Globally suicide is identified as a serious public health issue which causes 800,000 deaths per year, proportionate to 1 death every 40 seconds (World Health Organisation, 2015). In New Zealand, rural suicide rates have been of particular concern due to falling dairy prices, drought, and other contributing factors (Federated Farmers, 2014; Goffin, 2014; Walker, 2012). One promising suicide prevention strategy, ‘gatekeeper training’, includes educating groups of people how to identify and support individuals at high risk of suicide (Clifford, Doran, & Tsey, 2013; Walker, 2012). With utilisation of the PECOT model (Whitehead, 2013) the research question was formulated: Does gatekeeper training effectively enable the trainee to develop the knowledge and skills required for suicide prevention? Results from the literature review indicate that gatekeeper training does effectively enable the trainee to participate in suicide prevention by enhancing knowledge, improving skills and by changing attitudes.
Suicide: A Serious Public Health Issue
Suicide is defined as an intentional self-inflicted death which occurs due to harming behaviour directed at one’s self with the objective to die as a result of the behaviour (Ministry of Health, 2015). As reported by the World Health Organisation (2015), every year over 800,000 people worldwide die due to suicide; the equivalent of 1 death every 40 seconds. The World Health Organisation (2015) recognises suicide as a serious public health issue in the world currently and perceives suicide prevention as a public health priority. Annual provisional suicide statistics reported a total of 564 deaths by suicide in New Zealand for 2014/2015, with a total per 100,000 being at 12.27 (Coronial Services of New Zealand, 2015).
Rural suicide is a current clinical health issue in New Zealand, as with recent drops in dairy prices, droughts, financial pressure, social isolation and general associated stress, these aspects can significantly affect the mental health of members of a rural New Zealand community (Federated Farmers, 2014; Goffin, 2014; Walker, 2012). In defining the term rural, Statistics New Zealand (2016) comment that there is no definition that is recognised globally, however they pin down the general key aspects of rurality; a diverse range of inhabitants (farmers, ‘alternative lifestylers’, crafts people etc.), limited access to healthcare, recreational and economic services, located a distance from urban centres, and rural centres are defined by their population size of 300-999 people. Increasing rural isolation and living in agricultural communities are significantly associated with greater suicide rates for both adults and adolescents (Hirsch, 2006). A reported 169 New Zealand farmers have committed suicide since 2007/2008 (Federated Farmers, 2014). Walker (2012) reported that after national suicide death statistics were released in August 2011 by the New Zealand Chief Coroner, rural suicides from years 2008-2011 averaged 25 completed suicide deaths per year, the Coroner acknowledged the reported suicide toll was a very concerning aspect of our society. The Coroner also brought up that we must discover strategies to put into practice to bring rural suicide numbers overall in New Zealand down (Walker, 2012).
Federated Farmers (2014) independently accessed further data from the Chief Coroner, nailing down the most recent rural suicide rates which had not been reported in the 2013/2014 Chief NZ Coroners report, which revealed that there had been twenty two suicide deaths in rural communities in the year 2013/2014 (Coronial Services of New Zealand, 2015). In 2014, Milne, Federated Farmers Health & Safety spokesperson stated that the national rural suicide statistics are a ‘disgrace’ (Federated Farmers, 2014). Clay (2014) reported that suicide rates are high in rural areas because there are fewer health care professionals and access to emergency medical facilities, use of drugs and alcohol and greater reported access to firearms.
Gatekeeper Training: A Promising Intervention
Suicide rates continue to increase globally despite significant efforts to implement evidence-based suicide prevention approaches (Isaac et al., 2009). One particular intervention utilised as a preventative approach is gatekeeper training as a suicide prevention strategy. Gatekeeper training for suicide prevention can be defined as “teaching specific groups of people in the community how to identify and support individuals at high risk of suicide” (Clifford, Doran, & Tsey, 2013, pg. 466). This involves enabling participants to enhance their knowledge of suicide prevention, improve their skills so that they may apply them in practice, and to change their attitudes towards the stigma associated with suicide (Isaac et al., 2009; Smalley, Warren, & Rainer, 2012).
