you've introduced the idea of it. And then the nation is \u0026ndash; first of all, they need to get their phones, sometimes they don't have their phones on them, then they have to connect to the Wi-Fi, and that's kind of a pain sometimes. Then they look for the app, they download the app, that can take some time. And then it's kind of like, for that whole interaction, the clinician is just kind of sitting there waiting, right. And it doesn't really make sense for the clinician to leave and then come back in a few minutes. Because that's kind of an awkward amount of time, where it doesn't really give them an opportunity to work on anything else\" [003]\u003c/p\u003e \u003cp\u003e\"I think the practice change is going to be relatively easier. Because from my perspective, it just comes across, like I said, of having a tool on hand in my pocket, that will actually help me explain a safety plan better. And then I still have the option of offering the paper copy, which I generally offer anyways. The only thing is it requires more time.\" [003]\u003c/p\u003e \u003cp\u003e\"I think we are technology savvy enough for each team member to if they need to sit down and show the patient how to use it. But that also takes time and that\u0026rsquo;s the thing that\u0026rsquo;s in short demand in the [ED]. So everybody is just so busy. So initially, just kind of sitting down and going through with patients how to use it, I can imagine staff members will feel like that\u0026rsquo;s another burden on their time. \" [017]\u003c/p\u003e \u003cp\u003e\"I think it might create new workload, in the sense of you might have people have, staff having to help patients figure out, how to download the app, how to open the app. And I think staff might see it as a more time consuming task.\" [009]\u003c/p\u003e \u003cp\u003e\"I think it'll be hard, just because the idea of paper safety planning is so ingrained, and I think it's been going on for so many years... ... I think just when you get down to it, it's not that much effort, I suppose to download an app and open it up. But I think in the perception of people who are very busy, nursing is always so busy in the emerge, they might see all the extra step of you have to get the patient to download the app, then you have to open me up and presumably you'd have to check the app after they're finished, to read that they've done the safety plan. Just at a glance, it would seem a lot more work. \" [009]\u003c/p\u003e \u003cp\u003e\" I feel that it's a practical tool and the steps that it takes to put it on our phone and review it, it's not too heavy, it's not too intensive. It presents nicely, I don't think it would be difficult.\" [012]\u003c/p\u003e \u003cp\u003e\"If, let's say you're the client, you come in, your phone was never used, or you don't know how to connect to Wi-Fi. Now I have to take away maybe five, 10 minutes, sit down with you, connect it with Wi-Fi. If you're unfamiliar with Wi-Fi, I have to explain that to you. And in that situation, I think you would probably give me your phone, I would do everything and just give it back to, and you have the app and you do it. That interaction itself would be five, 10 minutes\" [004]\u003c/p\u003e \u003cp\u003e\"I think \u0026ndash; like, when it comes down to time, not everyone has the time to actually sit down for \u0026ndash; I guess, a [unintelligible 00:08:37] amount of time to be able to \u0026ndash; that would be a situation where I feel like you\u0026rsquo;re teaching a patient as well as trying to... maybe just assist them in filling out this information. And I feel like that could double the time that it could take to actually just fill it out if it was just paper. If that makes sense. \" [025]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUncertain benefits of safety planning beyond discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"Or maybe their situational factors are just too overwhelming for them in the moments where they presented, to the point where they weren't really able to use the safety plans. In those kinds of cases, trying to engage patients in a pen and paper plan felt more like a formality. And it felt like I was doing it partially because of a responsibility or a checkbox, and less because I really thought it would change the trajectory of care for the patient\" [003]\u003c/p\u003e \u003cp\u003e\"It\u0026rsquo;s honestly hard because if it\u0026rsquo;s successful, like, a lot of these people might not even come back to the ED. \" [021]\u003c/p\u003e \u003cp\u003e\"It would be great to survey people who have actually downloaded the app, whether or not they find it useful. I don't know. Because I never been in that sort of emotional predicament where I'm needing a safety plan for myself. So I don't know whether it's useful. I mean, objectively, it looks like it should be useful. But I don't know whether we have feedback from end users\" [007]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerceived benefit and disadvantages of the Hope app\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think the other thing is, as I mentioned, having those toggles of just, oh, yes, this applies to me, this applies to me, might make it a little bit more passive.\" [009]\u003c/p\u003e \u003cp\u003e\" people are really excited about it. Patients are really onboard. \" [024]\u003c/p\u003e \u003cp\u003ebetter - at hand: \" The paper you can leave in your car, in your home, in your bag and or lose it and eventually \u0026ndash; with the app, you can always open it up and then remind yourself it's always with you, if you want it, instead of trying, OK, I left my safety plan at home. But now at my parents\u0026rsquo; house, I don\u0026rsquo;t feel safe, I feel distressed and tried to remember what I did. And this way I have it on you. I think that's a big advantage.\" [002]\u003c/p\u003e \u003cp\u003e\"I do support going paperless, it's just tough, I think. Then also patients can easily lose that, there is a benefit to the app in the sense that those who have phones have their phones with them all the time. The app \u0026ndash; I think there's obviously some people who don't have phones or can't figure out their smartphones.\" [009]\u003c/p\u003e \u003cp\u003e\" I feel the app is really great, because it's just easier to have in one place, especially when they're on their phone, and they can send it directly to whoever right away. And sometimes it's just helps. It's more than that. It's better than writing because sometimes they can get so stressed out that they get fed up and they don't want to write something\" [010]\u003c/p\u003e \u003cp\u003e\"I think it's so great that they can carry it with them when they leave. Because people \u0026ndash;especially people, they don't care about paper like that. They'll throw it out, but on their phone, they can take it everywhere. \" [010]\u003c/p\u003e \u003cp\u003e\"when we're cleaning the rooms, we see so many safety plans left behind.\" [010]\u003c/p\u003e \u003cp\u003e\" it's a tool that a client can access wherever they are people, more than likely always have their phone with them. A client can access it no matter where they are and at any time, versus the paper document that probably gets shoved in a drawer. And the client will forget about and not take seriously. At least it's something that can be accessed anywhere. And that's helpful for the team to remind the person, the client that this safety plan is with them at all times. And it's instantly accessible. I think it just helps the team because it helps us reassure the client that the plan is with them at all times.\" [012]\u003c/p\u003e \u003cp\u003e\"I mean, when would they use it again? Only in moments of crisis, right. And in moments of crisis, they would be here. I think if this was more scheduled somehow as a weekly check in. If you guys could navigate for every so often, depending how high the safety risk, just have the app check in on them and see, hey, are these still your safety plans? Do you still feel the same way? Because if this is a one moment of the thing, it doesn't really serve too much purpose for the individual, more so for the clinician.\" [003]\u003c/p\u003e \u003cp\u003e\"I think it's useful, more mostly in the clinician\u0026rsquo;s perspective, as opposed to the patient's perspective. And that's only because, like I mentioned that piece of paper, once we've given it to them, more times than not, they just throw it out, it doesn't actually mean too much to them. I think out of 10 patients, maybe three or four would actually use that as the set purpose, the safety plan.\" [003]\u003c/p\u003e \u003cp\u003e\" I will say the biggest thing is patients really like it. And like I said, a lot more than they like the paper. Not that they ever minded the paper, but they really like it, and they really like having it on their phone and being able to open it easily and it feels like, I think, like this comforting thing that you can't lose the way that you would immediately lose the paper. And that it\u0026rsquo;s a working document and that you can change it\" [024]\u003c/p\u003e \u003cp\u003e\"So the app will increase client engagement, because it allows them, it's kind of like the paper, the paper is also allowing the client to independently be the focus of the care. It's different when I tell you, \u0026ldquo;Hey, these are the resources. Use them if you want.\u0026rdquo; Versus you telling me this is my personal one, because what works for you, won\u0026rsquo;t work for the next person. So the app is just an extension of that, which allows them to do their individual unique safety plan, which is different than other persons.\"[004]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnticipation of patients' reactions for checking the phone (Reading over patient's phone may not be well-received)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"Looking over somebody's phone is invasive a little bit? Yeah, a little bit. And not everyone might be comfortable to do that or to hold the phone itself or with COVID, germs.\" [012]\u003c/p\u003e \u003cp\u003e\"I think it makes it a little bit difficult in the sense that I'd have to go back in and see the patient and read their phone. Whereas in this scenario, it's usually nursing brings me back the worksheet that the patient has completed. And then I just review it, copy it, give the original back to nursing so they can give back to the patient or give back to the patient myself.\" [009]\u003c/p\u003e \u003cp\u003e\"Yeah, for me, the only thing I don't like is it sometimes I'd like to write, like, I'll write like, somebody will write the safety plan with a person. So they'll tell me and I'll write it up for them. So I don't know if I would grab a person's phone and tech, like start typing on their phone, necessarily.\" [027]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeliefs about equity with regard to the Hope app\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"My grandfather has a cell phone, but he'd rather write something down and type it into a phone. He doesn't even probably know how to type a text message. So it's nice to have it accessible. So, I mean, the phone helps for younger folks or people that are interested in technology. But that's not the majority, right, unfortunately. Well yeah, we see a lot of homeless people, impoverished people come in with police, they don't have cell phones.\" [005]\u003c/p\u003e \u003cp\u003e\"There might be some people who are not very good with English, they might need extra help. And also I\u0026rsquo;m just assuming this, but the app is probably just in English, right?\" [006]\u003c/p\u003e \u003cp\u003e\"if that patient then decides to come in and use our tablet, because they don't have a phone. And now it's out in the ether in the internet on a server, but they don't have access to technology. If they wanted to send that, where do they go to access technology, when they send it, to access their email? I've met a lot of people that have emails, but no means to access it.\u003c/p\u003e \u003cp\u003eInterviewer: So that's why we can't replace paper.\" [005]\u003c/p\u003e \u003cp\u003e\"I think using cellphone for the population out there is feasible just because smartphone are so \u0026ndash; they are everywhere.\" [020]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGoal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSafety planning is high priority for ED care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"the purpose of [safety plan] used in the emergency is to understand the client and their individual needs and what we can do to prevent further safety risks. That allows the clients to be more involved in their own care as well.