Short Abstract

This evaluation of the Hertfordshire Suicide Prevention Pathway combined the Implementation Research Logic Model and Theoretical Domains Framework within a developmental evaluation to enable real-time adaptations and improved adoption and implementation across acute healthcare settings.

Description

Background

We present an evaluation of the early implementation of a novel healthcare pathway and use of a developmental evaluation approach to influence pathway development and improvements in implementation.

In 2024, Hertfordshire Partnership University NHS Foundation Trust, in collaboration with Hertfordshire Mental Health, Learning Disability and Autism Health Care Partnership, launched the Hertfordshire Suicide Prevention Pathway (HSPP). Based on scientific evidence, the HSPP aims to enhance early identification, safety planning, and continuity of care across services. HPSS was developed in response to local and international evidence base relating to rising suicide rates and acute healthcare settings as critical intervention points for suicide prevention.

The evaluation employed the Implementation Research Logic Model (IRLM) and Theoretical Domains Framework (TDF) to explore both organisational and behavioural determinants to understand how the pathway was adopted, adapted, and embedded across a multi-agency system.

Methods

A developmental evaluation approach was used to support real-time learning and adaptation between April 2024 and February 2025. Qualitative data were gathered through stakeholder workshops and individual conversations. Purposive sampling included clinicians and senior leaders from acute and mental health services. The IRLM guided the mapping of determinants, strategies, mechanisms, and outcomes, while the TDF informed topic guides and coding, enabling analysis of behavioural factors such as knowledge, skills, beliefs, and motivation. Thematic analysis was applied to transcripts and detailed notes.

Results

Implementation was iterative and adaptive. The IRLM helped to identify key strategies, including face-to-face and simulation-based training, e-learning modules, promotional materials, leadership-led communication and IT system improvements. The evidence-based structure of the intervention was well received, although some training content and terminology were less relevant. Workload pressures, and inconsistent understanding created barriers to adoption. At the individual level, leadership at both senior and team levels acted as key enabler, while confidence varied according to clinical experience. Emotional factors, e.g. fear of making mistakes, also influenced uptake. In terms of process, promotional activities, IT optimisation, and flexible training formats helped support engagement.

Mechanisms of change included strengthened shared language around suicide prevention, increased staff confidence following simulation training, and improved visibility of the pathway in high-risk settings. Early outcomes included increasing numbers of staff trained and referrals to the pathway, greater awareness among acute teams, and improvements in signposting to external services.

The TDF highlighted variability in staff knowledge, confidence, motivation, and emotional resilience. Whilst variability in staff understanding and engagement remained a challenge, changes to training improved confidence, and improvements in communication gaps and IT integration enhanced adoption and acceptability.

The combined IRLM-TDF analysis and regular feedback workshops to share emerging findings enabled real-time adaptations; targeted communication strategies, expanded training formats, and improved electronic system integration.

Conclusion

Early implementation of the HSPP reflects strong organisational commitment, iterative adaptation, and growing cross-sector engagement. Integrating IRLM-TDF provided a robust, theory-driven framework to identify actionable improvements and behavioural drivers. The developmental evaluation approach ensured findings were rapidly translated into implementation. This combined methodology offers a transferable model for evaluating complex, multi-agency health service innovations that require quick translation of findings into actions.