Staff focus groups
In total, 27 Lifeguards participated (22 women and 5 men), with representation from all eight intervention pharmacies attending a focus group. Analysis identified four main overarching categories of themes of Setting, Impact, Staff Experience and Improvements with 14 sub-themes as shown in Fig. 2.
For the purposes of this analysis a distinction is made between “customers” who are the people generally using pharmacy services and the “clients” who are the people that the Lifeguards specifically used Lifeguard resources and had consultations with. A further distinction is made between “cases” which were cases of clients that met the study criteria of experiencing either DA and/or SI and “interactions” which were Lifeguards used their learning, skills and Lifeguard support materials for other issues.
Theme 1: Impact - Participants described at length the perceived impact that the service had had on them and their clients, giving outlines of cases that they had had.
Overall value of the service - All participants agreed that the service was of overall benefit. They had applied their Lifeguard training to their interactions with customers and found the Lifeguard resources invaluable in giving them a supportive structure to delve deeper and enquire about possible SI and/or DA in those interactions.
....and his [client’s] demeanour changed, so I did the same and sort of probed a little further, until basically, asking the right question and him saying “I’m getting the last few things in order and then I want to do it.” [referring to taking his life] So, it escalated really quickly, over the space of about five minutes. And then, obviously that changed the conversation and we set up a few different things in place.
(staff participant - online FG, group 1, 25/04/23)
Connections made through these interactions often built over time, with customers returning to continue conversations.
I've had one person myself that has actually come back twice to me. First time, it was for suicidal ideation, and the second time it was for domestic abuse. So, because, the first time we met, we made such a good impression and we've been touching base, because it's a village setting and it was, sort of, a case of she'd become familiar and safe with us, she then felt open enough to come and speak about something else she was concerned about and we could help her further.
(staff participant - online FG, group 2, 2/05/23)
Relationship with Customers – Staff often had very good relationships with their customers, they had many “regulars” that they knew well. This facilitated identification of signs of distress if somebody looked “slightly off”. Staff reported seeing clearly what had previously been hiding in plain sight. For example, realising that a woman, whose daily methadone supplies were often collected by her partner, was not receiving them and was experiencing domestic abuse. Several staff reported that having Lifeguard consultations with their customers who were already “regulars” created a bond and improved their relationship with them.
…it made a bond that we didn’t expect as such. It’s stronger somehow...
Yeah, there’s no question about it, the clinician-patient relationship jumps a level if you have that interaction….
(discussion between two staff participants in in-person FG, 17/04/23)
Overcoming access barriers – Staff spoke about the perceived barriers that clients face in asking for help, such as fear of prejudice and judgement from others and the client’s own experiences of shame or pride about asking for help.
“ I think it is so difficult for people to ask for help in the first place. If they’ve been to their GP and they get knocked back, if there’s nobody there to fill that little gap and fight for them, they’re not going to get the help they need”.
(staff participant, online FG2 25/4/23).
Even when a connection had been made there could be a further reluctance to being referred due to fear and possible repercussions such as social services becoming involved. This was particularly apparent for some clients experiencing DA who often had their partner waiting outside. One participant reported how he and a fellow Lifeguard had used a pincer approach to deliberately delay the dispensing of a client’s prescription to give the Lifeguard an opportunity to talk to the client. Staff found the QR code client support cards invaluable in these reluctant or hurried type situations.
Substance Use Disorder – A particular group of customers that featured extensively in the focus group discussions were people who were being treated for substance use disorder. It was notable that staff often had a particularly good relationship with these clients and that they recognised that these customers had often had incredibly difficult lives and needed extra attention.
A few of ours have been some of our “blue scripts”, which are addict scripts that we've gone in to give them that dose in a private room….Because they're people we see day in, day out, you know when something is not right. We tend to be, sort of, “Are you okay? Is there something wrong? You don't seem yourself today.” That's where the conversation tends to start.
(staff participant, online FG, group 2, 25/04/23)
Theme 2: Setting - Staff considered community pharmacy to be a suitable setting if there was local need, flexibility around the scope of the service and sufficient capacity to deliver the service effectively.
Community Pharmacy Setting – Being drop-in, easily accessible and a neutral environment were considered to be facilitators for help-seeking behaviour.
… the perfect place. Because you can walk into a pharmacy and it’s not suspicious
(staff participant, in-person FG, 17/04/23)
A key enabler was not only that customers could “drop-in”, but that they could also “drop-out”, in that they could leave when they wanted. Many clients were in a hurry or had somebody waiting but were able to have snatched conversations that may not have been possible in an appointment-based service.
Most cases were identified opportunistically whilst doing another service or were connected to issues with medicines. Having good links with local GP practices was advantageous.
And as soon as I knew that he wasn’t taking his meds, that’s where I probably changed my questioning style […] when he said he wasn’t taking his meds, that is automatically like a red flag for me that there’s always, usually, a reason for it
(staff participant, online FG, group 1, 25/04/23)
Local need – Some pharmacies had requested to be intervention pharmacies because they perceived there to be a local need due to encounters with previous cases of SI. In rural areas, pharmacy services were considered to be more essential because of a lack of other services. However, a counter consideration was the concern that clients may not ask for help from the staff who themselves lived in the small community.