\" [004]\u003c/p\u003e \u003cp\u003e\"I just think that at the end of the day, it's promoting safety, right. So we promote mental health in a way that is not like this daunting cloud? It\u0026rsquo;s something that you can work towards? Yeah, you're having a rough day, but at the same time, there are ways that you can work towards having a better day tomorrow and the safety plan, is that\" [010]\u003c/p\u003e \u003cp\u003e\"Safety planning in the emergency department. It is always at kind of like top\" [018]\u003c/p\u003e \u003cp\u003e\"Usually it's a requirement for somebody that has depression or suicide. For some sort of history of self harming. Then for sure that they require, a complete safety plan, they can\u0026rsquo;t even be discharged. So, can't really think of instances that I've seen where it's been absolutely missed\" [028]\u003c/p\u003e \u003cp\u003e\"If there's anything particular \u0026ndash; if it's chaotic, sure, it might get missed. But when it's determined by the doctors that a safety plan is required, we have to complete it. ...I don't see the doctors not using it when they clinically determine, OK, we're going to need to do a safety plan for the patient, then that has to be done\" [012]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eProfessional responsibility*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eProfessional responsibility for safety planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think it comes from discussions with your team, and the feedback that you get from each other. And reminding each other of opportunities to have a safety plan be discussed. I know that's a little bit vague, but I think it comes with a cultural shift, where we eventually start thinking of safety planning as a therapeutic tool and incorporate that as a focus of our plan for a patient, as opposed to just something that we do before discharge.\" [003]\u003c/p\u003e \u003cp\u003e\"I think it\u0026rsquo;s very important. Like it\u0026rsquo;s one of our \u0026ndash; it should be one of our key assessments that we do as nurses here. Because even though the doctor, you know, is mainly the one who makes the decision about a disposition for a patient, our value as nurses is most of the time like taken into account by the doctors.\" [012]\u003c/p\u003e \u003cp\u003e\"Yeah, I think it's \u0026ndash; I don't think it should be just a nursing task. I think the psychiatrists could mention [the Hope app]. The social workers could mention it. Nurses could mention it. And even the program assisted staff could mention it. I don't think this is strictly nursing tasks.\" [014]\u003c/p\u003e \u003cp\u003e\"I think safety is all of our responsibility. And the Hope app supports patient safety.\" [015]\u003c/p\u003e \u003cp\u003e\"I think it's very feasible. Just about making sure that we do it. And how to you make sure well, we have team meetings, social work team meeting. So if we say that this is a goal, we have, seasonal meetings. So at that next meeting, if we say, let's make sure we do this for each client, it's going to be on our to do list.\" [012]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedical legal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I don't know if I if they did the hope app. I probably would just say they complete the hope app. And I eyeballed it looks good. And then if there was an adverse outcome, that's all the information we would have, but I think that would be enough for the safety committee. And they would know they could pull up what is the Hope app? The recent version was that look like what would the client have filled? I think that would have been enough medical legally.\" [027]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShared responsibility to support the Hope app implementation including tech support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"[Tech support is] something that we can all do. Because if we are familiar with the app, and we know how to use it, we should be OK\" [010]\u003c/p\u003e \u003cp\u003e\"we also have other people that can help with some of those things like PAs can help with, with setting up the Internet, they can help them to open the app. And then if they need any more help, they can ask the nurses, so it's not solely on the nursing staff.\" [013]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVariability in how clinicians approach safety planning related to time spent with patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"Yeah, there are definitely certain days where there's no time, but I think you have to make time. Especially for these vulnerable patients, right. And for me, personally, my practice, I don't \u0026ndash; especially these patients that are going through depressive episodes or have suicidal ideation, I never want them to think that I kind of abandon them. So for \u0026ndash; the safety planning takes 10 minutes of your time, right, maybe a little bit more. But I don't know, I think it's, I think this is a nurse to nurse question. And everyone's practice is different. But I personally, even if I'm really, really busy, I will try to make time for these people.\" [014]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSPI is important professional role for all disciplines in the ED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"So my role is to help people safety plan, but also to give them some sort of independence to safety plan. I'm not going to give them the answers, I will work with them to get the answers. But yeah ultimately, I really try to encourage people to safety plan by themselves, because nurses aren't going to be there with you forever, right. Patients also have to be self-sufficient, right. And one of the things that's really important about safety planning is that you don't coddle patients, you let them have their independence and do it themselves. I think that's really important.\" [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e\"I think emergency nurses are special because, you know, they work with patients for a brief period of time but they have to build the relationship really quickly and probably spend more time with patients than the physicians do. So nurses are really well positioned to take the lead on supporting patients with the Hope app. \" [015]\u003c/p\u003e \u003cp\u003e\" I\u0026rsquo;m working here, like an ED, I feel like anyone that comes to seek for help, like, I feel obligated to do my best to, like, keep them safe. And just because they come at the lowest moment of their life and, like, I\u0026rsquo;m able to help \u0026ndash; that\u0026rsquo;s great. But if I don\u0026rsquo;t do enough then, like, I question myself, like, you could have done better. Like, you could have spent more time with that person. Or just because I was preoccupied with something else and I couldn\u0026rsquo;t spend more time with that person, that person could have gotten better care. So I feel like safety planning is part of me doing my obligation in by sitting with them and just go through the questions with them. \" [016]\u003c/p\u003e \u003cp\u003e\"Not to stop using paper for people who prefer it or don't have another option. And to still provide that. Like again, the process of the safety plan and the mental process of working through it is a lot of the intervention, so even if they do lose it, I do believe that a lot of people that way at least can generate it again. So, it still was helpful. \"[024]\u003c/p\u003e \u003cp\u003e\"Safety planning in general. I mean, I think that that's part of our assessments, that's really the sort of bread and butter of what we do in the emergency department\" [007]\u003c/p\u003e \u003cp\u003e\"Yeah, I just \u0026ndash; I mean, safety planning is really important, right? We don't like to leave \u0026ndash; we don't like to let people leave hospital if they're not really to safety plan. And as a nurse, especially as a mental health nurse, I feel it's my due diligence to safety plan, and the Hope app is something that they'll always have with them. So yeah, it's a really good way to Safety Plan.\" [014]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOptimism/\u003c/p\u003e \u003cp\u003epessimism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePersonal preference towards digitizing healthcare services including safety planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"if it\u0026rsquo;s not integrated with the health record it\u0026rsquo;s \u0026ndash; like, we would prefer paper because paper gets stand in.\" [015]\u003c/p\u003e \u003cp\u003e\"I even myself, like, prefer writing, like, on the paper.\" [016\u003c/p\u003e \u003cp\u003e\"Yeah, for me, the only thing I don't like is it sometimes I'd like to write, like, I'll write like, somebody will write the safety plan with a person\" [027]\u003c/p\u003e \u003cp\u003e\"I'm getting kind of tired with technology. And so maybe like what resistance do I have as a, I think my biggest resistance is probably paper to me feels a bit more therapeutic than a computer screen. Also, given the documentation doesn't get into the charts. So it doesn't feel as it might be more worthwhile for the patient. But from a clinician perspective, having a in the chart to me is very important.\" [027]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"13\" rowspan=\"14\"\u003e \u003cp\u003eOpportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSocial opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunication for safety planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"There's suicide risk assessment and suicide evaluation. But there's no checkbox for was a safety plan administered? Or should we do it? It's just case by case? We feel in the moment that clinically it's a necessary tool, then we'll, the doctor will say let's do a safety plan or the social worker would say let's do a safety plan. Then we do it and then review it.\" [012]\u003c/p\u003e \u003cp\u003e\"I was just saying sometimes, I guess, we \u0026ndash; like in my experience, every time a safety plan needs to be done the doctor has told me, \u0026ldquo;Can you just make sure they fill out a safety plan before they leave?\u0026rdquo; Other than that time I think I \u0026ndash; well I guess it would be based on the nurse\u0026rsquo;s judgement whether or whether or not the safety plan should be filled out. That\u0026rsquo;s actually a grey area for me. I'm actually not too sure if it\u0026rsquo;s every time the doctor says to do one, or if it's based on also if we think that the patient needs to do one. That's a grey area for me.\" [025]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTeam culture in the ED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eI found the team is really cohesive in the emerge. It\u0026rsquo;s a really great team to work with. [024]\u003c/p\u003e \u003cp\u003e\"Communication is important. And our team does that well. And we support each other outside of our roles, because we're family, so. And we try to pass that on to the patients for sure. And once we acclimate ourselves, I don't see any problems rolling it out.\" [005]\u003c/p\u003e \u003cp\u003e\"With this new practice change, we have to do, take some time, people get used to it, but then once you're used to it, it's fine.\" [028]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003ePhysical opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLack of access to smart devices among subgroup of ED patient population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"What I'm saying if that patient then decides to come in and use our tablet, because they don't have a phone. And now it's out in the ether in the internet on a server, but they don't have access to technology. If they wanted to send that, where do they go to access technology, when they send it, to access their email? I've met a lot of people that have emails, but no means to access it.\" [005]\u003c/p\u003e \u003cp\u003e\"I think a lot of our clients who are homeless, living in shelter, they're chronically getting their items stolen because of the culture in shelters so many of our clients might get one phone and it's gone in a week. Or with people with chronic addiction, they're selling their phones. \" [012]\u003c/p\u003e \u003cp\u003e\"I think the barrier, from my perspective, is that is that is that people need to have a smart, smart device. Yeah. Or phone. I think that's, I know that probably most people do now, but we also do work with people who are experiencing homelessness or poverty. So not everybody has access to that. And then and then like, like, you know, and like I said earlier, like people can have technological challenges, which again, we can help problem solve. But sometimes people just don't like to use apps and that's a preference thing\" [029]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBusy ED setting and being understaffed, need for prioritizing multiple tasks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"But I think during very peak periods of busyness, they won't use it, because they forget, or it will just be too though they'll opt for like the quickest thing to do, which would be like grabbing a piece of paper.