Declarative Knowledge, Confidence, and Perceptions on Suicide Prevention After Standardized Patient Observation

• Online suicide prevention education can significantly improve athletic training students' declarative knowledge, confidence, and perceptions regarding suicide prevention.

• Observation of standardized patient encounters in addition to online suicide prevention education can significantly increase learners' agreement with the statement that suicide is preventable compared with online suicide prevention education alone.

• Observation of standardized patient encounters in addition to online suicide prevention education can significantly improve learners' declarative knowledge regarding suicide prevention compared with online suicide prevention education alone.

Suicidal ideation (SI) and death by suicide are significant issues facing individuals of all ages.¹  In 2020, the most recent year of available data from the Centers for Disease Control and Prevention,¹  suicide was a top 10 cause of death for individuals 10 to 64 years old. Athletic trainers (ATs) work with a variety of patient populations across multiple backgrounds and ages and therefore might encounter patients who have experienced SI. For ages 10 to 24, which encompasses secondary school and college students, suicide was a top 3 leading cause of death¹  in 2020. A study examining college-aged individuals reported that 6.4% of student-athletes experienced SI and 1.3% of student-athletes reported a suicide attempt in the last 12 months.²  From 2003 to 2012, suicide represented 7.3% of all deaths in National Collegiate Athletic Association athletes, with the highest rate occurring in men's football.³  Moreover, minoritized and marginalized populations are at an even greater risk for SI.⁴  Sexual minorities have attempted suicide at a rate 2 times higher than their heterosexual peers, and genderqueer individuals experience one of the highest rates of suicide attempts of any marginalized population.^4,5  Athletic trainers provide significant social support to the patients they treat and are in a position to help when patients express concerns or signs of SI.⁶  However, ATs report a lack of confidence in their ability to help patients experiencing SI.⁷  Education about suicide prevention can help increase learners' confidence in their ability to intervene appropriately if a patient is experiencing SI.⁸ 

One method that can be used to increase health care providers' and students' confidence with different clinical scenarios, including behavioral health scenarios, is practicing through a standardized patient (SP) encounter.^9–15  In athletic training education, SP encounters are the predominant method used to assess students' clinical skills.¹⁶  Studies have investigated the use of SPs portraying SI with medical students, pharmacy students, and allied health care professionals who interact with at-risk populations.^13,16–18  Not only can participating in SP encounters increase students' confidence with SI, it has also been shown that observation of others interacting with SPs can help increase students' confidence with care of patients experiencing SI.⁹  Learners who observed their peers engaging in a SI SP encounter demonstrated significant increases in their confidence that they could appropriately provide care to the patient. The learners who engaged with the SPs, as well as a third group of learners who did not participate in the SP encounter or observe the SP encounter, also reported significant increases in confidence.⁹ 

Using SP encounters in education can be beneficial; however, there are barriers to implementation.¹⁴  Three commonly mentioned barriers to implementing SP encounters by athletic training educators were time, personnel, and financial resources.¹⁴  Preparing for, recruiting, training, and compensating SPs requires educators to spend extra time, personnel, and/or financial resources on each actor.¹⁴  One alternative to these barriers is prerecorded videos of SP encounters. Implementing prerecorded videos of SP encounters for learners to observe may serve as a beneficial way to expose learners to conditions that are difficult to simulate with high fidelity or are rare for learners to encounter in clinical practice. The purpose of this study was to determine whether observation of a SP encounter increases students' declarative knowledge, confidence, and perceptions to appropriately manage scenarios in which patients are displaying SI.

We created a quasi-experimental study design to determine the effects of observation of simulated SP encounters on learner declarative knowledge, confidence, and perceptions pertaining to suicide risk assessment, intervention, and prevention. Programs were sorted into 1 of 2 groups, with the intervention group receiving the educational module with SP encounter videos and the control group receiving only the educational module. This project was approved by the Indiana State University Institutional Review Board. We used the Strengthening the Reporting of Observational Studies in Epidemiology guidelines to guide the design, data collection, and reporting of this project.¹⁹ 

We recruited professional master's in athletic training programs through the Association for Athletic Training Education to enroll their program in our study and include the educational content in their curriculum. Programs were eligible to enroll if they were (1) in good standing with the Commission on Accreditation of Athletic Training Education and (2) professional-level master's in athletic training programs. Programs willing to participate provided consent to recruit students into the study, but the educational requirement was included in each program, regardless of whether students chose to allow us to use their data for research purposes.

