Training for All
When an organization makes a commitment to Zero Suicide, everyone understands that safe suicide care begins the moment the patient walks through the door for the first time. It is essential that all staff members have the necessary skills to provide excellent care, which in turn will help staff to feel more confident in their ability to provide caring and effective assistance to patients with suicide risk.
In a Zero Suicide approach:
- Employees are assessed for the beliefs, training, and skills needed to care for individuals at risk of suicide.
- All employees, clinical and non-clinical, receive suicide prevention training appropriate to their role.
How will we formally assess staff on their perception of their confidence, skills, and perceived support to care for individuals at risk for suicide? What training will we then provide for staff to develop the needed skills?
To Implement Zero Suicide
Assess Staff Skills
- Conduct an assessment of staff knowledge, practices, and confidence in providing safer suicide care.
- Repeat the assessment at least every three years.
The Zero Suicide Workforce Survey is the ideal tool for assessing staff knowledge, practices, and confidence. See the Zero Suicide Workforce Survey tab above for detailed information.
Train Staff in Key Skills
- Provide staff training commensurate with their roles in providing safer suicide care.
- Repeat training at least every three years.
- Ensure that training contains the following elements:
- The fundamentals of the organization’s Zero Suicide philosophy
- Policies and protocols relevant to the staff member’s role and responsibilities
- Basic, research-informed training on suicide identification for all staff
- Additional training to all clinical staff to ensure a basic level of skill in assessing, managing, and treatment planning for patients at risk of suicide, including safety planning and reduction of access to lethal means
- Advanced training to deepen skills and increase confidence and effectiveness
Many training workshops are available and choosing the right one for your organization’s needs may seem challenging.
Go to the Training Workshops tab above for information about training programs and an activity demonstrating how an organization might go about choosing the right training for specific categories of staff. See Suicide Care Training Options for a chart summarizing the most widely used programs and their audiences and length.
The Zero Suicide Workforce Survey
Overview of the Workforce Survey
One component of a Zero Suicide framework is a competent, confident, and well-trained workforce, regardless of role or responsibility. The Zero Suicide Workforce Survey is one tool your organization can use to assess staff self-perception of their knowledge and comfort interacting with patients who may be at risk for suicide, including comfort and skill providing specific elements of care such as screening, treatment, and support during care transitions.
This survey can serve multiple functions:
- Provide for leadership a snapshot of how prepared staff actually feel about providing suicide care and will also likely reinforce that change is needed and welcome
- Provide an opportunity to let staff know that their input throughout the launch and implementation of your system-wide suicide care initiative will be welcome and desired
- Assist your implementation team in designing and prioritizing training needs
Using the Survey Results
Survey results should inform leadership about how prepared staff feel to provide suicide care, assist in the development of training plans in your organization, and help establish a baseline for your implementation approach.
The following quote from the Zero Suicide Breakthrough Series: Outcomes and Recommendations report illustrates what you can learn by administering the Workforce Survey:
See the Guidelines for Administering the Workforce Survey resource for additional information about analyzing and sharing results.
Findings from Other Organizations
The general findings from more than 35,000 responses to an earlier version of the Zero Suicide Workforce Survey across nine states showed that a large number of staff at all levels do not have specific training in suicide care:
- Between 35% and 45% don’t feel they have the skills
- Between 40% and 50% don’t feel they have the training
- Between 30% and 40% don’t feel they have the support2
Most organizations are likely to see similar results since clinicians get so little suicide-specific training in graduate school. Zero Suicide Implementation Teams can use survey results to motivate staff commitment to the Zero Suicide goal and to guide selection of training workshops to build staff skills in areas the survey shows to be weakest.
For example, one organization that administered the survey at the launch of their Zero Suicide initiative and repeated administration of the Work Force Survey a year later found dramatic changes in staff responses:
- Number of all staff responding that they had the training, skills, and support increased by more than half, from just 36% on the first survey to 86% on the second
- Number responding that they did not have the training, skills, and support decreased from 27% to 2%
Administering the Workforce Survey
The Zero Suicide Workforce Survey takes an average of 10–15 minutes to complete, and the responses are anonymous. It contains branching logic to match certain categories of survey questions with relevant staff based on their role in the organization.
Organizations can either request access to the online version of the Workforce Survey or use the PDF document with the survey questions to create their own online survey or administer the survey on paper.
We recommend the survey be re-administered at least once every three years, either among a specific group of staff members or the entire staff, to re-assess knowledge, comfort, and skills.
Accessing the Workforce Survey
To request access to the online Workforce Survey please click the following link: Workforce Survey Request Form.
