Evaluation of the Impact of the PABBS Suicide Bereavement Training on Clinicians' Knowledge and Skills.

Background: Health-care professionals do not routinely receive training on how best to support parents bereaved by suicide. Evidence-based training - Postvention Assisting Those Bereaved by Suicide (PABBS) - was designed to address this gap. Aims: The study aimed (a) to pilot PABBS training and evaluate its perceived effectiveness (impact on self-reported knowledge, skills and confidence) in managing suicide bereavement; and (b) to explore training acceptability. Method: A pre- and postevaluation design was used. Professionals attended intensive, structured 1-day PABBS training comprising: didactic/interactive teaching; practice-orientated activities supported with real-life materials and a manual/workbook. Evaluation forms completed immediately before and after training analyzed: (a) self-reported changes in knowledge, skills, and confidence (perceived effectiveness of training); and (b) the acceptability of training.
Results: In total, 62 professionals completed training. Perceived knowledge, skills, and confidence improved after training as did self-reported understanding, motivation to learn more, and intention to change practice. Training was highly rated, particularly the evidence-based, real-life materials, with some suggestions for improvement. Limitations: Self-selected sample and reliance on self-report measures are the study's limitations.
Conclusion: PABBS training may help address gaps in professionals' capacity to support parents bereaved by suicide. The evidence-based content was highly acceptable and appeared to be a key ingredient in effecting self-reported changes in attitudes/intentions.

Over 800,000 people worldwide die by suicide annually (World Health Organization, 2014). Each suicide may affect 135 people (Cerel et al., 2018), who may be at higher risk of dying by suicide themselves (Pitman, Osborn, Rantell, & King, 2016).

Suicide bereavement is a complex global health issue (World Health Organization 2014). It may involve complicated mourning (Kolves & De Leo, 2014), isolation, stigmatization, and lack of support (Department of Health, 2012; Pitman, Osborn, King, & Erlangsen, 2014). Family members may be at elevated risk of self-harm or suicide, with mothers of the deceased at potentially highest risk (de Groot & Kollen, 2013; McDonnell, 2006; Pitman et al., 2014; Pitman et al., 2016). Parental bereavement has frequently been described as the most difficult type of bereavement an individual can experience (Mitchell, Kim, Prigerson, & Mortimer-Stephens, 2004). Little is known about the effectiveness of postvention strategies (Andriessen et al., 2019). Those affected see general practitioners (GPs) as an important source of support but often rely on the voluntary sector alone and need help to navigate services (Ross, Kolves, & De Leo, 2019; Wainwright et al., in press).

While UK guidelines for developing/evaluating suicide bereavement services stress the importance of primary care physicians/GPs being vigilant to the potential vulnerability of these families (Department of Health, 2012), many GPs are anxious and/or uncertain how to respond (Foggin et al., 2016; Halligan & Corcoran 2001). It is known that some professionals are vulnerable to intense distress when a suicide occurs (Seguin et al., 2014) and do not receive training in suicide bereavement (Gibbons et al., 2019; Sanford, Cerel, McGann, & Maple, 2016). Gaps in professionals' knowledge and training can be a barrier to providing better care; however, there are other, more complex challenges for professionals including feelings of powerlessness to help, especially if the deceased was also their patient (Foggin et al., 2016). Furthermore, the importance of developing theory-informed postvention training has been recognized (Andriessen, Castelli Dransart, Cerel, & Maple, 2017).

To address these gaps, the Postvention Assisting Those Bereaved by Suicide (PABBS) training program was developed/piloted, aiming primarily to provide GPs and mental health professionals with the knowledge, skills, and confidence to respond to parents bereaved by suicide (a specific subgroup whose needs may be different from those of other family members). This paper reports the evaluation of the pilot to obtain preliminary indications of (a) perceived effectiveness of training and (b) training acceptability.