\" [001]\u003c/p\u003e \u003cp\u003e\"And I feel like it\u0026rsquo;s something that shouldn\u0026rsquo;t be rushed but it ends up being rushed because we \u0026ndash; like, even today we have, like, five, six discharges happening at the same time. And if that\u0026rsquo;s the only thing that\u0026rsquo;s holding them back then, like, hey, as long as we have something on the paper then, like, you can go.\" [016]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLack of documentation infrastructure in the EHR for the Hope app\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think downloading an app should be fairly simple. I think most people in emerge would be fine with that. One other issue that I'm just now thinking about is that, as I mentioned, we like having the safety plan to put in the file. We like having \u0026ndash; before I discharged someone, I like seeing that they filled out the safety plan. And if it's on their phone, I kind of wonder how I would be able to see that? Would I have to go and look on their phone in order to see that they filled things out? Because that sounds like it would be \u0026ndash; it's a lot easier then for the patient to say they'll do it, and then not fill it out.\" [009]\u003c/p\u003e \u003cp\u003e\"I think tools like a pop up reminder or a tab can be added to our multidisciplinary assessment.\" [011]\u003c/p\u003e \u003cp\u003e\"But if it does become placed into the multidisciplinary assessment, which is the tool that we do for every emerge visit, if it's part of that standard checklist of things to do, then it's part of what we have to do so then it's not, it won't be overlooked.\" [012]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWi-Fi connection in the ED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think the most challenging part is getting access to the Wi-Fi, because it\u0026rsquo;s like a long code to type. And then some patients, they can't see properly so then we\u0026rsquo;ll have to take their phones and then we\u0026rsquo;ll type it in for them. \" [023]\u003c/p\u003e \u003cp\u003e\u0026ldquo;Yes, like I said, so if the patient was really eager to get discharged, telling they can stay safe. But I want to see a safety plan before they go. But now they're telling me, \u0026ldquo;Well, I can't seem to download it. The internet\u0026rsquo;s really spotty.\u0026rdquo; Then we're kind of at, like, a difficult situation where I technically, I don't have grounds to keep them. I can't really imprison them in the hospital to do this app. To finish this.\u0026rdquo;[026]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOrganization culture - Alignment of the Hope app's purpose with the organizational value and goal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think it fits with the organisation in the sense that [the organization] is continually striving to innovate the way that care is provided. So as I mentioned, it makes sense as generations change and things become more digital.\" [009]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eApp-specific\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLayout, usability, resources,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"It's pretty straightforward, I think that's what matters. And like I said before, it's, multiple choice is always easier than to come up with something, less time consuming\" [002]\u003c/p\u003e \u003cp\u003e\"Yeah, it's pretty user friendly,\" [007]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLack of translation function in the app\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"The multi language could be useful. Because that eliminates the needs of getting it translated and all that stuff.\" [020]\u003c/p\u003e \u003cp\u003e\"I noticed there are a lot of language barriers as well. So, maybe just having an option to translate the page or the app. Or I don't know if that's a feature that will be with the phone. Like, if the phone is set to French will the app be installed with French language built into it?\" [023]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eToggle options in the safety plan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think one of the challenges that I've encountered is, depending on how engaged the patient is with the process of coming up with a safety plan, and what their mental status is, they may have difficulty coming up with items that they can put on the list. For example, someone presenting in crisis might say something like, \u0026ldquo;Oh, I have no one supportive in my life.\u0026rdquo; And they would have a really hard time coming up with resources or people or clinical team members who would be able to support them if they were ever in crisis in the future. So in a way, I think having options that are presented to them, can be really valuable.\" [003]\u003c/p\u003e \u003cp\u003e\"The one other thing that I was just thinking of, I like that you have the little toggles to decide, if that applies to them, and then at the end, it's optional to write in. Actually kind of feel like it's sometimes beneficial that on the worksheet, it's totally blank. And they have to think and write it in. Whereas they feel like there might be a passive kind of just, yeah, sure, sure, like checking off a bunch of ones. And it's hard to tell then if the safety planning was really thought through.\" [009]\u003c/p\u003e \u003cp\u003e\"I think the other thing that actually is a con of the app, in my opinion, is actually having the choices there may make the clients, it might be easier for them to not really actually think about it, if that makes sense. Like we're actually doing a paper form, even though because there's no options, they have to come up with them. So it's more spontaneous, they actually have to think about it. Whereas this app, there is a small risk. I think it's small, but a risk that like you, or I could just click on the thing, and then just toggle whatever we think and even if we're not really processing, like, do we actually mean that? Does that actually apply for us? You know, yeah, so that's the only other risk I see.\"[029]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSocial opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeadership support for change management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think that people, if you make it mandatory, and you make all of us attend, I think that'll be easier than a sticker on \u0026ndash; you can still have the poster on the wall.\"[010]\u003c/p\u003e \u003cp\u003e\"it\u0026rsquo;s called ED Communications. And then in that email, there\u0026rsquo;s always like a section about, you know, this is a change in practice and then she kind of types it out, describes it. For example, if it was for the safety plan it would be like, you know, \u0026ldquo;Usually we do safety plan by paper but now we\u0026rsquo;re doing something new using the app.\u0026rdquo; \"[012]\u003c/p\u003e \u003cp\u003e\"I don't really have anything to add to that, because our team is pretty good. And if [leadership team] asks us to implement something in our practice, I think everyone is pretty good about it.\" [014]\u003c/p\u003e \u003cp\u003e\"I think if we can, you know, get people on board with it through leadership, like, endorsing it, through physician leadership endorsing it, some champions, maybe, or whatever we want to call them, then yeah, I think it could work well. But it will take time. Practice change takes a lot of time.\" [015]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients' readiness for safety planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003epretty much sometimes patients who don't want to be discharged, they will sabotage the discharge by refusing to participate in the safety plan or so on. I think that's the biggest challenge sometimes, if someone doesn't want to leave, and the doctor insists on leaving, and a part of the discharge, conditional being discharged, completing a safety plan. So that could be a challenge. [002]\u003c/p\u003e \u003cp\u003e\" And there\u0026rsquo;s been instances where they, for example, just say that there\u0026rsquo;s nothing. Like they can't fill it out at all, they have nothing to write. And that becomes a little bit tricky to kind of persuade them. Especially when we're really rushed in the emerge and there\u0026rsquo;s so many other clients to be seen. It can be difficult to kind of engage them meaningfully.\" [024]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients characteristics including age, preference, mental health conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\". So, I mean, the phone helps for younger folks or people that are interested in technology. But that's not the majority, right, unfortunately.\" [005]\u003c/p\u003e \u003cp\u003e\" I got to say, even elderly people with cognitive impairment, if they have a smart phone, this is not a problematic app to use. It is a short download, people find it, they find it easy to use. If they have a smart phone.\" [024]\u003c/p\u003e \u003cp\u003e\"I think it depends on the age range. I found with younger clients that are in their teenage years or maybe a bit more reluctant to fill out a physical paper or early twenties they don't want to do it. I'd rather scroll on their phone. So I think the app might actually be a solution to that. It'd be easier to kind of click through the questions and type it versus writing on a physical paper that they're going to lose right away.\" [028]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlignment of the app's purpose and ED and organizational goal/vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\"I think [the organization] is, is really great like that we were always sort of ahead of the curve, I think. And when people come here, they're always very impressed by all the technology and all the new things that we do. Everything like that. So that's pretty cool.\"[013]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e* Means salient themes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026lt;Insert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026gt;\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eCapability\u003c/h2\u003e \u003cp\u003eThe COM-B defines psychological capability as the skills, knowledge, and ability to engage in the necessary reasoning and decision-making processes. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Related TDF domains under capability include knowledge, skills, memory, decision making, and behavioural regulation, such as intentional habit breaking. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Clinician\u0026rsquo;s psychological capabilities influenced their use and non-use of the SPI app.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimited awareness about the app\u003c/h2\u003e \u003cp\u003eMost notably, reasons for clinicians having not used the app was due to unawareness, even though the app has been available since 2020 and was developed by the organization. This could potentially be attributable to staff turnover in the ED, especially during the pandemic; there are occasional new staff members, and residents rotate throughout the health institutions. Even if clinicians had heard about it through organizational emails, they lacked knowledge about the app\u0026rsquo;s features and contents. Few clinicians knew that the app included wellness activities such as journaling and boxed breathing, as well as community resources tailored to users\u0026rsquo; locations, to better support them in managing their SRTB.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"So what I know is, it's a free phone app that anyone can download. And there's some tools on it. Like suicide safety planning. And I believe there's breathing exercises, grounding exercises, and perhaps some maybe quick phone numbers for the hotlines. That's from my memory.\" [011, social worker]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I don\u0026rsquo;t know much about them. I think this is the first I\u0026rsquo;ve actually ever heard of an app used for safety planning, like the type of safety planning that we use in the emerg.