Once programs were enrolled in the study and submitted site letters to the research team, the programs implemented the educational materials into their curriculum, at a time that aligned with other coursework. The module was designed to be implemented as a course module with readings and assignments, where students would get course credit for completing the module and submitting their score to their instructor. Before starting the module, students filled out an informed consent and indicated if they wished to include or exclude their data from the study. If students elected not to include their data, they were still required to complete the module for course credit. Participants received a proof of completion after finishing the learning module that they could show to their instructors. Instructors could make decisions regarding course credit for completing the module but not for inclusion or exclusion of data in the study. Instructors did not know if students included or excluded their data in the study, and there was no penalty for students who elected to not include their data for analysis. Students needed to be age 18 years or older to participate in the study. Participants ranged from being in the first semester to the second to last semester of their professional program. Table 1 indicates the participants' previous experience with suicide prevention training and SI.

We created a learning module, including 5 reflective questions and 3 SP videos, to educate professional athletic training students about suicide risk factors, intervention, and prevention (Table 2).

Learning objectives were as follows:

• Identify risk factors and signs and symptoms associated with SI and/or suicidal behaviors.

• Consider protective factors and prevention strategies for suicidal behaviors.

• Characterize policy surrounding routine and emergent mental health situations.

• Interpret patient behaviors and identify proper referral strategies.

The module was delivered through eAuthoring software (SoftChalk). The primary investigator completed Suicide Triage training through the Question Persuade Refer Institute (https://courses.qprinstitute.com/index.php?option=com_content&view=article&id=315&catid=54&Itemid=101) before creating the module. All members of the research team reviewed the module and assessment tools during the outline process and again before implementation. To ensure that the module was comprehensive and relevant to athletic training, we used 4 content reviewers who had extensive knowledge and experience with behavioral health interventions in athletic training to examine the educational materials and provide feedback. Feedback included a review of the module content and the scripts used to deliver the SP videos. The reviewers' expertise is outlined in Table 3. A cohort of practicing ATs enrolled in a doctorate of athletic training program pilot tested the module, including observing the SP videos. Resources to support mental health were provided before the start of the lesson and at the end of the lesson for participants to access if they experienced psychological distress from the content. Before starting the module, participants received a message that the content may cause emotional distress for some and directed participants to stop the module and use resources specific to their campus or the resources provided in the module, including the National Suicide Prevention Lifeline (https://988lifeline.org/talk-to-someone-now/), Crisis Counselor Text Line (https://www.crisistextline.org/), ATs Care online form (https://forms.nata.org/ats-care-contact), or ATs Care Hotline (https://forms.nata.org/ats-care-contact). Information about SI and suicide prevention is already included in athletic training education, and this module did not pose a unique risk to learners with its content; however, all efforts were made to reduce the risk of an adverse event as part of participation.

For the experimental group, we created and filmed 3 videos depicting an AT interacting with 3 different adult patients experiencing varying levels of emotional distress and SI. In the videos, the AT displayed strategies from the learning module to help the patients. The video and SP actor scripts were developed by the researchers, using best-practice information for ATs' management and referral of individuals experiencing SI as described by the National Athletic Trainers' Association (NATA).^20,21 

The experimental group participants completed the suicide prevention lesson and then watched a series of videos that depicted an AT demonstrating the appropriate management of a patient actor who depicted SI. The control group completed the same suicide prevention lesson but did not receive the video SP encounters. Before the training (pretest), immediately after the training (posttest), and 6 to 8 weeks after the training (follow-up test), students completed an assessment regarding their declarative knowledge, confidence, and perceptions for appropriately managing a patient with SI.