Method

Development/Piloting

Training was delivered in four 1-day workshops between August 2015 and February 2016 in the North of England. Content was largely based on findings from the PABBS study that ran from 2011 to 2015 (McDonnell et al., 2015) including: (a) exploration of parents' and health professionals' perceived needs (Foggin et al., 2016; Wainwright et al., in press); (b) best evidence about suicide bereavement support; and (c) a detailed content analysis of existing policy/training materials, for example, Grad (2012); NHS Scotland and Cruse Bereavement Care Scotland (2013); SAMH and NHS Scotland (2012); and SANE Australia (2012). Members of a local self-help suicide bereavement group formed part of the training development advisory group.

Delivery methods were designed in accordance with the perceived effectiveness of training framework (Perryman, 2014), acknowledging the importance of theory-informed approaches (Andriessen et al., 2017). Training focused on: suicide prevention; attitudes and stigma; suicide and its impact on health professionals; bereavement; suicide bereavement; parents bereaved by suicide; building resilience and instilling hope, with associated key learning objectives (Table 1). Training materials included lecture slides and high-quality short films made specifically for PABBS, highlighting key issues in the context of real practice. Issues included the experiences of parents bereaved by suicide and those of clinicians responsible for their care; parents' needs; examples of good consultation practice. A manual/workbook supported learning. The mixed format included didactic sessions interspersed with presentations of the films, group discussion, as well as individual and group exercises. All activities aimed to advance and enhance trainees' understanding, motivation, and stimulate discussion.

Table 1

Key learning objectives

Training topics	Learning objectives	Change targets Knowledge – K Skills – S Confidence – C
1. Suicide prevention	• Suicide statistics/extent	K, C
2. Attitudes and stigma	• Attitudes to and language about suicide	K, S, C
3. Suicide and its impact on health professionals	• Impact on clinicians/importance of self-care (including support systems for professionals)	K, C
4. Bereavement	• Impact of bereavement in general	K
5. Suicide bereavement	• GPs' and Suicide Liaison Officers' perspectives on caring for bereaved parents	K, S, C
6. Parents bereaved by suicide	• Experiences of bereaved parents • Parents' needs • GPs' vulnerabilities/holistic view of parent/GP perspectives	K, S, C
7. Building resilience and instilling hope	• Guidance for clinicians on how to respond to/care for parents bereaved by suicide • Guidance on language use • What individuals bereaved by suicide find helpful • Where to signpost parents • Good consultation practice • Reflections on how training will change practice including action plans on managing bereaved parents	K, S, C

Evaluation Design: Quantitative/Qualitative Questionnaire

Sampling and Recruitment

Ethical approval was obtained from the National Research Ethics Service Committee North West (Reference: 11/NW/21047). A convenience sample of participants was recruited between July 2015 and February 2016 by advertising via: (a) the staff intranet of an NHS Trust in the North of England; (b) Twitter; and (c) personal invitation of the research team. Participants were invited to attend one of four workshops as follows: staff of the NHS Trust who might come into contact with those bereaved by suicide (Workshop 1); individuals with specialist experience (i.e., up to 15 years of either working in suicide prevention/bereavement and/or delivering suicide prevention training), and individuals who had participated in the PABBS study or were known to the research team to be personally or professionally affected by suicide (Workshop 2); any professional in the UK who was interested in attending (Workshops 3 and 4).

Data Collection

During attendance at a workshop (free of charge) delegates completed a questionnaire to evaluate:

The perceived effectiveness of training. Immediately before/after training, participants scored (a) perceptions of their own knowledge, skills, and confidence in dealing with those bereaved by suicide and (b) perceived posttraining changes – positive, negative, or none – to understanding, confidence, motivations for/intentions to change practice.

Training acceptability. After training, participants scored the perceived usefulness of training tasks and gave written impressions of the training.

The questionnaire (Electronic Supplementary Material 1) comprised 38 items on a 5-point Likert scale, six items on a visual analogue scale, five yes/no items, and five free-text open questions. Perceived posttraining changes were measured with six simple numerical rating scales (NRSs) where scales ranged from +3 indicating positive change to −3 indicating negative change and 0 no change.

Following the unanticipated disclosure by several participants during Workshop 1 of having been personally/professionally bereaved by suicide, subsequent workshop attendees were given the opportunity of recording their bereavement status, to capture the number of trainees directly affected.