\" [012, nurse]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I didn\u0026rsquo;t know anything about it until I read your email. But I all I know is that it\u0026rsquo;s related to creating safety planning for patients. \" [016, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMemory and decision making\u003c/h2\u003e \u003cp\u003eClinicians mentioned that information (i.e., posters, flyers, etc.) about new innovations, like the app, often goes unnoticed due to the abundance of other posters. For this reason, clinicians have expressed concerns that it may be difficult to remember to use the app to complete safety planning, especially during the early phase of implementation and when clinicians are managing multiple priorities simultaneously.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I think, to be honest, we see so many random posters and signs everywhere, it's easy to just kind of tune them out.\" [003, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eBehavioural regulation and habit breaking\u003c/h2\u003e \u003cp\u003eClinicians emphasized that in order to transition away from using paper SPI in the busy ED setting, the value proposition must be clear. In other words, the app implementation and use must be easy and more efficient than the current method of delivering safety planning. This also relates to both the physical environment and clinicians' anticipation of future outcomes. Due to the nature of the busy ED setting, clinicians tend to gravitate towards the quickest way to complete assigned tasks, including safety planning. Since the app is not replacing the paper method entirely, this option will always be available. Thus, if instructing patients to download the app or providing technical support to patients proves to be time consuming, clinicians will likely opt for the quicker method, which is using paper.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I can see how, if staff is busy, if you have eight patients you need to run between, it's easier to hand the patient here, a paper form and say, \u0026ldquo;Here, do it\u0026rdquo; rather than a patient be coming back to you, \u0026ldquo;How do I do this? How do I download it? My Wi-Fi is not working.\u0026rdquo; Yeah, I can see how it can be a barrier, but with technology improving, maybe Wi-Fi gets more stable here. Because quite often, they ask you for a password and all that stuff and password expires.\" [002, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDemonstrated knowledge and skills for safety planning\u003c/h2\u003e \u003cp\u003eSince safety planning is a standard discharge practice in the ED, the majority of interviewed clinicians demonstrated knowledge and skills for completing safety planning using paper. Often, nurses, social workers and psychiatrists are directly involved in safety planning. Program assistants, who are not directly involved in safety planning process, also seem to have a good understanding of safety planning and its purpose.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;What the warning signs are, coping strategies. What their support system looks like. How they can keep themselves safe, their reasons for living. What they could do when they're in crisis, and who they can reach out to when they're in crisis\" [013, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eOpportunity\u003c/h2\u003e \u003cp\u003eBarriers and facilitators within the social and physical ED environment can shape the opportunities for clinicians to use the app to deliver SPI. Physical opportunity is determined by environmental factors such as time, location, and physical and human resources in the ED. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Social opportunity refers to social factors such as cultural and social norms, peer pressure, relationships, and social cues that influence behaviors. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCommunication about safety planning in the ED amongst clinical team\u003c/h2\u003e \u003cp\u003eThere is currently no standard method of communicating about safety planning in the ED. Safety planning is not included in order forms in the electronic health record (EHR). Moreover, safety plans can be initiated by psychiatrists, social workers, or nurses. When safety planning is initiated by a psychiatrist and completed by a nurse, communication primarily takes place verbally. Alternatively, nurses sometimes discover that a safety planning paper was provided to the patient by a psychiatrist. This barrier is not specific to app-based safety planning but rather applies to safety planning in general, which may impact the adoption of the app and add an additional layer of socio-technical complexity in routine practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"There's suicide risk assessment and suicide evaluation. But there's no checkbox for was a safety plan administered? Or should we do it? It's just case by case? We feel in the moment that clinically it's a necessary tool, then we'll, the doctor will say let's do a safety plan or the social worker would say let's do a safety plan. Then we do it and then review it.\" [012, nurse]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"In my experience, every time a safety plan needs to be done the doctor has told me, \u0026ldquo;Can you just make sure they fill out a safety plan before they leave?\u0026rdquo; Other than that time I think I \u0026ndash; well I guess it would be based on the nurse\u0026rsquo;s judgement whether or whether or not the safety plan should be filled out. That\u0026rsquo;s actually a grey area for me. I'm actually not too sure if it\u0026rsquo;s every time the doctor says to do one, or if it's based on also if we think that the patient needs to do one. That's a grey area for me.\" [025, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLack of documentation infrastructure in the EHR for the app\u003c/h2\u003e \u003cp\u003eAnother barrier was related to the current documentation infrastructure in the EHR. Currently, the patient\u0026rsquo;s paper safety plan is photocopied and scanned into the EHR. If the app-based safety plan were to be used, clinicians were uncertain about how they would document or keep record of the completed digital safety plan in the EHR. Clinicians also discussed the medical-legal responsibilities and the importance of documenting the safety plan. This documentation provides them with an idea of whether patients can be safely discharged to home and allows for the assessment of patients' insights to manage their symptoms. As such, clinicians discussed the opportunity to change or add in a new form within the EHR to document completion of a safety plan.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"One other issue that I'm just now thinking about is that, as I mentioned, we like having the safety plan to put in the file. We like having \u0026ndash; before I discharged someone, I like seeing that they filled out the safety plan. And if it's on their phone, I kind of wonder how I would be able to see that? Would I have to go and look on their phone in order to see that they filled things out? Because that sounds like it would be \u0026ndash; it's a lot easier then for the patient to say they'll do it, and then not fill it out.\" [009, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePatient populations in the ED\u003c/h2\u003e \u003cp\u003ePatient population characteristics tend to influence clinicians\u0026rsquo; decisions regarding the use of the app for safety planning. Clinicians often mentioned that younger patients who visit the ED would benefit the most from the app due to their widespread use of smartphones and familiarity with apps. Conversely, clinicians assumed that older patients, particularly those who may not be as tech-savvy or reliant on smartphones, might face challenges in engaging with the app for safety planning. This assumption may influence clinicians' decisions to offer the paper version rather than the app.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\" So, I mean, the phone helps for younger folks or people that are interested in technology. But that's not the majority, right, unfortunately.\" [005, program assistant]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\" I got to say, even elderly people with cognitive impairment, if they have a smartphone, this is not a problematic app to use. It is a short download, people find it, they find it easy to use. If they have a smartphone.\" [024, program assistant]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I think it depends on the age range. I found with younger clients that are in their teenage years or maybe a bit more reluctant to fill out a physical paper or early twenties they don't want to do it. I'd rather scroll on their phone. So I think the app might actually be a solution to that. It'd be easier to kind of click through the questions and type it versus writing on a physical paper that they're going to lose right away.\" [028, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLack of access to smart devices among subgroup of ED patient population\u003c/h2\u003e \u003cp\u003eIn addition to patient characteristics and preferences, clinicians also discussed physical access to devices for downloading the app. They mentioned that individuals experiencing homelessness tend to misplace their belongings, but this barrier applies to both modes of SPI. Additionally, there are patients who do not have smart devices (i.e., flip phones) and will require a paper copy of the safety plan.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I think a lot of our clients who are homeless, living in shelter, they're chronically getting their items stolen because of the culture in shelters so many of our clients might get one phone and it's gone in a week. Or with people with chronic addiction, they're selling their phones. \" [012, nurse]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I think the barrier, from my perspective, is that people need to have a smart device. Yeah. Or phone\u0026hellip; I know that probably most people do now, but we also do work with people who are experiencing homelessness or poverty. So not everybody has access to that\u0026hellip; like I said earlier, like people can have technological challenges, which again, we can help problem solve. But sometimes people just don't like to use apps and that's a preference thing\" [029, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eWi-Fi and other technical resources in the ED\u003c/h2\u003e \u003cp\u003eAlthough the ED has public Wi-Fi for patients' use, clinicians expressed concerns about its speed, noting this as a potential barrier for using the app. Additionally, during night hours, access to the ED Wi-Fi requires a password. This concern is also linked to clinicians' anticipated changes in workload. The current process for accessing public Wi-Fi in the ED is not simple. Therefore, if patients awaiting discharge are delayed due to app downloads, this would not be ideal, especially considering the nature of the ED.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We shut [Wi-Fi] off at night and you need weird passwords, like it's \u0026ndash; I'm sure from a security standpoint, it's quite adequate. But in terms of accessibility for patients that are stuck here, the internet is not very good here.\u0026rdquo; [005, program assistant]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I think the most challenging part is getting access to the Wi-Fi, because it\u0026rsquo;s like a long code to type. And then some patients, they can't see properly so then we\u0026rsquo;ll have to take their phones and then we\u0026rsquo;ll type it in for them. \" [023, program assistant]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If the patient was really eager to get discharged, telling [me] they can stay safe. But I want to see a safety plan before they go. But now they're telling me, \u0026ldquo;Well, I can't seem to download it. The internet\u0026rsquo;s really spotty.\u0026rdquo; Then we're kind of at, like, a difficult situation where I technically, I don't have grounds to keep them. I can't really imprison them in the hospital to do this app. To finish this.\u0026rdquo;[026, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eClinicians also discussed access to computers in the same building for public use, as well as available tablets in the ED. Since the app has an email function to share the safety plan, clinicians talked about alternative ways for patients to access a digital version of the safety plan, particularly for individuals who do not own smart devices but would still like to have a digital copy of the safety plan.