A qualitative design, implementing focus groups was employed for this study. Focus groups on healthcare research have several advantages relevant to the current research study. The group setting encourages active participation from individuals who may be reluctant to be interviewed or voice their opinion on their own, facilitates the discussion of taboo topics, and allows participants to mutually support one another in expressing views that may deviate from that assumed of the research team [14]. The paper is following the Consolidated Criteria for Reporting Qualitative Research [15]; Appendix 1).
Sample size justification
Phenomenological qualitative studies require small samples of up to 10 cases for a thematic analysis [16]. Furthermore, research suggests that 80% of all themes are identified within two to three focus groups, and 90% are identified within three to six focus groups. Therefore, we aimed for 10 participants per participant group across three to six focus groups [17].
Participant selection
Three groups of participants with lived-experience was recruited: young people, carers, and mental health clinicians working in ED. The study was limited to the consumer advisory groups (consumers/community members involved in assisting the hospital to plan, design and deliver better health services for children and young people) and Acute Response Team (a 24 h ED-located team providing mental health triage and assessment to children and young people) and advertised at regular meetings. Recruitment emails were sent out by the convenors of the relevant groups (the Children’s Health Queensland CYMHS Beautiful Minds and the CYMHS Parent/Carer Advisory Group). Mental health clinicians were invited to participate on a voluntary basis, it was emphasised that there were no detrimental effects for clinicians who declined to participate and that transcripts would be de-identified (given that two members of the research team also worked in the CYMHS). Recruitment was limited to young people (aged 17–25 years) with lived-experience of discharge from the Queensland Children’s Hospital ED after a suicide attempt or self-harm incident, lived-experience caring for a young person who had been discharged from the ED following a suicide attempt or self-harm incident, or a mental health clinician working in the ED.
Data collection
Focus groups were conducted between April and May 2019 at the Queensland Children’s Hospital campus. Written consent was obtained prior to focus groups beginning. For participants under the age of 18 years, written consent was also obtained from a parent. During and immediately after the focus group, a clinician was available for support if a participant became distressed; no such events occurred during the study. All focus groups were conducted in conference rooms with refreshments provided. Focus groups were conducted separately for each type of stakeholder group with two focus groups being held for mental health clinicians, one for young people, and one for carers and parents. Participants completed a demographic questionnaire asking their age and gender. Focus groups were conducted separately for each type of participant to capitalise on individuals’ shared experiences. The homogenous group setting encourages active participation from individuals who may be reluctant to be interviewed or voice their opinion on their own, facilitates the discussion of taboo topics, and allows participants to mutually support one another in expressing views that may deviate from that assumed of the research team [18].
The focus groups were conducted by a female clinical psychologist with more than 15 years of experience in child and youth mental health and suicidality, who was assisted by a male PhD candidate in psychology. The first (experienced in conducting focus groups) led the focus group discussion following the interview booklet and kept participants on track. The second researcher assisted by observing, taking notes, and monitoring the audio recording device. Neither had previously met any of the participants and spent the start of each focus group establishing a rapport through general conversation and explaining the study’s purpose and personal biases. The research team members who were involved in recruiting participants welcomed the participants to focus groups but left prior to focus groups beginning.
Young people and carers were reimbursed for their time commitment (of up to 3 h) with an AUD$110 gift card. Mental health clinicians were offered the convenience of participating in the focus group during work time and at their workplace.
All focus groups lasted approximately 90 min and were audio recorded. Recordings were transcribed by Pacific Transcriptions with all participants de-identified. All participants were offered the opportunity to review the de-identified transcripts.
Ethics
All procedures were approved by the Children’s Health Queensland (HREC/18/QCHQ/44615) and Griffith University Human Research Ethics Committees (GU HREC 2018/990). By our ethical clearance we were limited to recruit participants of the Children’s Health Queensland CYMHS Beautiful Minds and CYMHS Parent/Carer Advisory Groups, who were supposed to remain anonymous.
