Benefits of implementing an academic training of trainers program to promote knowledge and clarity in work with psychiatric suicidal patients

Short-term effects of a simulation-based training program on suicide risk assessment and intervention for first-year psychiatry residents

OBJECTIVES

Adequate training of mental health professionals in suicide risk assessment and intervention is crucial. Simulation-based education is a relevant method to acquire competences for challenging health interventions. Here, we aimed to evaluate the effects of a simulation-based training program on first-year psychiatry residents' skills, knowledge, attitudes and satisfaction.

METHODS

We conducted pre- and immediately post-training assessments in 153 psychiatry residents during their first or second postgraduate semester in Paris, France, in 2020 and 2021. The simulation-based training occurred a few weeks after a two-hour theoretical lecture on suicidal behaviors. It consisted of a full-day training of small groups (n=5 to 9) with six scenarios played by professional actors and facilitated by two trained psychiatrists, and a 45-60minute debriefing session after each simulation. Educational objectives focused on basic aspects of patient-psychiatrist relation, the investigation of suicidal ideation, and basic interventions in various contexts (outpatient consultation, emergency room, telephone) and patient profiles. Outcome measures included the Suicide Intervention Response Inventory (SIRI-2), a short questionnaire on basic knowledge, a self-confidence four-item scale, and a satisfaction questionnaire.

RESULTS

There were significant improvements in skills, basic knowledge, and self-confidence from pre- to post-training. Trainees also expressed a high level of satisfaction, an appreciation for this innovative pedagogy and a wish for more similar training.

CONCLUSIONS

This practical training program based on simulation improved self-confidence, knowledge and skills in suicide risk assessment and intervention in the short-term among first year psychiatry residents. Results from this study are therefore promising. Longitudinal studies are, however, needed to evaluate the persistence of changes over time, positive changes in care in real settings and health benefits for patients. In a time of easily accessible and rapidly growing factual medical knowledge, of necessary need for skilled professionals and of growing demand in mental health care, the development of simulation training in psychiatry should be a pedagogical and a public health priority.

The impact of train-the-trainer programs on the continued professional development of nurses: a systematic review

BACKGROUND

Train-the-trainer (TTT) programs are widely applied to disseminate knowledge within healthcare systems, but evidence of the effectiveness of this educational model remains unclear. We systematically reviewed studies evaluating the impact of train-the-trainer models on the learning outcomes of nurses.

METHODS

The reporting of our systematic review followed PRISMA 2020 checklist. Records identified from MEDLINE, Embase, CINAHL, and ERIC were independently screened by two researchers and deemed eligible if studies evaluated learning outcomes of a train-the-trainer intervention for trainers or trainees targeting nurses. Study quality was assessed with Joanna Briggs Institute's critical appraisal tools and data of study characteristics extracted (objective, design, population, outcomes, results). Heterogeneity of outcomes ruled out meta-analysis; a narrative synthesis and vote counting based on direction of effects (p < 0.05) synthesized the results. All records were uploaded and organized in EPPI-Reviewer.

RESULTS

Of the 3800 identified records 11 studies were included. The included studies were published between 1998 and 2021 and mostly performed in the US or Northern Europe. Nine studies had quasi-experimental designs and two were randomized controlled trials. All evaluated effects on nurses of which two also included nurses' assistants. The direction of effects of the 13 outcomes (knowledge, n = 10; skills, n = 2; practice, n = 1) measured in the 11 included studies were all beneficial. The statistical analysis of the vote counting showed that train-the-trainer programs could significantly (p < 0.05) improve trainees' knowledge, but the number of outcomes measuring impact on skills or practice was insufficient for synthesis.

CONCLUSIONS

Train-the-trainer models can successfully disseminate knowledge to nurses within healthcare systems. Considering the nurse shortages faced by most Western healthcare systems, train-the-trainer models can be a timesaving and sustainable way of delivering education. However, new comparative studies that evaluate practice outcomes are needed to conclude whether TTT programs are more effective, affordable and timesaving alternatives to other training programs.

TRIAL REGISTRATION

The protocol was registered in Research Registry ( https://www.researchregistry.com , unique identifying number 941, 29 June 2020).

Simulation training in suicide risk assessment and intervention: a systematic review and meta-analysis

PURPOSE

Suicide is a major cause of preventable death worldwide. Adequate training in risk assessment and intervention is key to suicide prevention. The use of simulation (role plays, simulated patients, virtual reality…) for practical training is a promising tool in mental health. The purpose of this study was to assess the effectiveness of simulation training in suicide risk assessment and intervention for healthcare professionals and gatekeepers.

METHODS

We conducted a systematic review in Medline and PsycINFO up to 31 July 2021 of randomized controlled trials (RCTs), non-randomized controlled trials, and pre/post-test studies. RCTs were furthermore included in a meta-analysis. We assessed the methodological quality of all studies with the Medical Education Research Study Quality Instrument, and the Cochrane Risk of Bias tool 2.0 for RCTs. Primary outcomes were changes in Kirkpatrick criteria: attitudes, skills, knowledge, behaviors, and patient outcomes.