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So some do have emails and the access to a computer can be sometimes arranged. They can even come here\u0026hellip; \u0026hellip;We can do it with them. Or we have some tablets. And we can do that with them so I can leave it with them to do here and email it to me and I could print it out for them. But then I\u0026rsquo;m not sure if that\u0026rsquo;s \u0026ndash; depending on \u0026ndash; it may be better than the one we have now because they can put their own options in and I think that would be the benefit of it.\u0026rdquo; [018, social worker]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eBusy ED setting and being understaffed, need for prioritizing multiple tasks\u003c/h2\u003e \u003cp\u003eThe ED is busy most of the time, with clinicians having multiple priorities depending on patient acuity, turnover and staffing levels. While the busy nature of the ED is not an issue specific to the app, it may serve as a barrier due to the added layer of complexity if the implementation process does not streamline the existing procedures.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"And I feel like [safety planning is] something that shouldn\u0026rsquo;t be rushed but it ends up being rushed because we \u0026ndash; like, even today we have, like, five, six discharges happening at the same time. And if that\u0026rsquo;s the only thing that\u0026rsquo;s holding them back then, like, hey, as long as we have something on the paper then, like, you can go.\" [016, nurse]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;All the little things add to each other. And in the ED, nurses have to be available for the patients, all of the patients they have in case of emergency because code whites and code blues can happen very frequently. So a nurse cannot stay with a patient for a long time to go do all this because they\u0026rsquo;re expected to do the initial assessment as well\u0026rdquo; [006, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eTeam culture in the ED\u003c/h2\u003e \u003cp\u003eA strong culture of team-based interdisciplinary collaboration is present in the ED. This culture is a significant facilitating factor for implementing new initiatives, including the adoption of the app. Clinicians mentioned how technical tasks, such as assisting patients with accessing Wi-Fi, is often a shared task amongst the team.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"Communication is important. And our team does that well. And we support each other outside of our roles, because we're family, so. And we try to pass that on to the patients for sure. And once we acclimate ourselves, I don't see any problems rolling it out.\" [005, program assistant]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think it\u0026rsquo;ll take some change management, for sure. But I think the team is very strong and, like, very open to trying new things.\u0026rdquo; [015, nurse]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I found the team is really cohesive in the emerge. It\u0026rsquo;s a really great team to work with\u0026rdquo;[024, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eLeadership support for change management\u003c/h2\u003e \u003cp\u003eClinicians spoke about leadership support and how they are aligned with the leadership\u0026rsquo;s decisions. Clinicians often mentioned that if the app adoption is made mandatory by the leadership team, it will be well accepted by the ED team.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think the leadership should promote this behaviour because we are not asked to do this with the patient, so we just don\u0026rsquo;t do it.\u0026rdquo; [006, nurse]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"If [leadership team] asks us to implement something in our practice, I think everyone is pretty good about it.\" [014, nurse]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I think if we can, you know, get people on board with it through leadership, like, endorsing it, through physician leadership endorsing it, some champions, maybe, or whatever we want to call them, then yeah, I think it could work well. But it will take time. Practice change takes a lot of time.\" [015, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eAlignment of the app's purpose and ED and organizational goal and vision\u003c/h2\u003e \u003cp\u003eClinicians unanimously spoke about the alignment of the app\u0026rsquo;s purpose with the organizational vision. As Canada\u0026rsquo;s largest academic mental health hospital, clinicians view the organization's vision as leading innovation and staying ahead of innovative trends, including the use of apps.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I think [the organization] is really great like that we were always sort of ahead of the curve, I think. And when people come here, they're always very impressed by all the technology and all the new things that we do. Everything like that. So that's pretty cool.\" [013, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eMotivation\u003c/h2\u003e \u003cp\u003eMotivation encompasses the brain processes that guide our decisions and behaviors. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] The COM-B distinguishes between automatic, such as emotions and impulses, and reflective motivations, including beliefs, values, evaluations, and plans for a target behavior. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Several barriers and facilitators for using the app for safety planning were found to be associated with clinicians\u0026rsquo; motivations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eProfessional role and identity related to safety planning\u003c/h2\u003e \u003cp\u003eThe interviewed clinicians unanimously emphasized SPI as a priority care goal in the ED, closely connected to their professional role and identity in ensuring patients\u0026rsquo; safety. Safety planning is already integrated into standard discharge practice and is considered fundamental to the care provided in the ED, described as the \u0026ldquo;bread and butter\u0026rdquo; of their work. For such reasons, the introduction of a new modality to improve the portability of safety plans was mostly well-received by clinicians.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Safety planning in general. I mean, I think that that's part of our assessments, that's really the sort of bread and butter of what we do in the emergency department. And safety assessments to some degree, are sort of incorporated into every assessment and discharge that we do\u0026hellip; \u0026hellip; I think there's a variety, I think there's sort of a spectrum of different safety assessments, as I said, depending on the patient, the provider, the risk threshold, all of these things. But I do think they're incorporated into most if not all of the assessments.\u0026rdquo; [007, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I almost feel obligated to \u0026ndash; like, it\u0026rsquo;s not my responsibility to keep people safe at all times. But at least while I\u0026rsquo;m working here, like an ED, I feel like anyone that comes to seek for help, I feel obligated to do my best to keep them safe. And just because they come at the lowest moment of their life and, I\u0026rsquo;m able to help \u0026ndash; that\u0026rsquo;s great. But if I don\u0026rsquo;t do enough then, I question myself, you could have done better. You could have spent more time with that person. Or just because I was preoccupied with something else and I couldn\u0026rsquo;t spend more time with that person, that person could have gotten better care. So I feel like safety planning is part of me doing my obligation in by sitting with them and just go through the questions with them.\u0026rdquo; [016, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite the importance of safety planning in the ED, variability in its delivery has been identified. Although crucial for all clinicians, the level of interaction provided to patients regarding safety plans differs. There is no prescribed time or amount of time that clinicians need to spend; it varies based on the clinician's discretion, whether the patient requires extra support when completing the safety plan for the first time or is already familiar with it. Therefore, when considering the app version of the safety plan, the amount of time that clinicians feel they need to allocate to each patient may vary. Although this is related to the busy nature of the ED, clinicians view safety planning as an important role regardless of the time allocated to this task.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"Yeah, there are definitely certain days where there's no time, but I think you have to make time. Especially for these vulnerable patients, right. And for me, personally, my practice, I don't \u0026ndash; especially these patients that are going through depressive episodes or have suicidal ideation, I never want them to think that I kind of abandon them. So for \u0026ndash; the safety planning takes 10 minutes of your time, right, maybe a little bit more. But I don't know, I think it's, I think this is a nurse to nurse question. And everyone's practice is different. But I personally, even if I'm really, really busy, I will try to make time for these people.\" [014, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConsidering the new modality, clinicians discussed how they saw technical support as part of their role. Technical support includes, but not limited to, assisting patients with Wi-Fi connection, downloading the app, or orienting patients with the app features. Although these tasks are not traditional 'clinical' roles, clinicians have been providing such support to patients already in the ED due to the ubiquitous use of technologies in healthcare. However, they talked about how important it is to share this responsibility among the team.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"[Tech support is] something that we can all do. Because if we are familiar with the app, and we know how to use it, we should be OK\" [010, program assistant]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"We also have other people that can help with some of those things like [program assistants] can help with, with setting up the Internet, they can help them to open the app. And then if they need any more help, they can ask the nurses, so it's not solely on the nursing staff.\" [013, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003ePerceived benefits and disadvantages of the app\u003c/h2\u003e \u003cp\u003eClinicians discussed anticipated benefits of the app. Some talked about some patients currently leaving the ED without their paper safety plan, so the portability aspect of carrying it with them via a phone was highly valued.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The paper you can leave in your car, in your home, in your bag and or lose it and eventually \u0026ndash; with the app, you can always open it up and then remind yourself it's always with you, if you want it, instead of trying, OK, I left my safety plan at home. But now at my parents\u0026rsquo; house, I don\u0026rsquo;t feel safe, I feel distressed and tried to remember what I did. And this way I have it on you. I think that's a big advantage.\" [002, nurse]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I do support going paperless, it's just tough, I think. Then also patients can easily lose that, there is a benefit to the app in the sense that those who have phones have their phones with them all the time.\" [009, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I think it's so great that they can carry it with them when they leave. Because people \u0026ndash;especially people, they don't care about paper like that. They'll throw it out, but on their phone, they can take it everywhere\u0026hellip; When we're cleaning the rooms, we see so many safety plans left behind.\" [010, program assistant]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA few clinicians commented on the layout of the safety plan in the app, suggesting that it prevents genuine reflection compared to the paper copy of the safety plan, which requires patients to come up with their own answers. Conversely, some mentioned that the app is more helpful and reduces time because it offers prompts to stimulate patients' thinking.