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
7 affiliations
- 1Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- 2Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- 3Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
- 4Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- 5Health Outcomes and Performance Evaluation (HOPE) Research Unit, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- 6Gerald Sheff and Shanitha Kachan Emergency Department, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- 7Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
Abstract
Background: Emergency departments (EDs) 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. As such, we found that tailored strategies that can mitigate barriers by targeting capability, motivation, and opportunity are essential, while facilitators that can sustain implementation should be leveraged. 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.
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BibTeX
@article{shin2026barriers,
title = {{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}},
author = {Hwayeon Danielle Shin and Keri Durocher and Iman Kassam and Sridevi Kundurthi and John Torous and Gillian Strudwick and Juveria Zaheer},
journal = {PLOS One},
year = {2026},
month = oct,
doi = {10.1371/journal.pone.0355517},
url = {https://doi.org/10.1371/journal.pone.0355517},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - 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
AU - Hwayeon Danielle Shin
AU - Keri Durocher
AU - Iman Kassam
AU - Sridevi Kundurthi
AU - John Torous
AU - Gillian Strudwick
AU - Juveria Zaheer
PY - 2026
DA - 2026/10/13
JO - PLOS One
DO - 10.1371/journal.pone.0355517
UR - https://doi.org/10.1371/journal.pone.0355517
AB - Background: Emergency departments (EDs) 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. As such, we found that tailored strategies that can mitigate barriers by targeting capability, motivation, and opportunity are essential, while facilitators that can sustain implementation should be leveraged. 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.
SN - 1932-6203
ER -