The current study was conducted to evaluate the proximate impact of a brief community level suicide prevention training program on observed gatekeeper skills. To our knowledge, this is the first study of observed gatekeeper skills in a community sample using rigorous methodology with a sample this size. The first objective was to develop methodology to assess skills that addresses a number of limitations of previous studies including: refining a brief, reliable, observational measure of general and specific gatekeeper skills; providing standardized stimuli with trained actors; assessing actor adherence to the standardized script; and assessing skills before and after training.
The second objective was to analyze the magnitude and statistical significance of changes in knowledge, attitudes and skills from pre- to post-training. The final objective was to examine the relationship between pre-training characteristics and skill enhancement after training. We expected that previous training and clinical interviewing, as well as a personality that is “open” to new learning and behaviors, would predict positive change in observable gatekeeper skills.
The Observational Rating Scale of Gatekeeper Skills (ORS-GS) developed for a previous study and refined for the current one, operationalized five gatekeeper skills (two general, three specific). Inter-rater reliability was generally high with the exception of pre-Active Listening and the Persuade item. Raters found the description of the Persuasion item to be unclear and consensus meetings were used to come to agreement on all differences, and to refine the measure for future studies. Nevertheless, there was significant change in participants’ suicide specific skills. The one-hour training program enhanced participants’ ability to ask directly about suicidality, to be persuasive about getting assistance, and to provide a helpful referral.
In contrast to positive changes in suicide specific skills, and consistent with at least one other study (Tierney, 1994
), we found no change in observed general skills (e.g., active listening) from pre- to post-training in this study. This is not surprising because this one-hour gatekeeper training is brief and does not specifically focus on teaching ‘soft’ skills such as empathic reflections. The training indicates that sensitive communication and clarifying questions are important to interacting with suicidal individuals, but, focuses specifically on dispelling myths about suicide and providing information about the three suicide specific skills (questioning, being persuasive, providing an appropriate referral). This finding strengthens Wyman et al.’s (2008)
suggestion that identifying students at high risk for suicide in school settings requires open communication about issues of emotional distress, and that the current QPR training does not change communication styles. To have an impact on general communication skills, it is likely that a more comprehensive training that focuses specifically on communication skills (e.g., empathy, active listening) and identifies participants who are ready to engage others in emotionally charged discussions, would be necessary.
The finding from the current study that 54% of participants demonstrated adequate gatekeeper skills post-training is consistent with a previous study that used a somewhat different criterion (Cross et al., 2007
). The current study defined adequate skills based on a combination of three suicide specific skills (question directly about suicide, moderate level of persuasiveness, contextualized referral). The previous study used a total score cut off for acceptable gatekeeper skills (11+ out of 15 on the scale) in a post-only design. Nevertheless, the percentage of participants is almost identical (54% and 55% respectively). The consistency of the results across two studies with different designs (post-only; pre-post) and populations, argues against practice effects alone as the mechanism underlying our results.
The finding that about half the participants in a one-hour training program demonstrate adequate gatekeeper skills following training is encouraging from a public health perspective—it appears to deliver a rather large impact in a relatively short amount of time Another way to measure cost-effectiveness from training would be to assess participants’ dissemination of knowledge, attitudes and skills to other community members. Broad diffusion of accurate information about suicide through personal contact among friends, and family could serve to reduce stigma and, over time, change social norms.
Nevertheless, there are two caveats to the finding that just over half of the participants demonstrated adequate gatekeeper behaviors. Despite a significant improvement in skills for the sample overall, 46% of participants did not show the ability to ask about suicide and make an adequate referral for help. This proportion is far from ideal for responding to a potentially life-threatening situation in a community setting. Moreover, post-training skills were assessed immediately after training and likely represent the ‘best case’ scenario for using rigorous observational methods with this type of training intervention (Snyder et al, 2006
). Future research is needed to establish whether a longer time lag (e.g. days, weeks) between training and assessment would result in improved long term outcomes of participants with adequate gatekeeper skills.
Clearly, the one-hour, community level gatekeeper training did not uniformly enhance skills among participants. There is significant room for improvement if the goal of gatekeeper training extends beyond knowledge and attitude enhancement.
Finally, it is interesting to note that a small proportion of participants (10%) demonstrated adequate gatekeeper skills prior to training. We examined relationships among the variables associated with pre-training observed skills and found that suicide prevention training was associated with adequate gatekeeper skills prior to training, but the relationship disappeared after training. Thus, other participants increased their abilities at the end of the hour such that prior training was no longer associated with gatekeeper skills. The implication is that some potential participants with previous suicide prevention training may not enhance their learning or skills with this level of gatekeeper training, and may not be good candidates for training particularly if resources are limited. On the other hand, not all participants with previous training demonstrated adequate gatekeeper skills at baseline.