RESULTS

We included 96 articles representing 43,656 participants. Most pre/post-test (n = 65) and non-randomized controlled (n = 14) studies showed significant improvement in attitudes, skills, knowledge, and behaviors. The meta-analysis of 11 RCTs showed positive changes in attitudes immediately after training and at 2-4 months post-training; in self-perceived skills at 6 months post-training; but not in factual knowledge. Studies assessing benefits for patients are still limited.

CONCLUSIONS

The heterogeneity of methodological designs, interventions, and trained populations combined with a limited number of RCTs and studies on patients' outcomes limit the strength of the evidence. However, preliminary findings suggest that simulation is promising for practical training in suicidal crisis intervention and should be further studied.

Suicide-Related Knowledge and Attitudes among a Sample of Mental Health Professionals

Inadequate knowledge of the potential signs and risk factors of suicide negatively affects the ability of healthcare professionals to recognize patients at risk of suicide. The principal aim of the present study is to assess the attitudes and knowledge about suicide in a large sample of mental health professionals. We examined the relationship between Suicide Knowledge and Skills Questionnaire items and the experience of a patient dying by suicide. We also examined whether various healthcare professionals respond differently to the items of the Impact of a Patient’s Suicide on Professional and Personal Lives Scale. Results demonstrated that healthcare professionals who had experienced a patient suicide reported greater skills than professionals who had not experienced a patient suicide. However, 44% of professionals who had experienced a patient suicide felt that they did not have adequate training on this particular issue. Among those who had experienced a patient suicide, there was an increased tendency to hospitalize patients with suicide risk and an increased use of collegial consultation. Concerning personal emotions, healthcare professionals reported troubled relationships with family members and friends and the loss of self-esteem. In conclusion, better knowledge and attitudes about suicide are necessary for suicide-prevention strategies.

The Impact of Knowledge of Suicide Prevention and Work Experience among Clinical Staff on Attitudes towards Working with Suicidal Patients and Suicide Prevention

Suicide-preventive training has shown to influence attitudes. This study aimed at investigating what impact other factors than knowledge might have on attitudes towards work with suicidal patients and suicide prevention. In 2007, 500 health-care staff working in a psychiatric clinic in Stockholm received a questionnaire with items concerning work with suicidal patients to which 358 (71.6%) responded. A set of attitude items were tested using structural equation modelling (LISREL). Three models were found to be satisfactory valid and reliable: Job clarity, Job confidence and Attitudes towards prevention. These were then used in regression analyses as dependent variables with predictors such as experience of work with suicidal patients, perceived sufficient training,age and gender. Perceived sufficient training was consistently the most important predictor for all three attitude concepts (p < 0.01, β = 0.559 for Job clarity; p < 0.01, β = 0.53 for Job confidence; p < 0.01, β = 0.191 for Attitudes towards prevention). Age was another significant predictor for Job clarity (p < 0.05, β = 0.134), as was experience of patient suicide for Job confidence (p < 0.05, β = 0.137). It is concluded that providing suicide preventive education is likely to improve attitudes towards the prevention of suicide, clarity and confidence regarding their role in the care for suicidal patients. These improvements may contribute to the prevention of suicide in health care settings.

Dissemination of psychotherapy for trauma spectrum disorders in postconflict settings: a randomized controlled trial in Rwanda

BACKGROUND

Dissemination of psychotherapeutic modules to local counselors seems a key requirement for coping with mental health disasters in conflict regions. We tested a train-the-trainer (TTT) dissemination model for the treatment of posttraumatic stress disorder (PTSD).

METHODS

We randomly assigned widowed or orphaned survivors of the 1994 Rwandan genocide with a PTSD diagnosis to narrative exposure therapy (NET) treatment (NET-1, n = 38) or to a 6-month waiting list (WL) condition to be followed by treatment (WL/NET-2, n = 38). Expert therapists trained a first dissemination generation of local Rwandan psychologists in NET complemented by 2 sessions of interpersonal psychotherapy modules. Under the supervision of the experts, these Rwandan psychologists (a) provided NET to the NET-1 participants and (b) subsequently trained and supervised a second generation of local psychologists. This second dissemination generation provided treatment to the WL/NET-2 group. The primary outcome measure was the Clinician-Administered PTSD Scale total score before therapy and at 3- and 12-month follow-ups.

RESULTS

At the 3-month follow-up, the NET-1 participants suffered significantly and substantially less from PTSD symptoms than the participants in the WL group. The treatment gains of NET-1 were maintained and increased at follow-up, with a within-group effect size of Cohen's d = 1.47 at the 12-month follow-up. After treatment by the second dissemination generation of therapists, the WL/NET-2 participants improved to an extent similar to that of the NET-1 group at follow-ups, with an effect size of Cohen's d = 1.37 at the 12-month follow-up.

CONCLUSIONS

A TTT model of PTSD treatment dissemination can be effective in resource-poor postconflict societies.