Data Analysis

Data were analyzed with SPSS Version 23.0 (IBM Corp., 2015). The McNemar test was used to compare differences in the proportions of participants reporting sufficient knowledge, motivation, and confidence to deal with those bereaved by suicide pre-/posttraining. Descriptive summary statistics indicated self-reported changes scored in the NRS and the proportions of delegates reporting that training had influenced their knowledge, motivation, or confidence.

Free-text items were exported to Microsoft® Excel, and a qualitative content analysis (Schreier, 2012) enabled coding/segmentation of data on perceptions of training.

Results

Of 72 individuals initially agreeing to attend, six withdrew before training and four did not complete an evaluation questionnaire. The results presented here reflect the responses of 62 participants (38 female, 24 male) who completed both the training and the evaluation questionnaires.

Although training was aimed primarily at GPs and mental health professionals, 11 different professions were represented (Electronic Supplementary Material 2). Just under one-third were nurses (32.3%), followed by GPs (11.3%), therapists/counsellors (11.3%), and social workers (9.7%). Non-health-care professionals also attended, including coroners officers, police officers, and suicide bereavement charity staff. The majority had been working in this field for over 10 years; several had considerable expertise in suicide prevention, bereavement, and prevention training.

Of the 46 delegates attending Workshops 2, 3, and 4, 32.6% (n = 15) reported having been personally bereaved by suicide and 87% (n = 40) reported having been affected in a professional capacity.

Perceived Effectiveness of Training

McNemar's tests on the three pairs of pre-/posttraining evaluation items (Table 2) indicated statistically significant differences in the proportions of the 62 participants reporting improvements in knowledge, skills, and confidence before and after training (McNemar with Yates' correction, exact p ≤ .001 for all three paired comparisons).

Table 2

Knowledge, skills, and confidence pre-/posttraining (n = 62)

		Increased knowledge after training?d			McNemar test chi square statisticg	Significance
		No	Yes	Totals n
Note. aMy knowledge of suicide bereavement is sufficient for my current role [Prior to training]. bMy skills to support people bereaved by suicide are sufficient for my current role [Prior to training]. cI feel confident that I could respond effectively to those bereaved by suicide [Prior to training]. dMy knowledge about suicide bereavement has increased [Following training]. eMy skills to support those bereaved by suicide have improved [Following training]. fI will feel more confident responding to those bereaved by suicide [Following training]. gContinuity corrected.
Sufficient knowledge before training?a	No	1	37	38
	Yes	3	21	24	27.23	p ≤ .001
Totals		4	58	62
		Increased skills after training?e
		No	Yes
Sufficient skills before training?b	No	3	40	43
	Yes	0	19	19	38.03	p ≤ .001
Totals		3	59	62
		More confident to respond after training?f
		No	Yes
Confident to respond before training?c	No	2	39	41
	Yes	1	20	21	34.23	p ≤ .001
Totals		3	59	62

On all six NRS indicators, all participants, including specialists in the field, stated that their understanding of suicide bereavement had increased. Moreover, 90% reported they now had fewer concerns about meeting bereaved parents in their future work. Self-reported motivation to learn more about suicide bereavement increased in 97% of cases; 81% reported intentions to find out more about suicide bereavement in the 2–3 months following training and 99% were more motivated to discuss this with colleagues. Furthermore, 97% reported intentions to make changes to practice. Electronic Supplementary Material 3 shows that median scores for each of the six NRS items were either 2 or 3 (where the maximum possible score for each was 3).

Training Acceptability

Questionnaire responses indicated that the vast majority of individual tasks were perceived as quite/very useful in relation to content, relevance, and potential to advance understanding (Electronic Supplementary Material 4). Approximately two-thirds (67%) reported that the training day contained the right amount of material; all agreed/strongly agreed that the materials were informative/of high quality and the facilitators were well prepared/successful in stimulating interest in suicide bereavement (Electronic Supplementary Material 5). All but one respondent (98.3%) reported that they would recommend the training to colleagues, while 57 of 61 (93.4%) indicated that they would not want to receive an online-only version (although 86% would value supplementary online resources to consolidate learning following face-to-face training).