There are several limitations to the current study. Although participants were randomly selected from training groups, sampling bias remains. Specific groups were invited to gatekeeper training at each university site and these groups were chosen by the sites. There is a self-selection bias because participants who volunteer may be quite different from those who choose not to respond to the invitation to participate in the study. In addition, the overall sample size, while substantial for the observational methods, is small for generalizability purposes and a control group is not included. A third limitation is related to the observational measure. Low inter-rater reliability for the Persuasion item is a limitation of the scale, although we used consensus ratings in the analyses. Finally, our findings do not address the critical issue of maintenance of skills over time or the relationship between observed gatekeeper skills and actual use of those skills. Longitudinal studies are needed to establish maintenance, loss or gain in skills over time, as well as the critical question about the relationship between observed gatekeeper skills and use of skills in daily life.
Implications for Practice
Several strategies may be useful in boosting the effectiveness of gatekeeper training. One strategy focuses on selection of participants. In the current study, we found that enhanced skills was not predicted by any of the pre-training characteristics under study, including previous training and interviewing experience. The gatekeeper training intervention had a significant impact on participants who did not have experiences of suicide or suicide specific skills. Similarly, Openness to Experience, a personality characteristic shown in previous studies to be related to new learning and behaviors (Barrick & Mount, 1991
), did not predict enhanced skills. Our sample size is small, however, and not representative of the population at large. Moreover, we assessed Openness to Experience using only 3 subscales. We are therefore cautious in interpreting the finding that openness is not a factor in skill development and recommend that these results be replicated in a variety of populations. Moreover, these or other variables may predict learning outcomes (e.g., skills) in comprehensive trainings programs for clinicians, where the goal is to develop very skillful interveners, or in programs that are longer and more intensive.
Another strategy is to modify the training model used in this type of gatekeeper training program. The current QPR community level training model goal is primarily knowledge transfer. Participants passively receive information about suicide and messages to increase awareness. Although the training is engaging and highly rated by participants as valuable (Cross et al., 2007
; Matthieu, et al 2007; Lezine et al., 2009
), from an adult learning perspective such a passive learning experience is not likely to result in transfer of that training for behavior change and use in daily life (DeNeve & Heppner, 1997
; Humair, & Cornuz, 2003
; Joyner & Young, 2006
). The QPR training program draws an analogy with cardiopulmonary resuscitation (CPR) in that both training programs teach a skill that community members can learn and use to aid others. Studies of CPR training have shown, however, that simulations of real life scenarios where CPR may be needed, as well as behavioral assessment with instructor feedback, are necessary to achieve skill acquisition and retention (Hamilton, 2005
). Although knowledge enhancement has been shown to persist for many months following CPR training, skills decline over that period, particularly if behavioral simulation is not a training factor (Hamilton, 2005
). Brief gatekeeper training, such as QPR, which are primarily lecture-based would benefit from research using similar training strategies. Role play practice with supportive feedback, as well as other active learning strategies, increases the likelihood of gatekeeper skill development and use. Our finding that there was an association between participants’ efficacy after training and enhanced skills is consistent with adult learning models that emphasize the mediating role of self-efficacy in behavior change (Cross, 2009
; Holton & Baldwin, 2003
). Training strategies that further enhance feelings of efficacy for intervening with suicidal individuals are likely to result in a greater proportion of participants with adequate gatekeeper skills. A study that randomly assigns participants to training as usual and training plus behavioral rehearsal through simulation would be needed to assess maintenance, decline or improvement in general and specific gatekeeper skills immediately following training and at follow up.
In sum, a brief, community-level gatekeeper program designed for “novice” trainees--individuals without previous knowledge or specific traits—resulted in positive changes in knowledge, efficacy and observable skills among a variety of new learners. Importantly, about half of participants demonstrated adequate suicide specific gatekeeper skills following a program that does not provide behavioral rehearsal or focus on skill development. The duration of these skills, however, has yet to be established through longitudinal studies and the strategies needed to increase the proportion of participants who acquire gatekeeper skills have yet to be studied. An effective population-based approach to suicide prevention requires broad-based training that is necessarily cost effective. Brief gatekeeper training programs, such as the one we studied, may be enhanced by a simple, “low technology” use of active learning strategies (i.e., role play rehearsal) in the training. Transfer of training to actual use of gatekeeper skills may also be improved when training provides opportunities for practice. Studies that test the impact of different training models on knowledge, attitudes, skills and use are critical to improving community-based suicide prevention.