Assistência hospitalar na tentativa de suicídio

Este artigo discute pontos relevantes que podem colaborar no sucesso da assistência hospitalar direcionada à pessoa com intenção suicida. O risco de suicídio aumenta de acordo com o número de tentativas e também está associado a intervalos de tempo menores entre essas tentativas. Assim, o acolhimento à pessoa com tentativa de suicídio durante a assistência hospitalar é fundamental, pois se realizado com segurança, prontidão e qualidade é possível determinar a aceitação e a adesão do paciente ao tratamento. Essas ações devem estar direcionadas ao cuidado integral prestado à tríade – paciente/família/equipe de profissionais de saúde e da área social. Existem fatores cruciais no alcance da qualidade assistencial que estão atrelados às condições para favorecer a adesão ao tratamento e a criação de uma equipe multidisciplinar com competência de utilizar uma combinação de fatores biológicos, psicológicos e intervenções sociais por meio de educação continuada.

Facing a Patient Who Seeks Help After a Suicide Attempt

Background: Although intervention with suicidal patients is one of the hardest tasks in clinical practice, little is known about health professionals’ perceptions about the difficulties of working with suicidal patients. Aims: The aims of this study were to: (1) describe the difficulties of professionals facing a suicidal patient; (2) analyze the differences in difficulties according to the sociodemographic and professional characteristics of the health professionals; and (3) identify the health professionals’ perceived skills and thoughts on the need for training in suicide. Method: A self-report questionnaire developed for this purpose was filled out by 196 health professionals. Exploratory principal components analyses were used. Results: Four factors were found: technical difficulties; emotional difficulties; relational and communicational difficulties; and family-approaching and logistic difficulties. Differences were found between professionals who had or did not have training in suicide, between professional groups, and between the number of patient suicide attempts. Sixty percent of the participants reported a personal need for training and 85% thought it was fundamental to implement training plans targeted at health professionals. Conclusion: Specific training is fundamental. Experiential and active methodologies should be used and technical, relational, and emotional questions must be included in the training syllabus.

The most effective way of delivering a train-the-trainers program: a systematic review

INTRODUCTION

Previous literature has shown that multifaceted, interactive interventions may be the most effective way to train health and social care professionals. A Train-the-Trainer (TTT) model could incorporate all these components. We conducted a systematic review to determine the overall effectiveness and optimal delivery of TTT programs.

METHODS

We searched 15 databases. Reference lists and online resources were also screened. Studies with an objective follow-up measure collected over 1 week after the intervention were included. The intervention had to be based on a TTT model for health and social care professionals.

RESULTS

Eighteen studies met the inclusion criteria. TTT interventions varied greatly, ranging from didactic presentations to group discussions and role-plays. The heterogeneity of the studies and limited data prevented meta-analysis. A narrative review found that the TTT programs in 13 studies helped to increase knowledge, improve clinical behavior, or produce better patient outcomes. One study showed no effect. Three studies showed possible effect and one study showed that a CD-ROM training method was more effective than a TTT training method in improving participants' knowledge. Ratings of the studies' methodologies suggested moderate risk of bias, which limits interpretation of the results.

DISCUSSION

There is evidence that using a blended learning approach to deliver TTT programs--combining different techniques such as interactive, multifaceted methods and accompanying learning materials--can help to effectively disseminate and implement guidelines and curricula to health and social care professionals. However, further research is needed to determine the optimum "blend" of techniques.

The European Psychiatric Association (EPA) guidance on suicide treatment and prevention

Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. SUICIDAL CRISIS: Acute intervention should start immediately in order to keep the patient alive.

DIAGNOSIS

An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential.

TREATMENT

Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT TEAM: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. FAMILY: The suicidal person independently of age should always be motivated to involve family in the treatment. SOCIAL SUPPORT: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks.

SAFETY

A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. TRAINING OF PERSONNEL: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Suicide prevention training outside the mental health service system: evaluation of a state-wide program in Australia for rehabilitation and disability staff in the field of traumatic brain injury

The training needs of staff working in mainstream (i.e., noncrisis) health settings with client groups that have moderate levels of suicide risk have not been extensively addressed. An initiative to train rehabilitation and disability staff working in the field of traumatic brain injury (TBI) is described. A program was adapted from a generic state health department training program, and disseminated by means of established training networks within the brain injury field. Program efficacy was evaluated as the training was provided across the state of Victoria in a series of 1-day workshops. Participants (n = 86) completed two evaluation measures designed for this purpose (objective knowledge test, self-rating of knowledge and skills) on three occasions (pre- and postworkshop, 6-month follow-up). Compared to a control group of rehabilitation and disability workers who did not receive the training (n = 27), the workshop participants made significant gains in objective knowledge and reported skills, and maintained these gains at the 6-month follow-up. The Suicide Interview Response Inventory-2 (Neimeyer & Pfeiffer, 1994) was administered to a subgroup of participants as a validating measure, and correlated significantly with scores from the objective knowledge test. This process may provide a template for developing more fine-grained suicide prevention strategies among other health-related at-risk groups.