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I just like to know that they've really thought about what responsibility they have in their own safety and what resources are available to them. It's kind of passive versus active learning. Like in the process of them writing out what resources are available to them, they're kind of actively participating in their own safety.\u0026rdquo; [009, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I'd say list the strategies and as you come up with those strategies, and sometimes you have to sort of brainstorm with the patients, or often solutions tailored to them. Because if you say to one individual that, \u0026ldquo;Well, you do this\u0026rdquo;, \u0026ldquo;Well, I don't have access to my family, I'm alone in this universe\u0026rdquo; type of thing. So it can be triggering to some people. But if it's just a select few options, that'll probably limit that, so it\u0026rsquo;ll be easier, you just tick, tick, tick.\u0026rdquo;[002, nurse]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003ePerceived impact of safety planning\u003c/h2\u003e \u003cp\u003eAdditionally, there were discussions regarding the anticipated impacts of safety plans in general. As SRTB exist on a spectrum, patients' engagement with their personalized safety plans to manage their daily lives extends beyond the control of the ED team. There appears to be some disbelief or skepticism towards the effectiveness of safety plans, which needs to be addressed despite the existing evidence.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I think it's useful, more mostly in the clinician\u0026rsquo;s perspective, as opposed to the patient's perspective. And that's only because, like I mentioned that piece of paper, once we've given it to them, more times than not, they just throw it out, it doesn't actually mean too much to them. I think out of 10 patients, maybe three or four would actually use that as the set purpose, the safety plan.\" [003, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I will say the biggest thing is patients really like it. And like I said, a lot more than they like the paper. Not that they ever minded the paper, but they really like it, and they really like having it on their phone and being able to open it easily and it feels like, I think, like this comforting thing that you can't lose the way that you would immediately lose the paper. And that it\u0026rsquo;s a working document and that you can change it\" [024, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I mean, they'll always be the person that thinks that it's rubbish. I mean, patient wise, right. Where they're just like, this isn't going to do anything. I'm going to scribble a couple answers that you like, down on a piece of paper, and you're going to discharge me now. It's like a check mark on the chart. But then there are some people that it's a good point of reflection, and then they rely on those new coping mechanisms when they're struggling in the future.\u0026rdquo; [005, program assistant]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003ePerceived level of workload changes and difficulty in using the app\u003c/h2\u003e \u003cp\u003eClinicians discussed workload changes regarding the implementation of the app. Some believed the app modality would decrease workload by minimizing time to retrieve and scan the paper forms, while others expressed concerns that it would increase their workload due to providing technical support to patients, potentially delaying the discharge process. Uncertainty regarding workload changes was an important consideration to address for future implementation efforts.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I think it might create new workload, in the sense of you might have people, staff having to help patients figure out, how to download the app, how to open the app. And I think staff might see it as a more time consuming task.\" [009, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I just think that it would be kind of a little bit time consuming. Of course, we don\u0026rsquo;t mind, but it\u0026rsquo;s just that there\u0026rsquo;s not always going to be that chance to \u0026ndash; it might not be even often, but you know, but it would all come down to how the day is going and how busy is that day.\u0026rdquo; [025, nurse]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I think the practice change is going to be relatively easier. Because from my perspective, it just comes across, like I said, of having a tool on hand in my pocket, that will actually help me explain a safety plan better. And then I still have the option of offering the paper copy, which I generally offer anyways. The only thing is it requires more time.\" [003, psychiatrist]\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I think we are technology savvy enough for each team member to if they need to sit down and show the patient how to use it. But that also takes time and that\u0026rsquo;s the thing that\u0026rsquo;s in short demand in the [ED]. So, everybody is just so busy. So initially, just kind of sitting down and going through with patients how to use it, I can imagine staff members will feel like that\u0026rsquo;s another burden on their time.\" [017, pharmacist]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnticipation of patients' reactions to checking the phone\u003c/h3\u003e\n\u003cp\u003eAnother barrier discussed was concerns about patient\u0026rsquo;s reactions to clinician\u0026rsquo;s viewing the safety plan on the patient\u0026rsquo;s personal device. Although it is the clinicians\u0026rsquo; responsibility to support patients in developing and going over the safety plan, they were unsure whether it would be appropriate to ask patients to hand over their phone or turn the screen towards clinicians. In either case, clinicians were concerned about how patients would react. Some mentioned that it would be \u0026apos;invasive\u0026apos;, potentially impacting the therapeutic relationship.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I think it makes it a little bit difficult in the sense that I\u0026apos;d have to go back in and see the patient and read their phone. Whereas in this scenario, it\u0026apos;s usually nursing brings me back the worksheet that the patient has completed. And then I just review it, copy it, give the original back to nursing so they can give back to the patient or give back to the patient myself.\u0026quot; [009, psychiatrist]\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Looking over somebody\u0026apos;s phone is invasive a little bit? Yeah, a little bit. And not everyone might be comfortable to do that or to hold the phone itself or with COVID germs.\u0026quot; [012, nurse]\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\n \u003ch2\u003eIdentifying potential solutions to behavioral change using the BCW\u003c/h2\u003e\n \u003cp\u003eGrounded in behavior change theory, the COM-B and TDF facilitated a comprehensive analysis of clinicians\u0026rsquo; capability, opportunity, and motivation for app use, shedding light on how these factors interact to influence behavior. We also discovered barriers and facilitators for safety planning itself, identifying important areas for improvement in the ED. It was important to note that barriers and facilitators within the COM-B and TDF domains can interact with each other. In other words, individuals\u0026apos; capability influenced aspects of their motivation, like the level of confidence, and factors related to opportunity, like the social environment or team culture, also influenced motivation to perform the target behavior. For example, physical resources such as slow Wi-Fi in the ED influenced clinicians\u0026rsquo; beliefs about anticipated changes in workload, creating a negative emotional response, which influenced the likelihood of performing the target behavior \u0026ndash; using the app to deliver SPI. As such, when designing implementation strategies, it is important to think comprehensively about the possible behaviour change solutions to target multiple COM-B domains. [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eOne major gap in implementation science is the absence of theoretical grounding in strategy development, alongside a discrepancy between context and implementation strategies, which frequently leads to inadequacy and unsustainability in implementation. [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e] To understand how the barriers can be addressed and facilitators can be leveraged, we examined suggested intervention functions (i.e., solutions) for the target determinants of behavioral change. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e is informed by the work of Michie et al. [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] and displays the matrix of intervention functions deemed most relevant to target the COM-B barriers, colored in green. These connections between intervention functions and COM-B domains have been previously established through expert consensus and reliability testing. [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] We mapped our study findings to the left column according to the COM-B. By using this matrix, we identified appropriate implementation strategies to target the barriers and leverage facilitators to support clinicians\u0026rsquo; behavior change. This aligns with evidence-based practice for designing rigorous implementation strategies to make the process of tailoring more effective. [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003e\u0026lt;Insert Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026gt;\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003eTable 3. COM-B matrix and intervention functions\u003c/div\u003e\n \u003ctable style=\"border: none;width:100.0%;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 37.62%;border: 1pt solid black;padding: 0cm;height: 14.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:6.55pt;margin-bottom:6.0pt;margin-left:6.55pt;text-align:center;'\u003e\u003cspan style=\"font-size:13px;\"\u003eBarriers and facilitators identified from the current study\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width:14.34%;border:solid black 1.0pt;border-left:none;padding:.75pt 5.4pt 0cm 5.4pt;height:14.55pt;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;text-align:center;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;text-align:center;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;text-align:center;'\u003e\u003cspan style=\"font-size:13px;\"\u003eCOM-B\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" style=\"width:48.06%;border:solid black 1.0pt;border-left:none;padding:.75pt 5.4pt 0cm 5.4pt;height:14.55pt;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;text-align:center;'\u003e\u003cspan style=\"font-size:13px;\"\u003eBCW Intervention Functions\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 76.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:5.65pt;margin-bottom:.0001pt;margin-left:5.65pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eEducation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.26%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 76.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:5.65pt;margin-bottom:.0001pt;margin-left:5.65pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003ePersuasion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 76.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:5.65pt;margin-bottom:.0001pt;margin-left:5.65pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eIncentivization\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 76.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:5.65pt;margin-bottom:.0001pt;margin-left:5.65pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eCoercion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 76.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:5.65pt;margin-bottom:.0001pt;margin-left:5.65pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eTraining\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 76.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:5.65pt;margin-bottom:.0001pt;margin-left:5.65pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eRestriction\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 76.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:5.65pt;margin-bottom:.0001pt;margin-left:5.65pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eEnvironmental Restructuring\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 76.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:5.65pt;margin-bottom:.0001pt;margin-left:5.65pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eModelling\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 76.