Development and evaluation of an educational module and workshop for pharmacists managing suicidal ideation

Introduction

Suicide prevention has become an important topic of conversation due to an increase in the prevalence of anxiety and depression worldwide. ¹ It is a widely accepted “guiding principle . . . that suicide is preventable, and action should be taken now to protect people’s mental health.” ² Health care professionals must ensure they are prepared to support their patients during the health challenges they may encounter, including prevention of suicide. Suicidal ideation encompasses a spectrum of intensities, including rumination and thoughts of suicide, but can progress from a general desire to die without a plan in place to active suicidal ideation in which a person has a detailed plan and intends on acting on said plan. ³ Suicidal ideation is a key risk factor for suicide attempts, and appropriately responding to it is crucial to suicide prevention. ³ A systematic review by Boukouvalas et al. ⁴ reviewed health care professionals’ knowledge of, attitudes toward, and confidence in caring for people at risk of suicide and noted that training on suicide prevention led to improvements in health care professionals’ knowledge, confidence, and attitudes, “thereby reinforcing that education is an integral component of suicide prevention strategies.”

An initial environmental scan identified pharmacists’ roles in suicide prevention,^5–8 primarily in the community pharmacy setting. The importance of community pharmacists in suicide prevention is believed to be 3-fold: “they are uniquely accessible health care professionals, they routinely interact with at-risk individuals, and they are the gatekeepers of medications that are commonly used in suicide attempts/deaths.” ⁵ Canadian research has also identified the role of community pharmacists in suicide prevention and the need for enhancement of “education, research, and policy agenda for pharmacists with respect to people who are at risk of suicide.” ⁶ However, it has been noted that there are significant gaps in education and training for suicide prevention within pharmacy practice, and we were unable to identify literature related to education in suicide prevention for pharmacists outside of community-based practice. ⁸ Pharmacists in team-based primary care settings have a distinct practice environment and provide face-to-face services to patients, physicians, nurses, and social workers through the health team (rather than a pharmacy), ⁹ in which their role in suicide prevention is less understood. The same principles are true of pharmacists working in acute care and ambulatory settings. These practice environments create opportunities for pharmacists to identify patients at risk of suicide or expressing suicidal ideation and reinforces the need for suicide prevention training. ⁵ It is important that pharmacists in all direct patient care settings are equipped with the skills required to start a conversation about suicide prevention, recognize warning signs in the people they are caring for, and manage these conversations as trusted members of interprofessional teams. As such, we endeavored to focus on these groups for our study.

A second environmental scan was performed to identify education on suicide prevention geared specifically toward pharmacists working in team-based primary care settings. This environmental scan consisted of searches of databases and gray literature to identify available material. During this search, online resources and modules on suicide prevention for pharmacists were identified^10–12; however, these programs were based in the United States, targeted toward community pharmacists, and largely inaccessible (requiring memberships, high cost, etc.). As the environmental scan did not identify easily accessible training specific to pharmacists working in team-based primary care but did reaffirm the importance of suicide prevention education for health care professionals, our objective became to develop and evaluate a continuing education module for pharmacists on the topic. An asynchronous, online module was developed to be readily accessible for pharmacists across Canada. Evaluation of the educational module subsequently informed the development of synchronous workshops to further support suicide prevention training for pharmacists. A live workshop was consequently developed, implemented, and assessed.

Methods

Educational content was developed and assessed in 2 sections: educational module and live workshop.

Education module

Literature on suicide prevention was reviewed, and multiple resources were analyzed to gather appropriate content for the education module. This included educational modules designed for family physicians and nurses, which reviewed concepts applicable to pharmacists working in team-based primary care environments.^13,14 The educational module was designed to provide a basic overview of the concepts of suicide prevention, formatted in a way that was directly applicable to pharmacists. Concepts reviewed in the module included background statistics about suicide in Canada, myths and facts about suicide, appropriate language, at-risk populations, risk factors, red flags and warning signs, protective factors, how to ask about suicide, risk assessment, safety planning, and self-care. The module also reviewed how to apply this information to a patient who may be experiencing suicidal ideation. The educational module was reviewed by content experts at the Centre for Suicide Prevention, the Mental Health Commission of Canada, and by a registered psychiatric nurse with expertise in suicidality. Feedback was received on the module and implemented to ensure all information provided was appropriate, accurate, and reliable. This information was then used to produce a 45-minute, prerecorded presentation that study participants were able to access and complete at their own pace. (The recorded content is available at: Suicide Prevention Module https://www.youtube.com/watch?v=oB0prNNrYGY).

An evaluation was designed to assess how the educational module affected participants’ self-reported confidence, efficacy, and attitudes toward managing patients with suicidal ideation. A post–pre-questionnaire required participants to answer a set of questions from 2 different perspectives, 1 based on their knowledge before the intervention and 1 based on their knowledge after the intervention; however, both were answered after the intervention was completed. This technique is used to reduce the response shift bias. Response shift bias occurs when the participants’ theoretical “measuring stick” has changed between the time prior to the intervention, and after the intervention. By implementing a post–pre-questionnaire and having participants answer both sets of questions at the same time, it allowed them to self-assess their competencies before and after the completion of the intervention, using the same theoretical “measuring stick.” ¹⁵ Questions were selected and adapted from previous research to assess the efficacy, confidence, and attitudes regarding pharmacists’ perceived skills in suicide prevention.^5,16,17 Descriptive statistics and analysis were performed using SPSS (IBM SPSS Statistics for Windows, version 27.0, IBM Corp., Armonk, NY, USA). Differences between pre- and post-answers were assessed using paired t-test analysis.

A website was designed to host the educational content, providing access to the prerecorded presentation, presentation slides, printable resources, helpful websites, and crisis line information. The website also provided background on the project, a disclaimer, and links to the questionnaire. Pharmacists were recruited to participate in this project through advertisements on the joint Canadian Pharmacist Association and Canadian Society of Hospital Pharmacists Primary Care Pharmacy Specialty Network forum hosted on QID.io. This research was approved by the University of British Columbia Behavioural Research Ethics Board and the Northern Health Research Ethics Board.

Live workshop

The evaluation of the above educational module prompted the development and evaluation of a synchronous workshop.

The format of the workshop was based on “Training Student Pharmacists in Suicide Awareness and Prevention” published by the American Journal of Pharmacy Education and “A Suicide Awareness and Intervention Program For Health Professional Students” conducted in Australia.^18,19 The workshop included a review of key points from the educational module; strategies for asking about suicidal ideation, including practice case scenarios and questions; and an overview of resources, including directing participants to the Columbia Suicide Severity Rating Scale educational module on the Health Authority’s internal learning platform. Three case scenarios with scripts for role-play were developed using information provided in the educational module and the literature.^18,19 Workshop material was reviewed by the team, including those working in mental health areas, to ensure that the material was appropriate and accurate.

A pre–post-survey was designed to assess how the workshop affected participants’ self-reported confidence and attitudes toward managing patients with suicidal ideations. The pre–post-survey required participants to answer a set of questions from 2 different perspectives: 1 based on their knowledge after the education module but prior to engaging in the workshop and 1 based on their knowledge after the workshop. The survey collected demographic data and asked a series of questions from the “pre” perspective (before completing the workshop) and “post” perspective (after completing the workshop). Questions assessing self-reported confidence and attitudes were adapted from the Attitudes to Suicide Prevention Scale (ASP) and Suicide Behaviour Attitude Questionnaire (SBAQ) used in the primary literature to assess health care personnel attitudes on suicide prevention after an educational intervention.^16,20 We removed questions pertaining to relation, and “him/her” pronouns were adapted to “they/theirs” to promote inclusion. Questions derived from the SBAQ were categorized into 3 sections: “Feelings Toward the Suicidal Patient,” “Professional Capacity,” and “Right to Suicide.” ²⁰ A paired t-test analysis was used to assess for statistically significant changes from pre–post-survey responses.

Pharmacists from Northern Health were invited to participate in this research and completed the recorded educational module up to 4 weeks prior to participating in the synchronous workshop, which was held using a videoconferencing platform due to geographical and COVID-19-related restrictions. Workshops ran for approximately 90 minutes and were hosted by 1 of the primary investigators (A.J.) with assistance from experienced nurses and a pharmacist (S.M.) working in psychiatric care. During the workshop, participants were given the option to anonymously ask questions using online polling software. After completion of the workshop, participants were directed to the post-survey and provided feedback on the workshop.

Results

Nine pharmacists from across Canada participated in the evaluation of the asynchronous education content in 2021. The assessment of the educational module confirmed that many pharmacists did not feel very confident in their abilities to manage patients with suicidal ideation, specifically noting a lack of confidence in their ability to provide resources, decide when medical intervention is necessary, and refer to other agencies. After the completion of the module, pharmacists then felt somewhat confident in their abilities to manage suicidal ideation and extremely confident in their ability to listen without judgment. The evaluation showed a statistically significant improvement (p < 0.05) for all questions assessing perceived confidence as shown in Figure 1, as well as self-perceived efficacy in primary care pharmacists’ abilities in managing patients with suicidal ideation. Participants noted going from completely unskilled in managing patients with suicidal ideation to now having some baseline knowledge and acknowledged an appreciation for the module as a starting point in further learning about suicide prevention.

Figure 1

Pharmacists’ perceived confidence in managing patients with suicidal ideation after the educational module

Written feedback from this education module identified the need for practicing suicide prevention skills. This led to the development of a case-based, synchronous workshop in which participants role-played scenarios using their knowledge to further develop comfort and skills in managing those with suicidal ideation. Seventy-one pharmacists from Northern Health were invited to participate, with 9 attending a workshop and completing the pre- and post-survey (n = 9).

Assessment of the live workshop showed a further improvement in perceived efficacy and confidence in managing patients with suicidal ideation (Figure 2). For example, for responses to “I am comfortable assessing someone for suicide risk” for asynchronous learning alone, participants ranged from “disagree” to “agree”, while the participants engaging in the asynchronous material plus the synchronous workshop all agreed to this. There was a statistically significant (p < 0.05) difference in post-workshop responses for questions 4 through 6. All participants “strongly agreed” or “agreed” the workshop was useful and delivered effectively and that the overall experience was positive.

Figure 2

Pharmacists’ perceived confidence and efficacy in managing patients with suicidal ideation with the addition of the workshop component

Discussion

Health care professionals should ensure they are prepared to support patients during the health challenges they may encounter, including the prevention of suicide. Pharmacists providing direct patient care in all settings have opportunities to intervene for patients at risk of suicide. Asking about suicidal ideation and assessing patients at risk of suicide are crucial skills that can be developed with suicide prevention training. ¹⁹ After the completion of a suicide prevention self-education module and live workshop, participants in this study developed a baseline knowledge of the management of suicidal ideation and saw an increase in their overall self-perceived efficacy and confidence in the management of patients with suicidal ideation.

Based on participant feedback, the asynchronous module was appropriate entry-level training for those with minimal experience in suicide prevention. However, written feedback from participants highlighted the need for case-based and synchronous learning opportunities. The creation of a synchronous workshop in addition to the education module provided a safe environment for pharmacists to practice skills taught in the asynchronous module with the support from mental health experts. All participants “agreed” or “strongly agreed” the workshop was useful, and the overall experience was positive.

These results highlighted that pharmacists were interested in pursuing further education in suicide prevention. We believe that this has several implications; participants identified that suicide prevention training is important for their practice and felt as though continuing education would be beneficial to further build their skill set. In addition, it may indicate that pharmacists do not feel as though they receive enough training to manage suicidal ideation in their pharmacy curricula and/or advanced training, consistent with the findings of Gorton et al. ²¹ Based on the results of work by El-Den and colleagues, ²² future iterations of this educational content should include information and post-intervention support for pharmacists.

This study had inherent limitations. First, the workshops reviewed scripted, role-play scenarios, which may not fully represent real-world encounters that pharmacists may see in practice. Second, the workshop component was only 90 minutes in length, which limited the number of case scenarios the participants completed, and was hosted virtually, which may have affected engagement. Lastly, the study had a potential risk of selection bias as the study required a significant time commitment; participating pharmacists may have had increased interest in the subject matter and an increased motivation to grow in this area of practice, which may have subsequently contributed to the improvements seen in the results.

Conclusion

The educational content developed was well-received by pharmacists and led to an improvement in self-perceived confidence and efficacy in managing patients with suicidal ideation. This research supports the need for ongoing suicidal prevention training geared toward pharmacists in all settings and can be used to develop accredited, educational activities for pharmacists and pharmacy students. ■