The Zero Suicide Workforce Survey Resources page contains the additional resources listed below:
- PDF document with the survey questions
- Guidelines for Administering the Workforce Survey
- Sample letter to staff about the survey
- Sample survey results report
The link to the Zero Suicide Workforce Survey Resources page is also found in the Tools section below.
- 1. National Council for Behavioral Health. (2015). Zero suicide breakthrough series: Outcomes and recommendations. Retrieved from http://zerosuicide.sprc.org/sites/zerosuicide.actionallianceforsuicidepr...
- 2. Silva, C., Smith, A. R., Dodd, D. R., Covington, D. W., & Joiner, T. E. (2016). Suicide-related knowledge and confidence among behavioral health care staff in seven states. Psychiatric Services, 67(11), 1240–1245. Retrieved from http://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201500271
Selecting Training Workshops
For Clinicians and Staff
Clinicians and staff members must be confident in their ability to create a helping alliance with a person contemplating suicide. Confidence can arise from various sources:
- An understanding that suicide is preventable
- Clear policies and management plans to engage with patients and clients who are thinking about suicide
- A staff member’s skill in asking “Are you thinking about taking your life?”
The following provides a brief overview of training suggested for various staff roles and responsibilities:
- Non-clinical staff
- All professionals who screen incoming patients
- Behavioral health clinicians
- Primary care staff and clinicians
The resource Suicide Care Training Options describes the most widely used training workshops for the health and behavioral health care workforce.
All non-clinical staff, including receptionists, administrative staff, and technicians, should be trained to identify patients who are at risk for suicide. People who are experiencing suicidal thoughts often disclose them to non-clinical staff, so all staff members should be on alert for someone who might be at risk from the moment the person first calls for an appointment or walks in the door.
The trainings that would be appropriate for non-clinical staff are generally called gatekeeper training.
Gatekeeper training provides an overview of suicide prevention. Participants learn how to recognize suicidal behavior, how to respond, and where to make a referral and find help. It does not teach how to do a clinical assessment of a person at risk for suicide.
All professional staff members who will be asked to screen new patients at intake must be trained in how to conduct a screening, preferably using a tool that is informed by evidence of its ability to accurately identify those at risk. Those staff members may include paraprofessionals, nurses, nurse practitioners, and physician assistants in primary care settings or emergency department staff. In integrated or primarily behavioral health organizations, intake workers, case managers, or other professionals may be included in this category.
Primary care staff, including physicians, nurses, nurse practitioners, physician assistants, paraprofessionals, and administrative staff should receive training in recognizing risk factors and warning signs. Primary care practices should develop policies and protocols for referring and managing patients at risk for suicide.
Behavioral health clinicians working with patients or clients who may be at risk for suicide include social workers, psychologists, professional counselors, marriage and family therapists, psychiatric nurses, and psychiatrists. Training for this group should teach these essential skills:
- An approach that acknowledges the ambivalence of the person considering suicide and affirms that alternatives to alleviating the patient’s pain do exist.
- The ability to gather patient information beyond suicide screening information that will inform a risk formulation.
- The ability to form and communicate to other clinicians, supervisors, and the patient a contextualized risk formulation to aid safety planning, counseling to reduce access to lethal means, crisis support, and treatment planning.
- The ability to write a clear risk formulation for the patient record.
- A commitment to collaborating with the patient and others who are significant in the patient’s life to create and record a safety plan and crisis support plan.
- Knowledge of the available treatment options and the ability to consider those options that are least restrictive to the patient whenever possible.
Assess and Train Clinical and Non-Clinical Staff
The basic next step to assess and train clinical and non-clinical staff is:
- Administer the Zero Suicide Work Force Survey to all clinical and non-clinical staff to learn more about staff’s perceptions of their comfort and competence caring for those at risk for suicide.
There are several additional items to help you plan these next actions:
Quick Guide to Getting Started with Zero Suicide. This one-page tool lists ten basic actions to take to implement a Zero Suicide initiative. Use this tool to get an overall vision of the path you will take to adopt this comprehensive suicide care approach.
Zero Suicide Organizational Self-Study. Every organization should complete the self-study as one of the first steps in adopting a Zero Suicide approach. While the self-study is available in the Lead section of the Zero Suicide online toolkit, it’s provided again here for your convenience.
Zero Suicide Work Plan Template. This form contains an expanded list of action steps to guide your implementation team in creating a full work plan to improve care and service delivery in each of the seven core Zero Suicide components.
Train all staff—clinical and non-clinical—to identify individuals at risk and respond effectively, commensurate with their roles.
Overview: The Need to Train for Safer Suicide Care
It is essential that all staff members have the necessary skills to provide excellent care, which in turn will help staff feel more confident in their ability to identify and to provide caring and effective assistance to patients with suicide risk. Safer suicide care begins the moment a patient initiates contact, and it is critical that all staff understand their role and are trained to provide excellent care appropriate to that role.