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:5.65pt;margin-bottom:.0001pt;margin-left:5.65pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eEnablement\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.62%;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:0cm;margin-bottom:6.0pt;margin-left:6.55pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eAwareness, knowledge, skills, memory, decision making, behavioural regulation and habit breaking\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.34%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003ePsychological capability\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.26%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 25.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.62%;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:6.6pt;margin-bottom: 6.0pt;margin-left:6.55pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eWi-Fi and technical resources, documentation infrastructure, access to smart devices, busy ED, short staffing, patient population\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.34%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003ePhysical opportunity\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.26%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 21.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.62%;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:6.6pt;margin-bottom: 6.0pt;margin-left:6.55pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eCommunication about SPI, team culture, leadership support, organizational vision\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.34%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eSocial opportunity\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.26%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 23.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.62%;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:6.6pt;margin-bottom: 6.0pt;margin-left:6.55pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eProfessional role and identify, preferences for technology, technical competence\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.34%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eAutonomic motivation\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.26%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 15.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.62%;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:0cm;margin-right:6.6pt;margin-bottom: 6.0pt;margin-left:6.55pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eProfessional role and identify, beliefs about consequences for using the app, perceived impact of SPI, goal\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.34%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003eReflective motivation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.26%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.36%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(112, 173, 71);padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.38%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.84%;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0.75pt 5.4pt 0cm;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0cm;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'\u003e\u003cspan style=\"font-size:13px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eThe matrix confirms that to address limited awareness of the app, education and training is necessary to support the implementation. Web-based training and informational resources about the app are available within the organization, but these educational tools may require updating and active dissemination efforts in the ED. Training and education are popular implementation strategies for suicide prevention [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]; however, it is important to note that addressing limited awareness and promoting familiarization of the app alone cannot lead to successful implementation. There are other barriers we identified that require more attention, such as motivation and opportunity, which are often not adequately addressed and lead to ineffective implementation in ED related to suicide prevention care. [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e] To address concerns related to the busy ED and workload challenges, environmental restructuring may be necessary. Environmental restructuring refers to making changes in social or physical environment. [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] Possible ideas include making EHR form changes to streamline the SPI documentation process and standardizing communication process that clinicians are concerned about. Additionally, to address skepticism towards the effectiveness of SPI, persuasion may be necessary. Persuasion-type interventions can be particularly helpful in mitigating negative emotions or attitudes. [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] For example, referring staff to systematic reviews on the effectiveness of SPI and patient testimonials for the app and its impact on their SRTB management can help increase their awareness of the positive impacts that SPIs can have on suicide prevention.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study involved interviews with 29 ED clinicians, comprising nurses, psychiatrists, social workers, program assistants, and a pharmacist, with varying levels of clinical experience. Most participants had not used the app, highlighting a lack of awareness despite its availability since 2020. Clinicians mentioned staff turnover rate, busy schedules, and an overflow of information as contributing factors to their limited awareness for the app. The study revealed key barriers such as the absence of standard communication methods for safety planning, limitations in EHR documentation infrastructure, and concerns regarding patient access to smart devices and Wi-Fi connectivity in the ED. In addition, clinicians discussed the anticipated consequences of workload changes in an already busy ED setting. Despite the perceived barriers, clinicians expressed positivity to adopt the app, emphasizing its potential benefits in enhancing safety planning portability and patient engagement. Notably, strong team culture, leadership support, and alignment with organizational goals emerged as facilitators for the app use in routine care. These findings underscore the need for tailored strategies addressing clinicians' capabilities, opportunities, and motivations to promote successful implementation of the app in the routine clinical care.\u003c/p\u003e \u003cp\u003eAnticipated concern for workload changes associated with the app implementation was one major concern that we heard from many clinicians. This finding is corroborated by a previous qualitative systematic review, which suggests that the integration of new technology can be perceived as creating an additional burden of care, including administrative tasks related to technology. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Lack of time and additional tasks for a newly introduced technology was also discussed, similar to the current study findings. Additionally, limited infrastructures for supporting new technology implementation in clinical settings [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] were also similarly identified in the current study. Integrating apps into the EHR is one effective way to support sustainable integration of these interventions. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] Various interoperability standards exist to support the linkage of apps with the EHR, such as the Health Level 7 Fast Healthcare Interoperability Resources (HL7 FHIR). [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] However, this is not always feasible within the healthcare organization, especially as FHIR itself faces its own implementation challenges. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWe also identified several facilitators, which represent strengths that can be leveraged for future implementation efforts for the app. Notably, within this ED, we observed a strong sense of professional responsibility, a cohesive team culture, and strong leadership support. While targeted implementation strategies are often customized to tackle identified barriers, as recommended in implementation practice, it is also equally important to capitalize on existing facilitators when supporting implementation. One critical facilitator for technology implementation in healthcare is leadership and team culture. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] The current study setting is in an advantageous position due the robust leadership support and positive team dynamics. While the lack of leadership support and the absence of positive team dynamics have been barriers in previous mental health app implementations, [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] in this setting, these factors can be capitalized as strengths to sustain the app implementation and adoption. Despite this strength, it is also essential to consider the non-static and iterative nature of healthcare systems. Sustainability (i.e., long-term use and maintaining benefits) remains to be one major gap for implementation of evidence-based interventions in healthcare. [\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] Team culture and leadership may evolve over time and new barriers may arise during the implementation process. Therefore, while we can capitalize on and sustain these existing strengths, it is imperative that we continue to monitor them. This includes making necessary adaptations [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] to the deployed implementation strategies and considering the introduction of new strategies [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] to ensure the sustainability of the app use for SPI.\u003c/p\u003e \u003cp\u003eAs more innovative technologies are integrated to augment care, clinicians are increasingly assuming non-traditional clinical roles, such as supporting patients in connecting to Wi-Fi and troubleshooting technical glitches. Although these roles are not traditionally considered clinical, clinicians in the current study reported that they undertake these tasks, nonetheless. This was identified as a facilitator in the current study; clinicians were already providing this technical support to patients in the ED, primarily with Wi-Fi connection. Additionally, there may be added tasks with the app implementation, such as introducing and orienting the app to patients. To ensure the sustainability of the app implementation, further exploration is necessary, as technical support cannot always be guaranteed due to human resource challenges and increasing patient volumes, [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] potentially limiting clinicians' availability to provide such support to patients. Digital navigators are an emerging area to support the adoption and integration of technologies into care. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] Major roles of digital navigators include technical assistance, [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] workflow optimization, [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] and providing support for digital literacy, [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] among others. Similarly, in the current study, program assistants were more frequently involved in tasks resembling those of digital navigators compared to other clinical disciplines. To ensure the sustainable implementation of technologies in healthcare, formalizing digital navigator roles could offer potential solutions to address human resource challenges.