To assess declarative knowledge, confidence, and perceptions, we created pretest, posttest, and follow-up assessments for learners to complete via a web-based survey (Qualtrics, Inc). Because of low levels of completion of the follow-up assessment (n = 9), these data were excluded from the analysis. The assessments asked questions pertaining to the students' knowledge about suicide, their confidence with suicide prevention, and their beliefs about prevention, reluctance, or stigma about addressing suicide. The declarative-knowledge questions are listed in Appendix 1. The questions pertaining to self-reported confidence asked learners to rate their confidence using a 5-point Likert scale with a score of 1 indicating not confident at all and a score of 5 indicating very confident (strong internal consistency, Cronbach α = 0.80). The questions pertaining to beliefs about suicide, stigma, and reluctance to intervene asked learners to rate their level of agreement with statements using a 5-point Likert scale with a score of 1 indicating strongly disagree and a score of 5 indicating strongly agree (strong internal consistency, Cronbach α = 0.69). All declarative-knowledge questions were reviewed by members of the research team with professional experience in education. We included 14 questions that addressed either risk factors or protective factors for suicide or intervention strategies. Questions were presented in multiple-choice format, with 8 of the questions being scenario based. The highest possible score on the quiz was 15 points.

At the end of the posttest assessment, learners could provide feedback on their experience using the online module to learn about suicide prevention. The first question asked about the length of the training, and learners could answer too short, too long, or just right. The second question had students use a sliding numerical scale to rate their level of agreement with the following statements: “Using an eLearning system was easy for me,” “Important skills can be learned through eLearning modules,” “My beliefs about suicide prevention have changed because of this lesson,” and “I intend to use this information in my clinical practice.” A rating of 10 indicated strongly agree, and a rating of 1 indicated strongly disagree.

At the start of the learning module, students followed a link to the informed consent form in Qualtrics. Participants entered their name in the Qualtrics forms as an identifier so that we could match pretest and posttest responses. Participants completed their informed consent and pretest assessment and then returned to the module. Reflection questions were embedded into the lesson and students' answers were saved in the eLearning module. After completion of the module, participants followed a second survey link to compete the posttest assessment (Figure). We deidentified participants' information for analysis to protect their privacy. The research team stored data on a secure file-hosting cloud. Only members of the research team had access to the file-hosting cloud. Participants could retroactively request that their data not be included in the research for up to 7 weeks after data collection.

We analyzed the objective data using SPSS version 27.0.1.0 (IBM Inc). We analyzed the scores for a statistically significant change in declarative-knowledge scores, self-reported confidence, and perceptions about suicide prevention from pretest to posttest. Significance was set to P < .05. The scores of the group receiving the SP encounter videos (experimental group) were compared with the scores of the group that did not receive the videos using a 2 (time) × 2 (group) analysis of variance. Means at each point in time were compared between the experimental group and the control group.

The experimental group that received the module and the SP videos had 31 students and the control group that received only the module contained 45 students. Few participants had previous experience with SI prevention training (n = 13, 17.8%), with students reporting sources of previous training from organizations such as Question Persuade Refer, the Red Cross, the Institute for Healthcare Improvement, and Mental Health First Aid and from experiences such as the military and undergraduate coursework. Many participants had previous exposure to SI by knowing someone who had died by suicide or experienced SI (n = 49, 64.5%).

We identified main effects for time (P < .001) and group (P < .025), where the experimental group scored higher overall (11.4 ± 1.63 of 15, 76%) than the control group (10.7 ± 1.55 of 15, 71%) on the posttest assessment (Table 4). The experimental and control groups both improved (mean change = 1.7 ± 1.8, 11.3%) their overall score on the posttest assessment after the module compared with the pretest assessment they took immediately before starting the module.

Both groups demonstrated a significant change over time relative to self-reported confidence (P < .001) with identifying risk factors associated with SI, intervening with patients experiencing SI, using the NATA framework for helping individuals in crisis, and appropriately referring patients experiencing SI. There was no significant difference between groups for confidence with identifying risk factors associated with SI (P = .622), intervening with patients experiencing SI (P = .079), using the NATA framework for helping individuals in crisis (P = .293), or appropriately referring patients experiencing SI (P = .512).