The free-text qualitative data offered a further level of insight into delegates' perspectives on training acceptability. Three key themes are presented with brief illustrative data extracts.

Useful Aspects

Increased awareness of the impact of suicide bereavement on both parents and professionals, the potentially longer duration of bereavement, and the importance of continuity of support for parents/self-care for professionals were noted:

Clear information regarding what families find helpful; effect on practitioners professionally and personally when a person ends their life by suicide. (P39)

The real-life experiences linked to practical exercises and skill-building helped increase confidence:

Real life examples helped to relate to the theory. (P56)

Sharing information and networking with other professionals from a range of backgrounds and services helped consolidate learning:

… having the opportunity to share experiences with other …agencies i.e. police and coroners officers, was invaluable. (P30)

Intended Changes to Practice

Delegates reported intentions to more proactively support individuals bereaved by suicide (i.e., less fear of making an approach/being direct/using techniques):

Gives me the confidence to open up discussions about people's experiences of being bereaved by suicide. (P19)

There were expressed intentions to share learning with colleagues to support them to manage suicide bereavement:

Up-skill team now on information learnt – difference between suicide bereavement and bereavement. (P5)

Delegates intended to use the knowledge and confidence gained to push for/develop/improve services:

… more of an "evidence-based" rationale to argue a point with management/service directors. (P8)

Suggested Improvements

Delegates suggested a longer duration of training as it was so packed with valuable information/exercises:

It's such an important issue that … it needs adequate training time – felt a bit rushed … and … more discussion would have been really helpful. (P10)

Many suggested a re-balancing of content to focus more on activities/skill-building with some of the knowledge elements put online or sent to participants in advance:

I think some of the videos could be viewed online. (P3)

Other suggestions were that the experiences/perspectives of other professionals could be included:

…could be broadened to cover a wide variety of health specialties, if not "professionals" in general. (P12)

It was also suggested that case studies of particularly challenging suicide bereavement scenarios could be included to deepen learning:

Coping with situations when things go wrong. (P37)

Discussion

To our knowledge, PABBS is the first international, evidence-based, theory-informed suicide bereavement training. It improved the perceived self-reported knowledge, skills, and confidence of a wide range of professionals in supporting parents bereaved by suicide. Further, self-reported understanding of suicide bereavement and motivation/intention to learn more and change practice also increased after training. The acceptability of training was rated highly with some suggestions for improvement.

GPs have an important role in the care of bereaved families after suicide (Clark & Ebert, 2017). Despite training being specifically designed for GPs and mental health professionals, we received a high volume of interest from diverse professionals and chose not to restrict the training to certain groups during the pilot/evaluation phase to respond to this clear unmet need. Despite the variation in professions, a high proportion of delegates reported positive changes in knowledge, skills, and confidence after training while almost all reported fewer concerns about meeting bereaved families. This suggests that PABBS training may help to address previously identified gaps in professionals' expertise (Foggin et al., 2016; Pitman, Osborn, King, & Erlangsen, 2014), for specialists and nonspecialists alike, and go some way to addressing the needs of bereaved families (Ross et al., 2019). Although PABBS was piloted in the UK, it has international relevance since suicide bereavement is a globally recognized phenomenon. Postvention support is considered to be a key aspect of suicide prevention internationally (Andriessen et al., 2019; World Health Organization, 2018) since support/training are protective factors (Castelli Dransart, Treven, Grad, & Andriessen, 2017).

Feedback and Suggestions for Improvement

The evidence-based content was highly acceptable and appeared to be a key ingredient in effecting self-reported changes in attitudes/intentions. This is encouraging, considering the diversity of the professions attending.

Several suggested that the training be delivered over 2 days, or slides be reduced/content made available online so that time could be dedicated to skills-building activities and that training could be widened to a greater range of professionals and include studies of particularly challenging cases.