Training is a key component of Zero Suicide because health and behavioral health professionals have regular contact with individuals at risk for suicide. Despite the frequency of these encounters and the significance of suicide risk, studies show that many behavioral health professionals do not receive the training or have the confidence to effectively interact with suicidal individuals.1,2 This lack of expertise impacts their ability to provide comprehensive quality care for individuals at risk for suicide.2
Of all the people who died by suicide, 45 percent of individuals had contact with their primary care provider in the month before death. 77 percent had contact with their primary care provider in the year before death.3 Over 70 percent of older adults who died by suicide had contact with a primary care provider within a month of death.4 In South Carolina, 10 percent of persons who died by suicide were seen in an emergency department in the two months before death.3 Therefore, there are opportunities to screen, identify, intervene, and treat only if 1) health and behavioral health professionals are trained to do so and 2) health and behavioral health systems include this as a part of standard protocols and procedures.
Recommendation: Comprehensive Training for Suicide-Specific Care
There is evidence that training has an impact on professionals’ confidence, practices, and policies in providing suicide care.1,2,5 One study assessed whether training in an empirically-based assessment and treatment approach to suicidality administered through a workshop could impact practices, policy, clinician confidence, and beliefs.6 According to Oordt et al., in the 6-month follow-up “results found 44 percent of practitioners reported increased confidence in assessing suicide risk, 54 percent reported increased confidence in managing suicidal patients, 83 percent reported changing suicide care practices, and 66 percent reported changing clinic policy.”5
Health care organizations should assess employees’ beliefs, training, and skills, and provide training appropriate to staff roles. The Zero Suicide Workforce Survey is designed to assess staff self-perception of knowledge, skills, and comfort with patients who are at risk for suicide. This tool can provide an opportunity to assess the competency, culture, and comfort of staff in addition to letting staff know their input throughout the launch and implementation of the system-wide Zero Suicide initiative is desired. As a part of continuous quality improvement and the Improve Element of Zero Suicide, health care organizations should reassess staff with the Workforce Survey throughout Zero Suicide implementation, especially after initiating a training plan.
Conclusion: Safer Suicide Care is Everyone’s Responsibility
According to the Joint Commission, “Clinicians in emergency, primary and behavioral health care settings particularly have a crucial role in detecting suicide ideation and assuring appropriate evaluation.”7 Therefore, an investment in comprehensive training is required.
Training should include:
- Screening and identification for all levels of staff that include risk factors, protective factors, warning signs, and early identification
- Internal policies and procedures for all levels of staff that outline role-specific training plans and competencies
- Assessing suicide risk, safety planning, suicide care management plans, continuity of care, referrals, and care transitions for health and behavioral health professionals
- 1. a. b. National Action Alliance for Suicide Prevention: Clinical Workforce Preparedness Task Force. (2014). Suicide Prevention and the Clinical Workforce: Guidelines for training. Washington, DC. Retrieved from http:// theactionalliance.org/resource/suicide-prevention-and-clinical-workforce-guidelines-training
- 2. a. b. c. Schmitz, W.M., Allen, M.H., Feldman, B.N., Gutin, N.J., Jahn, D.R., Kleespies, P.M., Quinnett, P., & Simpson, S. (2012). Preventing suicide through improved training in suicide risk assessment and care: an American Association of Suicidology Task Force report addressing serious gaps in U.S. mental health training. Suicide and Life-Threatening Behavior, 42(3): 292-304. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1943-278X.2012.00090.x/abst...
- 3. a. b. Abed-Faghri, N., Boisvert, C.M., & Faghri, S. (2010). Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): Enhancing the assessment and treatment of psychiatric conditions. Mental Health in Family Medicine, 7(1), 17-25.
- 4. Trados, G., & Salib, E. (2007) Elderly suicide in primary care. International Journal of Geriatric Psychiatry, 22(8): 750-756. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/gps.1734/full
- 5. a. b. Oordt, M., Jobes, D., Fonseca, V., & Schmidt, S. (2009). Training mental health professionals to assess and manage suicidal behavior: can provider confidence and practice behaviors be altered? Suicide and Life-Threatening Behavior, 39(1), 21–32. Retrieved from http://onlinelibrary.wiley.com/doi/10.1521/suli.2009.39.1.21/abstract
- 6. Smith, A.R., Silva, C., Covington, D.W., & Joiner, T.E. (2014). An assessment of suicide-related knowledge and skills among health professionals. Health Psychology, 33(2), 110-119. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23379384
- 7. The Joint Commission. (2016). Sentinel Event Alert, Issue 56: Detecting and treating suicide ideation in all settings. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf