Interprofessional Education in Suicide Prevention

Introduction to Interprofessional Education

This is an essay I wrote in 2015 for the course HSRV 306 Critical Reflection for Practice at Athabasca University.

Interprofessional education (IPE) is defined as “the process, through which two or more professions learn, with, from and about each other to improve collaboration and the quality of service” (CAIPE, 1997) IPE has been practiced in various forms for decades (Smith & Clouder, 2010) but is most commonly associated with healthcare and the social sciences.

The advantage of interprofessional education is that it allows allied fields to benefit from “pooling together of expertise in teams [that] would make them more effective and efficient” (Illingworth & Cheivanayagam, 2007) than those professions working on their own. As there is much overlap in the work provided by professionals in social work, psychology and psychiatry this pooling together of resources has the potential to improve their skills and competencies.

One competency required by these professions is the ability to prevent suicide, which involves the interrelated skills of risk assessment and suicide intervention. How much an individual may need to intervene will differ depending on their role, with some professionals needing only to recognize the signs and refer them on, while others may be required to perform regular and comprehensive suicide risk assessment and intervention.

Suicide and Mental Health Professionals

The suicide rate in Canada has remained relatively steady in Canada for several years, with more than 3,000 individuals dying by suicide in Canada each year. (Statistics Canada, 2014) A 2002 meta-review demonstrated that many of these people visited physicians or nurses for physical health complaints before their death. (Luoma, Martin & Pearson, 2002) Whether or not these physical complaints were related to their mental health issues or not, an opportunity for suicide screening and subsequent referral was missed.

One study on suicide screening, focused on Emergency Departments in the United States found that when universal screening was implemented, requiring all patients to be screened for suicide regardless of their presenting problem, the rate of detected suicidal thoughts doubled. (Boudreaux, et. al., 2015) This demonstrates the importance of all healthcare professionals being competent in the basics of suicide screening.

Mental health professionals regularly treat suicidal clients, with Feldman & Freedmanthal’s 2006 study reporting 78% of social workers had provided service to a suicidal client in the previous year. While mental health professionals regularly work with suicidal clients they may lack the skills or confidence to respond appropriately.

Ruth et. al. (2006) conducted interviews with social work students, faculty and Deans and discovered that the majority of programs provided their social worker students less than 4 hours of education on suicide assessment during their graduate programs. This resulting lack of coverage left social work students feeling unconfident working with suicidal clients, and indeed scared of the possibility that a client will reveal suicidality, a fact noted by other researchers as well. (Osteen, Jacobson & Sharpe, 2014) This paralyzing fear may contribute to burnout or other negative professional consequences and ultimately make them less effective practitioners.

Interprofessional education has the potential to improve the care of suicidal clients by allowing professionals to take advantage of the best practices in education present in allied fields. By borrowing best practices from other helping professions the number of competent professionals may ultimately be increased and the number of suicides or potential suicides that are undetected may be reduced.

Potential drawbacks to adopting interprofessional education that have been documented in the literature include the costs of implementation (such as redesigning curriculums) and the possible loss of professional identity among different groups who learn the same skills (Smith & Clouder, 2010) Given that mental health care is already well-diffused (with each professional area like social work, psychology and psychiatry having specialties but ultimately all being able to provide counselling or therapy with training), this may be less of an issue in suicide prevention, which is currently practiced by volunteers all the way up to Psychiatrists and Psychologists holding doctorates.

Interprofessional Education in Physical and Mental Health

There are a number of approaches to education in mental health fields (social work and psychology) and physical health fields (nursing and non-psychiatric medicine), including best practices that have demonstrated improved knowledge transfer, satisfaction and skill within their respective professional programs.

Physical health professions include general medicine practiced by physicians as well as nurses, who are recognized as professionals in their own right (College of Registered Nurses of Manitoba, n.d.). Professional schools of nursing have a long history, stretching back to the early 1900s (Schekel, 2009), while the first medical school opened in Italy in the 9th century. (de Divitiis, Cappabianca, & de Divitiis, 2004)

Education of physicians and nurses has always emphasized hands-on treatment and “learning by doing”, but especially since the 15th century when the first cadaver dissections were performed for medical students. (Rath & Garg, 2006)

Current techniques used in medical and nursing education include case studies, where the signs and symptoms of an illness and a patient’s history are described in detail and a diagnosis or treatment is sought (Raurell-Torreda, et. al., 2015), and simulated patients who are specially trained actors that medical students interact with in order to experience conducting clinical interviews, assessment and diagnosis (Uys & Treadwell, 2014).

Both case studies and simulated patients have shown utility in general nursing and medicine according to Luebbert & Popkess (2015). Some studies have specifically explored their utility with suicidal patients, such as Norrish (2009) who used cases to teach suicide risk assessment skills to Omani medical students.

Techniques that have demonstrated effectiveness with Psychology and Social Work students on the other hand, include role-playing (Murdoch, Bottorff & McCullough, 2013) where students practice simulated complaints with each other in order to develop the skills of recognizing and responding to suicidal statements, and evidence-based lecture. (Scott, 2015)

Gate-keeper training programs that are designed to teach lay people the basic skills of recognizing the signs of suicide and referring individuals to trained professionals, for instance, QPR (Lancaster, et. al., 2014) have demonstrated effectiveness in increasing confidence and skill in both nursing (Bolster, Holliday, Oneal & Shaw, 2015) and social work students. (Sharpe, Frey, Osteen & Bernes, 2014)

While domain-specific education for nurses and physicians has begun to be developed, it lacks the exploration of knowledge-transfer and rigorous methodology necessary for it to be as effective as possible. One example of beginning nurses education is Kishi et. al. (2014), who had emergency room nurses in Japan completing a 1 day workshop. The workshop covered suicide risk assessment, management of the immediate suicidal crisis, referring patients to long-term resources, and attitudes towards suicidal patients. This workshop was taught using lectures and case studies, with a pre and post-test design on a scale measuring attitudes towards suicide (but not knowledge transfer or skill acquisition.) The lack of a knowledge-transfer component means these nurses are unable to demonstrate whether they learned anything or if they apply their training to their patients.

Other exercises in integrating suicide prevention into social work including Scott (2015) who developed a full-semester course for MSW students that taught suicide risk assessment, intervention, and public health interventions such as media guidelines around suicide. Luebbert & Popkess (2015) had students complete either a video-taped lecture or speak to a standardized patient after being exposed to material on suicide assessment and found that the group that worked with the standardized patient felt much more confident.

What is lacking in nursing and medical education is a focus on evidence-based practice in suicide prevention, an issue noted by nursing faculty (Kalb et. al., 2015) Additionally providing opportunities for hands-on practice through exercises like case studies, simulated patients, and roleplaying will allow for necessary deep knowledge transfer.

Conclusion

Suicide prevention is a field ripe for improvement by integrating the best practices from a variety of allied fields. Most notably, from nursing and general medicine the case study and simulated/standard patients may help social workers and psychologists reduce their fear of working with suicidal clients, while the strong evidence-based lecture, roleplaying and gate-keeeper training may give busy nurses and physicians an opportunity to develop suicide awareness and referral skills that will allow them to intervene to prevent death.

References

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Boudreaux, E., Allen, M., Goldstein, A.B., Manton, A., Espinola, J. & Miller, I. (2015) Improving Screening and Detection of Suicide Risk: Results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Effectiveness Trial. Society for Prevention Research 23rd Annual Meeting. Accessed Dec 10 2015 from https://spr.confex.com/spr/spr2015/webprogram/Paper23206.html

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