Ethical Issues

An unexpected characteristic of the sample was the relatively high proportion of delegates who disclosed personal/professional experience of suicide bereavement, highlighting the potential vulnerability of professionals attending training (Marzano, Smith, Long, Kisby, & Hawton, 2016). PABBS training is particularly informed by the work of Grad (2012) such that self-care is a key tenet. Ethically, it is essential that: (a) trainers are adequately skilled/qualified to appropriately support attendees; and (b) more than one trainer delivers these programs to ensure that attendees receive one-to-one support should they need it. (National Action Alliance for Suicide Prevention, 2014, 2015).

Limitations and Strengths

The generalizability of findings is limited owing to the self-selected sample of relatively small size and reliance on nonstandard, study-specific, self-report measures alone. There was no control group to act as a comparator or to help identify potential confounders of the results. An important caveat is that the experience of being participants could have led to these findings alone, rather than changes being attributable to the specific content of this training (Brown, 1992).

It could also be argued that professionals bereaved/affected by suicide might be attracted to such training. The pre-/post-self-reported knowledge, skills, and confidence items were not identical and thus interpretation of these results should be undertaken with some caution. We do not have evidence that immediate changes identified would be maintained over time, nor is it known if newly acquired knowledge or skills would translate into changes in practice. However, participants expressed clear intentions to use the skills/knowledge learned and PABBS stands as a useful guide for developing future suicide bereavement training.

Despite these limitations, the study is the first known evaluation of a suicide bereavement training program that (1) is informed both by academic research and a theory of training delivery, (b) is delivered by recognized experts in the field of suicide prevention, and (c) formally evaluates both the perceived effectiveness and acceptability of training in frontline professionals with a high likelihood of interacting with those bereaved by suicide. A particular strength is in highlighting the importance of trainers with skills in dealing with unexpected/unresolved issues that might be evoked for trainees.

Training Implications

This study supports the view that specialist training is required for professionals who come into contact with those bereaved by suicide (Hawton & Simkin, 2003). The development of evidence-based suicide bereavement training is in its infancy but is a key aspect of suicide prevention, requiring postvention policies worldwide to support it.

Arguably, international suicide prevention strategies need to pay more attention to the needs of frontline staff, who are exposed to suicide or suicide bereavement. Additionally, although online training may be perceived as "cheaper," if delivered in isolation without appropriate face-to-face support, it could be potentially unethical. Indeed, over 90% of participants in this study were opposed to online training alone.

GPs were only the second largest group of professional participants in this study, suggesting that it may be difficult to engage GPs in postvention training. Postvention strategies may need to be mindful of this issue and adopt measures to address it. Campaigns to raise awareness of the importance of such training and/or making postvention training mandatory may be of benefit.

Ideally, training evaluations should address both real-time (immediate) and long-term effectiveness. We were only able to capture immediate changes; however, longer-term changes to practice as well as maintenance of attitude shifts and knowledge gains should all be assessed qualitatively/quantitatively to inform appropriate modifications to training, as well as inform decisions about frequency of updates or refresher sessions.

Future Research

PABBS training responds to the call to increase theory-informed research in the postvention field (Andriessen et al., 2017; Neimeyer, Cerel, & Maple, 2017); however, there is also a need to increase intercultural collaboration and build bonds between research and practice.

Specifically in relation to postvention training, it is understandable in the current economic climate that organizations are developing online methods of delivery as a potentially cheaper solution. Future research should explore the benefits and drawbacks associated with delivering postvention training online, including whether it adequately supports trainees who are themselves bereaved/impacted by suicide. Additionally, if PABBS training is effective in improving knowledge skills and confidence among professionals, it will be important to assess its impact on people bereaved by suicide themselves.

Conclusion

There is evidence that PABBS training helped improve the self-reported knowledge, skills, and confidence of a wide range of professionals in supporting parents bereaved by suicide. In addition, reported understanding of suicide bereavement, motivation to learn more, and intentions to change practice all increased.

The provision of PABBS training is a step in the right direction in acknowledging and addressing the emotional, practical, and training needs of professionals since it responds to a previously unmet need and fills a training gap both in the United Kingdom and beyond. This type of training should be included as a key objective in future suicide prevention strategies and form a key part of future postvention research.

Electronic Supplementary Material

The electronic supplementary material is available with the online version of the article at https://doi.org/10.1027/0227-5910/a000646