I'd hope it would continue and spread a lot further, because I think it's invaluable. It should be shouted from the rooftops, in my opinion, especially for the rural places who've been in desperate need of mental health because the only place they've got to go to is the GPs. A lot of the time, they don't have time to see them…
(staff participant, online FG, group 2, 2/05/23)
Scope - Participants described that community pharmacy interactions were completely unfiltered, unpredictable and difficult to fit into neat diagnosable categories. This made it challenging to identify if clients met the study eligibility criteria. Some of the challenges around identifying suicidality were discussions around clients who had been suicidal in the past but were not actively suicidal now, clients who had significant risk factors but were not actively suicidal now and clients who expressed passive suicidality.
One sort of older chap come in who struggles with mental health anyway…He wasn’t actively suicidal at the time, but he did say that he has thought in the past about hanging himself. So, we gave him… in fact, I had already given him the numbers off the green card before that because he’d already been in when he wasn’t particularly bad, but I knew he was a bit lonely.
(staff participant, online FG, group 1, 25/04/23)
Similarly, there were discussions around what counts as domestic abuse, for example does it include abuse from carers, or from gang members.
Capacity – The Lifeguard service increased the responsibilities on staff, but also increased their capacity as individuals and a team to handle difficult conversations.
The consensus around the length of time needed for a Lifeguard consultation was a minimum of 15 minutes, but ideally 20 to 30 minutes. It was considered that if you have the correct staffing levels, 30 minutes should be possible. The Lifeguard service was seen as a priority over other services, which needed time to conduct a consultation satisfactorily.
I’d rather it take longer and the patient feels happy and then be improved and it take 45 mins rather than them be 15 minutes and them not feel any better. I’d rather take 45 minutes and not get (another) job done.
(staff participant, online FG, group 2, 2/05/23)
Working in a strong team was seen as important so that others would pick up tasks whilst the Lifeguard colleague was in a consultation.
Although conducting Lifeguard consultations placed extra time burdens on staff, it was recognised that these encounters can happen anyway. If there is a structured process, such as Lifeguard, in place, then it may actually save time and reduce stress, because they know how to respond, and it allowed pharmacists to delegate to others.
And so, whereas I would always deal with these myself (as a pharmacist), I now turn to another Lifeguard and go, actually, I need you to deal with this. And you can tell they straighten as if to say, right, time to do something good…. it gives me the confidence and it gives me a mental health sub team.
(staff participant, in-person FG, 17/04/23)
Theme 3: Staff Experience - Staff were empowered and felt a sense of duty and pride in being a Lifeguard, but there was a risk of negative emotional impact.
Staff empowerment – staff felt enabled to identify and intervene in suspected cases of SI and/or DA. Having clear referral/signposting pathways, support cards and QR code cards increased confidence and ability because staff now had the tools to refer and support clients.
I'm much more confident because I do have the facility to signpost people to the correct places they need to be. Also, if I'm not sure, there's all the list of places they can go. I can pass that on to them. Then, if they don't want you to do it themselves, they've got this card where they can take it away, look at it, and then decide what they want to do, rather than an on-the-spot decision
(staff participant, online FG, group 2, 25/04/23)
Emotional impact – Concerns were expressed about the service blurring into counselling and being a crutch for people, with fears of it being emotionally draining and time consuming. It was also noted that DA and SI conversations could be triggering for staff.
Being a Lifeguard – It was evident in the way participants spoke that being a Lifeguard had a clear identity, that came with a definite sense of duty, a sense of satisfaction for helping people and also feeling proud of those achievements.
I would say that it felt like you had a bit of a title, and you feel like, “I’ve got my own arm bands on and being a lifeguard myself….(laughs). Puts a lot of pressure on your shoulders, that, “I’m a lifeguard.
(staff participant, group 1, 2/05/23)
The key success of the project was seen as being that it has left a legacy of trained and empowered staff.
“A lot of people have had well-intentioned schemes that are a dead end, and I think if I made a difference here for me that sets this apart, it’s that you haven’t made a scheme as such. You’ve made people.”
(staff participant, in-person FG, 17/04/23)
Theme 4: Improvements - Suggestions were made for improvements to the paperwork and marketing. Staff were keen that the service should continue and be implemented more widely, and they made recommendations for improvements.
Paperwork – Staff participants all reported that they found the paperwork associated with consenting client participants overwhelming and burdensome. There were only 4 consented client participants in which staff were able to collect the full set of data. Reasons for the difficulties obtaining consent, were firstly that most cases were staff initiated and it seemed awkward and that it would disrupt the flow of a sensitive conversation to ask for consent during a conversation that had arisen opportunistically.
I can't even visualize myself at all having a conversation, a deep conversation with somebody and then saying ohh, then just get some paperwork out and asking them to complete it then.
(staff participant, online FG, group 2, 25/04/23).
Secondly, staff reported that some clients were reluctant to complete paperwork because it made it more formal, and the volume and language of the participant information sheets and consent forms was off-putting for staff and clients alike. It was noted that pharmacy staff are not used to obtaining written consent for any services and that interactions occur in a fast-paced responsive manner. Some staff said that they just forgot to ask.
Marketing – Staff participants stated that the Lifeguard Pharmacy name meant something to them, but they thought the service had not been sufficiently advertised to the public, and that the marketing was too discreet. They thought that this may account for the lack of client-initiated cases.
Recommendations – Staff suggested ideas to increase access to the service, which included having referrals into Lifeguard Pharmacy from other organisations, and having an app that clients could use to make an appointment for a Lifeguard consultation. It was noted that the time of a first prescription for mental health medication is a critical time for patients. This would be a valuable time for Lifeguards to offer support and screen for risk of harm from SI and/or DA.