Abstract
This paper is concerned with the scope of suicide prevention curricula taught in universities within Australia. The review of the literature concerning university programs, and the survey of courses directed to a range of professional students forms a baseline for the Youth Suicide Prevention National University Curriculum Project funded through the National Youth Suicide Prevention initiative. (Further details of the Curriculum Project may be found at the following internet site: http://www2_hunterlink.net.au/^dejrw/backrpt.html)
Previous recommendations for education and training for suicide prevention seem largely to have omitted university courses, and have focused on the education of the public, and education of the socalled ‘gatekeeper’ professions [1, [2], [3], [4], [5]]. The latter usually receive their training in the context of advanced vocational courses rather than at the undergraduate level. Universities may not have been seen as a primary target for new initiatives in suicide education either because existing courses have been considered adequate, or because the target audience has been considered inappropriate.
Prior to conducting our survey, we undertook a systematic review of the international literature describing existing university programs directed to suicide prevention. The aim of the review was to examine the content of courses, and the results of outcome evaluation where they exist. We considered only programs that would usually be taught by universities in this country. We searched the Medline, PsycLIT and ERIC electronic databases using an extensive set of terms (available from the authors on request). We scanned the bibliographies of key papers, and conducted searches using key author names identified in our preliminary keyword search.
The search strategy yielded 2304 individual references. Through examination of the abstracts, we identified six papers addressing university teaching relevant to suicide prevention [6, [7], [8], [9], [10], [11]]. Target audiences were medical students [9], pharmacy students [11], graduate students in clinical psychology [7], sociology students [10], combined groups of medical and nursing students [6], and combined groups of medical, psychology, and theology students [8]. Five papers contained some description of a specific program, while one paper concerned a survey of university programs to determine the extent of teaching about suicide [7].
Evaluation of effectiveness was limited to three uncontrolled studies, of which only two included testing prior to exposure to the program [6, [7], [8], [9], [10], [11]]. None of the papers established a ‘satisfactory’ level of knowledge, attitude or skills, but rather simply reported the outcomes in terms of change scores. The papers do clearly suggest that significant change may occur in response to the programs, but it is not known whether the students were deficient prior to exposure, or whether their performance following exposure was clinically competent. Evaluations were undertaken immediately following the completion of each course, so that it cannot be determined whether the changes in knowledge, attitude or skills were sustained. None of the studies included an evaluation of interactional skills.
The aim of the present paper was to survey courses offered to students of medicine, nursing, psychology, social work, theology, education, pharmacy, law and journalism at Australian universities to identify the knowledge, attitudes and skills content of the courses, and the teaching methods used. Where courses offered teaching of skills we sought to identify how the skills were assessed.
Method
University courses were included in the survey if they provided accredited pre-employment training for professional groups which, in the view of the project reference group, had the potential to reduce suicide rates through early detection and referral of individuals at risk for suicide, therapeutic contact with such individuals, or through enacting social or environmental change. Some professional groups that may have important roles in suicide prevention were not represented in the survey because there is no clear tertiary educational pathway for their training. Examples of these professions include youth workers, social planners, politicians, and individuals working in public health and health promotion.
A survey instrument was developed by the authors in collaboration with academics from relevant departments at the University of Newcastle, and members of the Youth Suicide Prevention National University Curriculum Project Reference Group (see Acknowledgements). The instrument was designed to survey the content of the curriculum, and the dominant modes by which material was taught. The content items in the domains of knowledge, attitudes and skills are summarised in Appendix I. In an effort to enhance compliance with the survey instrument, we limited questions for individual disciplines to those areas that the Reference Group thought would be most relevant. For journalism, for example, we were advised that courses would be unlikely to include skills items, so these were omitted from the questionnaire.
The survey form was sent to the heads of department of each of nine disciplines (medicine, nursing, psychology, social work, theology or religious studies, secondary education, pharmacy, law, journalism). Where a university had more than one campus and one of the targeted disciplines was taught at each, a separate survey form was sent to each campus. Heads of department were asked to immediately return a form nominating a member of staff to be responsible for completion of the survey, which was due at a later date. Non-responding universities were followed up by a member of the project team. Where survey forms were not received by the due date, the nominated person was contacted on up to three occasions.
Data analysis was purely descriptive. We calculated the percentage of programs for each discipline reporting the inclusion of specific knowledge, awareness and skills topics. For the purpose of interpretation, we established the following categories to indicate the penetrance of items into each discipline: high == included in ≥ 70% of courses; medium == included in 50–69%; low == included in < 50%.
Methods
Response rate by discipline
Penetrance of knowledge, attitudes and skills items into university programs (%)
With respect to medical schools, there is considerable heterogeneity in terms of mode of entry and educational philosophy. Three schools have moved recently to graduate entry programs, one school has markedly different selection procedures, and three schools report extensive use of problem-based learning. All knowledge and attitude items fell in the high range, with the dominant approach to teaching being lectures and seminars. Two-thirds of the skills items were in the high range, and included assessment of the individual's level of suicide risk. Four skills items involving negotiation relevant to reducing suicide risk (e.g. removing access to means) and postvention fell in the medium range, and advocacy skills fell in the low range.