There was a significant decrease over time (P < .001), regardless of group, in perceptions of agreement to the statements “It's not my place to talk about suicide with patients,” “It is offensive to ask someone about a mental health concern,” and “Talking to someone about suicide increases their risk of dying by suicide.” There was a significant (P = .002) increase in participant agreement with the statement “Suicide is preventable.” There was no significant difference between groups for changes in perceptions of agreement to the statements “It's not my place to talk about suicide with patients” (P = .540), “It is offensive to ask someone about a mental health concern” (P = .399), and “Talking to someone about suicide increases their risk of dying by suicide” (P = .639). There was a significant (P = .039) increase in participant agreement with the statement “Suicide is preventable” in the experimental group compared with the control group.

Participants reported a high level of agreement (8.7 ± 1.8 of 10) for the statement “Using an eLearning system was easy for me.” Participants also reported a high level of agreement (8.2 ± 2.0 of 10) for the statement “Important skills can be learned through eLearning modules.” Participants reported a moderately high level of agreement (7.1 ± 2.6) for the statement “My beliefs about suicide prevention have changed because of this lesson.” Participants had a high level of agreement (9.2 ± 1.7 of 10) for the statement “I intend to use this information in my clinical practice.”

The purpose of this study was to investigate the effect of observed SP encounters on students' knowledge, confidence, and perceptions regarding suicide prevention. We found that participation in an educational online module with or without SP videos significantly increased students' confidence and knowledge regarding suicide prevention, as well as significantly adjusting their perceptions of suicide prevention. Learners scored significantly higher on the posttest assessment when SP encounter videos were included in their learning module compared with the learners without SP encounter videos in their module. Additionally, learners with the SP encounter videos in their module significantly increased their agreement with the belief that suicide is preventable compared with the learners without SP encounter videos in their module.

Related studies have used Mental Health First Aid training to educate learners on suicide prevention skills.^9,13  We created our own suicide prevention model to ensure that the content was relevant to the scope of practice of ATs, and provided specific examples related to athletic training, such as using an example mental health emergency action plan (Appendix 2). The module was delivered online and asynchronously. Available research suggests online education can result in knowledge gains for athletic training students.²²  Asynchronous video trainings for suicide prevention that include teaching new clinical skills have been implemented with nursing professionals and have demonstrated long-term (6-month) retention of increased beliefs about the nurses' ability to use suicide prevention skills in clinical practice.²³ 

After our data collection period concluded, an article²⁴  published in the Athletic Training Education Journal proposed a model for implementing suicide prevention training in athletic training education. Our module includes the following components suggested by the proposed model: foundational knowledge (terms, statistics, risk factors, and warning signs), assessment surveys, reflection questions, and a mental health emergency action plan (NATA guidelines, interdisciplinary teams, role delineation, crisis services, procedures, and review of a policy). Where our module differs from the proposed model is in its online delivery. The model suggests role-playing, debriefing, and skill-check scenarios, which we did not include in our module, but which could feasibly be incorporated into future versions of synchronous and asynchronous online education. Our module also differs from previous trainings because of the inclusion of the SP encounter videos. These videos also contribute to the relevancy of the lesson to athletic training because the health care provider in the videos is an AT simulating an encounter with actors portraying student-athletes. SP videos could also aid role-playing, reflection, and debriefing. While students watch the videos, they can imagine themselves in the role of the AT. While watching, the learners can reflect on the skills demonstrated by the AT and on how well or poorly the encounter goes. Additionally, the videos can facilitate debriefing by having learners examine the skills used by the AT and areas of improvement. Our study supports the proposed modules' suggestions of including foundational knowledge, assessment surveys, reflection, and a mental health emergency action plan.

Suicide prevention training is an effective way to improve individuals' knowledge, confidence, and perceptions regarding suicide prevention.⁹  Although trainings may differ, nurses, school personnel, pharmacy students, counselors, social workers, psychologists, and certified rehabilitation counselors have demonstrated improvements in their confidence and/or declarative knowledge about suicide after educational interventions.^{9,13,15,17,18}  Both groups significantly improved their declarative-knowledge assessment scores from pretest to posttest, indicating that the learning module was effective. The experimental group improved their pretest to posttest score significantly more than the control group, which may be attributed to the inclusion of SP encounter videos in the experimental group's module. In suicide prevention training with health care professionals who work with veterans, declarative knowledge significantly increased immediately after the training.¹⁸ 