\u003c/p\u003e \u003cp\u003eClinicians were concerned about potentially infringing upon their patient\u0026rsquo;s privacy by having to view their patients\u0026rsquo; personal device, despite clinical responsibility for assessing the completeness of the safety plan. As SPI is inherently collaborative, even with changes in modality, it is expected to maintain its collaborative nature. As such, the use of apps and other digital tools in healthcare raises questions about how it can be therapeutic and collaborative. [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] Additionally, SPI is one critical aspect of discharge planning. Discharge communication is crucial in all healthcare settings, including the ED. Despite this, ED clinicians face unique challenges due to the busy environment. For instance, the discharge process may be rushed, which can contribute to poor discharge communication, [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] leading to insufficient instructions, [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] impacting patients' post-discharge health outcomes and increasing return visits to the ED. [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] Considering the nature of SRTB and the critical window of opportunity for healthcare contact by patients living with SRTB, [\u003cspan additionalcitationids=\"CR59\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] the discharge process must not be rushed. Further exploration is needed to determine how the app can be integrated into clinical workflows. There is a specific need to determine how the app can be introduced in the ED, to maintain the collaborative nature of SPI, and there is a need to determine when to introduce the app during the patient\u0026rsquo;s stay in the ED. As outlined in the next phase of the study, [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] such details will be explored and discussed with a team of patient partners, families, and clinicians.\u003c/p\u003e \u003cp\u003ePrior implementation studies of SPI apps in European countries have highlighted limited uptake and sustained use of these apps over time, despite their high ratings for usability and acceptability. [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] Recent research in New Zealand has also shown a positive attitude towards digital tools among mental health clinicians, with smartphone apps being frequently utilized alongside other types of digital tools. [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] Similarly, clinicians in the current study expressed openness to the app because of its ease of use and their perceived digital literacy skills. Our study explored factors beyond usability and acceptability (i.e., motivation, opportunity) and their relationships, shedding light on potential explanations for the limited uptake and sustained use, and highlighting the importance of considering the dynamic nature of the healthcare system and the individuals involved when implementing new innovations. Additionally, previous research has used the BCW and TDF to investigate behavior change strategies aimed at encouraging primary clinicians to prescribe apps. [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] Similar to our findings, education and training were identified as necessary strategies to support clinicians in improving knowledge, self-confidence, and skills for using apps. However, none of the behavior change strategies identified in the current literature used rules or restrictions to increase app prescriptions or decrease competing behaviors. [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] In line with recommendations for behavior change solutions [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] and the findings presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, our future work will involve design sessions with clinicians, families, and ED services users to identify feasible behavioral strategies. We will ensure that these strategies maintain the theoretical backbone of the solution's design while establishing mutually agreed-upon expectations. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study's findings are limited to one ED context, which is unique, compared to other EDs that provide both medical and psychiatric emergency care services. As such, some findings may not be applicable, or there may be additional barriers unexplored due to the nature of the study context. For example, EDs are often described as having a biomedical focus, leading to hesitance and uncertainty from the ED team towards psychiatric care. [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] There also tends to be a dichotomy of care between psychiatry and medical/physical health care, which needs to be further challenged to promote holistic healthcare. [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] However, since the ED in this study provides psychiatric emergency health care exclusively, this could lead to a different culture, different attitudes and levels of professional role and identity related to SPI. To accommodate for these contextual differences and to support transferability of our study findings, we have attempted to provide contextual details where appropriate.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study, grounded in behavioral change theory, identified key behavioral factors influencing the implementation of an app to support SPI in the psychiatric ED. These factors encompassed barriers and facilitators that collectively impacted clinicians' capability, opportunity, and motivation. It was evident that tailored strategies were essential to address these barriers, while leveraging facilitators could help support and sustain future implementation efforts. In addition to the identified behavioral barriers and facilitators, our study highlighted the importance of ongoing monitoring and being open to adaptation of implementation strategies. By remaining attentive to evolving clinician needs and organizational dynamics, new barriers could arise, or facilitators might weaken, thus impacting the sustained use of the app in the ED.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe raw data supporting the findings of the manuscript can be requested to the corresponding author. The anonymity of the participants must be secured; in the raw data, it is possible to identify the participants, and therefore restrictions will be applied to the availability of these data. Reasonable requests concerning the data can be sent to the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research complies with all the relevant national regulations and institutional policies Ethics approval for the study was obtained from the Research Ethics Board at the Centre for Addiction and Mental Health (REB# 2023/078) and the University of Toronto (REB #\u0026nbsp;45110). All participants signed an informed consent form after having received written information to enable them to make an informed choice regarding participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants consented to have the findings shared through publications and presentations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have no competing interests to declare with this submission. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs a Doctor of Philosophy candidate in health services research at the University of Toronto, HDS is supported by the Canadian Institutes of Health Research Doctoral Research Award, the Canadian Behavioural Intervention and Trials Network Doctoral Studentship, and the Registered Nurses\u0026rsquo; Foundation of Ontario Research in Mental Health Award. Funding agencies did not have any role in content development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHDS, JZ, JT, GS conceived the study design. HDS designed and led data collection, analysis and interpretation. HDS, KD, IK, SK participated in data analysis. HDS wrote the first draft of the manuscript and worked on revisions. JZ, JT, GS provided guidance on all phases of the work. All the authors (HDS, JZ, JT, GS, IK, KD, SK) critically reviewed and provided feedback on the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe kindly thank all clinicians for their time and efforts in sharing their experiences and insights during interviews. Additionally, we wish to acknowledge the ED leadership team for facilitating the recruitment process, granting permission for the first author\u0026apos;s visits to the ED for recruitment and data collection in this research study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Suicide. World Health Organization. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/suicide\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/suicide\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 29 Jul 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverman MM, Berman AL, Sanddal ND, O\u0026rsquo;Carroll PW, Joiner Jr. TE. 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Journal of Technology in Behavioral Science. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s41347-024-00403-z\u003c/span\u003e\u003cspan address=\"10.1007/s41347-024-00403-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlkhaldi O, McMillan B, Maddah N, Ainsworth J. Interventions Aimed at Enhancing Health Care Providers\u0026rsquo; Behavior Toward the Prescription of Mobile Health Apps: Systematic Review. JMIR Mhealth Uhealth. 2023;11:e43561.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShin HD, Price S, Aston M. A poststructural analysis: Current practices for suicide prevention by nurses in the emergency department and areas of improvement. Journal of Clinical Nursing. 2020;n/a n/a.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mental Health, mHealth, Mobile Health, Technology Adoption, Implementation Science, Behaviour Change","lastPublishedDoi":"10.21203/rs.3.rs-4390525/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4390525/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEmergency departments (ED) play a crucial role in suicide prevention, with evidenced-based safety planning interventions (SPI) playing an important role. Traditional safety plans, which are often paper based, come with challenges (i.e., not easily accessible, or easy to misplace). Digital safety planning tools offer an alternative mode of intervention delivery, but clinical implementation remains limited. Using behavioural change frameworks, we aim to provide insights into the factors influencing app adoption. These insights will be used as a knowledge base to design behavior change strategies to promote the implementation of a SPI app in a psychiatric ED.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe used a qualitative descriptive design to conduct semi-structured interviews with clinicians in a psychiatric ED in Toronto, Canada. Participants encompassed all ED staff, irrespective of their SPI app usage. The semi-structured interview guide was developed using the Theoretical Domains Framework (TDF) and the capability (C), opportunity (O), motivation (M) and behavior (B) (COM-B) model. We then used directed content analysis, identifying findings within the TDF and COM-B domains as barriers, facilitators, or both.\u003c/p\u003e\u003ch2\u003eFindings:\u003c/h2\u003e \u003cp\u003eA total of 29 ED clinicians were interviewed, including nurses, psychiatrists, social workers, program assistants, and a pharmacist. The majority had not used the app. We observed strong motivation among clinicians across all disciplines to use the app, and they considered SPI as a high-priority ED care strategy closely linked to their professional identity and responsibility. Anticipated barriers regarding the app as a new mode of SPI delivery in routine practice included: documentation, communication, care efficiency, and patient access to smartphones. Some barriers were attributable to the lack of interoperability between the app and the electronic health record and documentation infrastructure for the app.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe identified key behavioral factors influencing the implementation of the SPI app in the psychiatric ED. We found that tailored strategies are essential to address barriers, while leveraging facilitators can sustain implementation. Additionally, ongoing monitoring and adaptation of strategies are necessary, as new barriers may arise or facilitators may weaken over time, impacting the sustained use of the app in the ED. We will use these findings to inform the next phase of this work, which involves co-designing targeted and tailored implementation strategies.\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to Using an App-Based Tool for Suicide Safety Planning in a Psychiatric Emergency Department: A Qualitative Descriptive Study Using the Theoretical Domains Framework and COM-B Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-21 18:51:43","doi":"10.21203/rs.3.rs-4390525/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"531918b3-ef35-47ac-ace9-b2ce59477cdb","owner":[],"postedDate":"May 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-03T17:08:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-21 18:51:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4390525","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4390525","identity":"rs-4390525","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}