There were considerable differences in the structure of the nursing courses, and the survey items were found to be included in a broad range of subject types. Undergraduate and postgraduate nursing courses primarily use a lecture and seminar style of teaching, although nine schools reported some use of problem-based learning. All knowledge, attitude and skills items surveyed were in the high range.
The survey items for psychology programs were more likely to be included in postgraduate than undergraduate courses. At both levels, the predominant style of teaching is lectures and seminars. While many knowledge and attitude items were in the high range, items which might equip psychologists to see the problem of suicide more broadly than individual pathology were in the low range (e.g. economic costs, cultural and racial factors, policy initiatives, lobbying roles, role of the media). The importance of arranging close supervision for young people in a suicide crisis fell in the medium range. Skills such as negotiating a ‘no suicide’ contract with the suicidal individual, and providing support to family members, were more likely to be taught in psychology courses than in medical courses. Skills items in the medium range included interpersonal skills training, interagency negotiation and advocacy. Aftercare planning and the development of suicide prevention programs were in the low range.
A broad range of teaching styles is used in schools of social work; however, only two schools reported the use of problem-based learning. Sociological content relevant to suicide prevention was covered infrequently by the courses. Suicide methods, racial and cultural issues, and lobbying were in the medium range, while policy issues and the role of the media were in the low range. Awareness of attitudes in self and others fell in the high range, but close supervision of the suicidal individual and maintaining and index of suspicion of suicide risk were in the low range. Only one-third of skills items were in the high range. Items in the medium range included eliciting mental health information, identifying depression, identifying suicide risk factors, identifying harmful drug use, and postvention support to families. Items in the low range were negotiating restricted access to means, negotiating a ‘no-suicide’ contract, therapy skills, interagency negotiation, and the development of suicide prevention programs.
Theology and religious studies courses were varied. Some focused mainly on theological and moral content, others focused on pastoral care, and some took a more comparative approach to religious studies. Knowledge items concerning the demographics of suicide, indicators of depression, and myths surrounding suicide fell in the high range, method of suicide, racial and cultural factors and precipitants to suicide fell in the medium range, while all other items were in the low range. Personal attitudes to suicide were in the high range, other attitude items were in the medium range. Skills concerning the establishment of rapport, response to distress, and referral to other agencies were in the high range. Identifying depression and determining need for medical referral fell in the medium range while all other skills items fell in the low range.
Students specialising in secondary education may do so by studying a specific undergraduate course or by undertaking a postgraduate qualification. Most of the knowledge and awareness items were included in the courses as part of a lecture, with very few universities reporting the use of problem-based learning. Knowledge items concerning demographics, risk factors, indicators of depression, precipitants and racial and cultural issues were in the high range. The role of media, and policy issues fell in the low range, while all other knowledge items were in the medium range. Attitude items were all in the medium range. No skills items fell in the high range, most were in the low range. Included in the low range were important skills such as the recognition of depression, other psychological dysfunction, and drug and alcohol use.
Data were available for four of seven schools of pharmacy. Knowledge items concerning demographics, suicide methods, risk factors, indicators of depression, precipitants, and practice guidelines for drug prescribing were in the high range. No knowledge items fell in the low range. All attitude items were in the high range. Skills of responding to distress and providing information about the safe storage of drugs fell in the high range, other items were in the medium range.
For law programs, nearly all knowledge, attitude and skills items were in the low range. For journalism programs, all knowledge and attitude items surveyed were in the low range. Skills items were not surveyed.
Discussion
This paper reports a national survey of a comprehensive range of university courses that may teach subjects relevant to suicide prevention. The response rate was high for most disciplines, and we feel provides a representative view of the current situation within Australia. Several limitations of the survey should be acknowledged. The survey was highly dependent on the knowledge of the informant from each department or faculty, and it is possible that we have therefore underestimated the extent of teaching in certain areas. We limited questions for individual disciplines to those items that we thought would be most relevant. On reflection, there were a few important omissions. For example, informants for medical and nursing courses were not asked about knowledge items related to public health policy, or skills in developing care plans after discharge from hospital. The survey tells us nothing about the quality and effectiveness of existing teaching.
Suicide prevention topics were taught to some extent in seven of the nine disciplines surveyed, contrasting with the limited interest in targeting university courses for suicide prevention education expressed in the literature. Skills relevant to suicide prevention were less commonly taught, consistent with the observation of Lester that more is taught ‘about’ suicide and suicide prevention than ‘how to’ [12]. Specific skills relevant to suicide prevention at the level of the individual are undoubtedly more difficult to teach, owing to logistic problems of gaining satisfactory and timely clinical access to people at risk for suicide under supervised conditions.