Interview guide
A semi-structured guide was developed after review of similar projects available in the literature and through clinical experience (Appendix 2). Briefly, however, the questions primarily focused on three distinct models of follow-up interventions (an existing unstructured model; assertive [7]; caring contacts [19]) post-discharge from the ED. A description of each model is provided in Appendix 3. Questions were asked about participants’ perception of a follow-up phone call service, what was useful or needed to be changed from each of the three interventions, helpful messages, and finally a section for open comments. This final section of the focus group allowed participants to suggest alternative solutions to follow-up care.
Participants’ demographics
Clinicians consisted clinical nurses (n = 5), social workers (n = 3), or psychologists (n = 2) and had between 6 and 20 years of experience in mental health (Mexp = 11.75, SDexp = 5.17). Ten clinicians (six female) participated across two focus groups (aged 27–47, M = 38.40, SD = 7.07). Five young people (3 male) participated (aged 17–21, M = 19.20, SD = 1.47) and three female parents/carers participated (57–65, M = 58.33, SD = 4.99) in separate focus groups.
Data analysis
The beginning of the qualitative analysis was creating a foundation for an intervention to be built upon. While funding, effective counselling methods, service access, and target populations may change over time, a solid foundation that reflects the lived-experience can provide the platform for a range of intervention iterations. To achieve this, the first phase of qualitative analysis involved a phenomenological analysis using the seven steps described by Colaizzi [20] using Nvivo (version 12). This method has previously been used to understand and represent the lived-experience of people across a range of experiences and was a logical method given the aim was to understand participants’ lived-experience of suicidal behaviour [21,22,23,24]. The following seven-steps were conducted:
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(1)
Familiarised and immersed in the transcripts (conducted by all authors);
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(2)
Identified all significant statements relevant to the phenomenon of receiving phone calls after ED discharge (DW, MP);
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(3)
Identified meanings from the relevant significant statements (DW, MP);
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(4)
Clustered meanings into similar themes into a computer word processor (DW, MP);
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(5)
Produced an exhaustive description of phenomenon with all themes (DW);
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(6)
Produced condensed description of primary aspects of the phenomenon (DW); and
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(7)
Returned the structure statement to all participants to ensure it captured their experience (DW).
The final step of the Colaizzi [20] method has not been endorsed by some due to the theoretical and practical concerns (e.g., [25]), however, this step was deemed crucial from the lived-experience involvement perspective and was therefore included in the current study. Inclusion of this final step meant that we were able to ensure those with lived-experience were included as far as practical throughout the study and write-up. A small number of young people (n = 2 who had completed the focus groups and n = 2 who had not), and parents/carers (n = 3) were consulted to discuss their satisfaction with the validity of the results. All of those consulted were satisfied with the accuracy of the interpretation of their experience.
Acknowledging that phase one provides only a foundation for the intervention and does not structure physical ‘content’, phase two aimed to develop this. While guided by clinical experience (SB; MP; JH), phase two involved a secondary qualitative analysis to help develop content for the intervention and analyse participants’ practical suggestions. As such, a deductive content analysis was conducted based loosely around the semi-structured focus group questions. For example, focus group questions broadly assessed what participants thought was helpful or what should be changed about existing post-discharge follow-up interventions; utility of the existing (phone call) intervention; preferences for intervention target and content; timing of intervention; and finally, messages that may be helpful to others in this situation (i.e., post-discharge). With this overarching framework in place, a deductive content analysis (as per [26] was applied to participants’ responses in relation to questions that were asked throughout the focus groups (e.g., “What do you think could be of help in this model?” and “If you could change anything about this model what would it be?”. This method is appropriate to help generate further structure and content to the intervention that was responsive to the participants with lived-experience [26]. All researchers separately familiarised themselves with the data, identified significant statements, and collated into overarching potential themes in relation to the focus group questions. All researchers then met to discuss preliminary themes and two researchers (DW, MP) progressed this separately into final themes that would inform intervention content.