Our results support that different interventions can lead to significant improvements in learner confidence and knowledge regarding suicide prevention skills. Pharmacy students who engaged in SP encounters, observed SP encounters, and had no involvement with an SP encounter all demonstrated significant increases in their confidence to address SI with patients after suicide prevention training.⁹  Participants in our study had similar results, with the control and the experimental group significantly increasing their confidence after engaging with the educational module and there being no significant difference between the 2 groups. Confidence may not serve as the best indicator of a learner's ability to appropriately implement suicide prevention skills. When evaluators scored pharmacy students on their observed behaviors during an SI SP encounter, students overestimated their ability to provide appropriate care.¹³ 

The experimental group significantly increased their agreement with the belief that suicide is preventable compared with the control group, which might be attributed to learners in the experimental group observing SP encounters. Both study groups adjusted their perceptions to align with beliefs that could help them with suicide prevention. A common misconception about suicide is that talking about suicide may cause someone to consider suicide as an option.⁹  Additionally, talking about mental health concerns remains stigmatized in many communities.²⁵  Stigma surrounding talking about mental health concerns such as SI and belief in myths about suicide present barriers to seeking and offering help.²⁶  Destigmatizing asking about mental health has been widely discussed as an important step in preventing suicide.^9,25,26  Participants in this study significantly realigned their beliefs to disagree with the statement that talking about suicide might cause someone to consider suicide. Other studies have investigated this misconception when performing preassessments for suicide prevention training for pharmacy students.⁹  The pharmacy students demonstrated aversion to using suicide-specific terminology when speaking to SPs, which the authors speculated may be from stigma around talking about suicide and a belief that talking about suicide may prompt someone to attempt suicide.⁹ 

The low number of participants who completed the follow-up survey is a potential limitation of this study when examining long-term retention of confidence and knowledge. The only learners to respond to the follow-up assessment were members of the experimental group, which limits our understanding of how their knowledge and confidence compares with the control group. Other studies have reported learners retaining their confidence but failing to retain gains in declarative knowledge at follow-up benchmarks.¹⁷  This could indicate the need for refresher courses to ensure that confidence levels and knowledge are aligned.⁹  To fully understand the usefulness of filmed SP encounters in clinical education, further research in this area should explore the difference between learner assessment scores after observed SP encounters and participation in SP encounters. This research could investigate if there is a significant difference in student declarative knowledge, confidence, and perceptions regarding suicide prevention between students who participate in an SP encounter and students who observe an SP encounter.

Although the module was scoping, passive SI was not among the topics discussed. Future iterations should include this emerging topic. Additionally, although the module included information about recognizing and referring individuals with concerns of SI in the secondary school setting, observers could presume all SP encounters demonstrated scenarios with adult patients because there was no inclusion of parents/guardians. Future iterations of the SP videos could include parents/guardians in the referral and communication plan. However, the same referral pattern is warranted whether the patient is a minor or an adult.

Participants who observed SP encounter videos in addition to engaging with the online suicide prevention module scored significantly higher on their posttest assessments of declarative knowledge and significantly increased their agreement with the belief that suicide is preventable compared with participants who did not observe SP encounter videos. The inclusion of the SP videos could account for the difference in scores, indicating that learners benefit from seeing suicide prevention skills demonstrated through filmed SP encounters. The potential benefits of using filmed SP encounters in clinical education include addressing reported barriers to training actors for live SP encounters, such as time spent training actors each time an SP encounter is used in curriculum, time creating SP scripts for actors, compensations for SP actors, and physical resources needed to implement SP encounters. Athletic training educators have reported a benefit of live SP encounters being an increase in students' confidence and their exposure to unique conditions. A filmed SP encounter could portray unique conditions as well, and participants in our study demonstrated increases in confidence after the module that included SP videos. Further research could help health care educators across professions understand if there is a significant difference between using filmed and live SP encounters.

We would like to thank Dr Stacy Walker, Dr Jessica Kirby, Jennifer Chadburn, and Bridget Salvador for their contributions to the creation of the suicide prevention module. Their collective expertise in behavioral health conditions management in athletic training helped us create a tailored educational module for athletic training students.