Using a threshold of 70% as a crude indicator of acceptable penetrance into university courses, medical, and nursing schools seem to provide the most comprehensive coverage of knowledge, attitude and skills topics. Medical courses fell short of this threshold mostly in relation to the therapeutic management of the suicidal individual and his family. This deficiency could best be addressed by using educational videos that model the skills necessary for the therapeutic management of the suicidal individual (such as the video produced by Martin [13]) in combination with quality supervision of contact with individuals at risk for suicide during clinical clerkship. Nursing courses fell short of the threshold for providing support to families following a suicide crisis (perhaps traditionally considered the domain of social work), and in developing suicide prevention programs. Both might be considered important skills for nurses working in the general medical setting, and could be included in modules specifically related to the management of suicidal patients, or more generally in relation to patients at some risk for self-harm, such as the patient with delirium. Some knowledge of developing and adhering to ward policy to reduce the risk of self-harm would be a minimum standard.
The epidemiological and social aspects of suicide were taught less commonly in psychology courses, although interpersonal and therapeutic skills were taught somewhat more comprehensively than in medical schools. The survey findings give more cause for optimism than a survey of clinical psychology programs conducted in the USA[7] in which the authors concluded that training was deficient. As more psychologists occupy positions as mental health workers in the ‘front line’ working with suicidal individuals, there is still probably room to increase both background knowledge and skills in this area.
Only some career paths in social work will bring the practitioner in contact with individuals at risk of suicide, therefore it may be anticipated that the penetrance of curriculum materials related to suicide prevention into social work courses may be lower than that for the other clinical professions. Nevertheless, many knowledge and awareness items, and some skills items were included in more than 70% of courses. Again, interpersonal skills would seem to be the area most in need of development.
For secondary education programs, training videos that promote the recognition of depression and other mental disorders in young people could be developed and disseminated reasonably inexpensively, and would meet an existing deficiency in suicide prevention education in current courses.
The disciplines of law and journalism at present contain the least suicide prevention content. Practitioners in both professions have the potential to enact suicide prevention measures at the level of the individual, and at the community level. At present, some journalists are defensive about the need for and content of suicide prevention education. They may feel that the freedom of the press may be under threat if there are directives to restrict or temper reporting. An equally sensitive issue is the weight of evidence linking media reports of suicide with copycat suicide. Inclusion of suicide prevention material in courses may be seen as an admission of culpability. Dialogue between the media and advocates of suicide prevention will be one avenue by which these difficulties can be overcome [14]. In addition, courses may be developed along a more general theme of sensitivity to public concern rather than specifically identifying suicide.
In conclusion, we found that knowledge and attitudes towards suicide are being taught in many existing courses within Australian universities and other tertiary institutions. Measured against an expert panel's view of what suicide prevention material could be usefully taught in Australian tertiary institutions, the greatest opportunities for curriculum development exist for the training of interpersonal skills relevant to suicide prevention. Programs directed to the interpersonal skills relevant to the management of suicidal individuals and their families could be introduced across the range of disciplines surveyed. There is room to increase knowledge and attitude content in courses directed to psychology and social work students, who may follow career pathways as generic mental health workers. Knowledge and attitude content could also be increased for students of education, who may usefully identify adolescents at risk of suicide and refer effectively. There is also potential to introduce suicide prevention material into law and journalism courses, since their graduates may play a role in community advocacy. Challenges to the development of suicide prevention curricula in Australian universities include fullness of existing courses, logistic difficulties in providing appropriate clinical experience, and heterogeneity of teaching approaches.
Footnotes
Acknowledgements
This project has been funded by a special grant from the Commonwealth Department of Health and Family Services. We wish to acknowledge the contribution made by members of the reference group for the National University Curriculum Project who are: Professor Pierre Baume, Dr Chris Cantor and Professor John O'Gorman (Australian Institute for Suicide Research and Prevention), Dr Robyn Cotton (Department of Psychology, University of Newcastle), Mr Stewart Davis-Meehan (Youth Sector Representative, Hunter Region), Dr Michael Dudley (War Memorial Hospital, Waverley, NSW), Professor Brian English (Department of Social Work, University of Newcastle), Ms Gail Garvey (Aboriginal Liaison Unit, Faculty of Medicine and Health Sciences, University of Newcastle), Professor Robert Goldney and Professor Robert Kosky (Department of Psychiatry, University of Adelaide), Professor Ray King (Faculty of Education, Charles Sturt University), Dr Penny Little (Centre for Advanced Learning and Teaching, University of Newcastle), Dr Chris Lennings (Faculty of Health Science, University of Sydney), Professor Terry Lovat (Department of Education, University of Newcastle), Assoc Prof Graham Martin (Child Adolescent and Family Health Services, Flinders Medical Centre), Professor Margaret McMillan (Faculty of Nursing, University of Newcastle), Professor Alexander Reid (formerly Discipline of General Practice, Faculty of Medicine and Health Sciences, University of Newcastle), Ms Marilyn Wilson (Aboriginal Health Coordinator for Hunter Area Health Service).
Appendix I
Items included in the survey of universities for each of nine disciplines