After a preliminary search of current evidence-based literature on interventions that are effective in practice for suicide prevention, gatekeeper training has been described as one of the most promising and effective strategies in suicide prevention (Walker, 2012). It is evident further development and research is required around the effectiveness of gatekeeper training on actual suicide rates, however a good amount of research has been conducted around how the training enables participants to actively be involved in suicide prevention (Isaac et al., 2009). Therefore gatekeeper training of the community could be an effective intervention for suicide prevention (Walker, 2012; Goffin, 2014). Due to limited research around gatekeeper training in rural communities, this aspect has been unable to be included in the literature review.
Historically gatekeepers have been divided into two types of groups (Isaac et al., 2009) the first is called the designated group which includes health professionals (i.e. nurses, General Practitioners (GPs), social workers, psychologists) and the second is titled the emergent group which includes community members with public roles (i.e. teachers, police, counsellors, clergy, coaches). The wider community and family members are also recognised as a very important group of people that can be effective in the prevention of suicide. This is supported by Quinnett (2007) who reported that those who you already know, such as family members and members of the community, are the most likely to prevent you from taking your own life. From various research articles located about gatekeeper suicide prevention training, the three main ideas of gatekeeper training that are evident are; enhancing knowledge around suicide prevention and mental illnesses, improving and teaching skills to assess for and recognise suicidal thoughts, and changing attitudes of health care professionals and community members so that the best support can be provided and intervention can take place.
The 'Designated' Trainees
Tsai, Lin, Chang, Yu and Chou (2010) published a study utilising the ‘designated’ group of gatekeeper trainees (health professionals). This study reported that after a gatekeeper intervention group of nurses received training in suicide prevention, knowledge around suicide awareness and mental illness had increased immensely. It stated that the nurses were more confident and overall willing to report a client that was experiencing suicidal thoughts. This research shows that gatekeeper training can develop one’s ability to notice and act on an individual that is illustrating suicidal ideation and behaviour (Tsai et al., 2010). These findings are supported by another designated group study, of a quasi-experimental design, which included general practitioners and their nurses receiving gatekeeper training education programmes over two five year periods; pre-programme and post-programme. Szanto, Kalmar, Hendin, Rihmer and Mann (2007) concluded that the suicide prevention training over this extensive time of observation showed a significant increase in knowledge and suicide prevention skills. This study also reported a decrease in their local annual suicide rate and a decrease in the female suicide rate in the controlled region by 34%. This is very positive outcome from a suicide prevention programme in training GPs and their nurses to develop their skills and knowledge and suicide prevention. Booster training sessions were also offered throughout this study which seems to have had an appropriate impact on participants retaining the knowledge and skills from the training. Health professionals are able to build up their knowledge regarding mental health and suicide, which greatly enables them to be in a position for the prevention of suicide, as Quinnett (2007) stated that people who are contemplating suicide commonly visit their healthcare professional before they act on their suicidal thoughts. This puts the ‘designated’ gatekeeper group in an ideal position for the prevention of suicide.
The 'Emergent' Trainees
Within literature published involving the ‘emergent’ group of gatekeepers (community members with public roles) Chagnon, Houle, Marcoux and Renaud (2007) observed within an ‘emergent’ group that at six months post-intervention suicide training, there was a continuous flow of improved knowledge and skills associated with the gatekeeper training programme. This is supported by Wyman et al. (2008) who reports that one year post-training, participants demonstrated a raise in knowledge and gatekeeper training had been reported to have been very rewarding in the school district. ‘Emergent’ gatekeepers are in a very privileged situation, as the trust that they already have established with community members enables people to open up in confidence to a gatekeeper about their suicidal thoughts and they are in the best position to pick up on suicidal signs (Cross et al., 2007). Cross, Matthieu, Lezine and Knox (2010) presented from their research an increase from pre-training to post-training knowledge an increase from 10% to 54% which demonstrated effective suicide prevention techniques. This clearly shows how effective an ‘emergent’ gatekeeper can be in the prevention of suicide.
Deane et al. (2006) also demonstrates that community members play an important role in suicide prevention. It was reported at a two year follow-up (from Capp, Deane, & Lambert, 2001) that after gatekeeper workshops in a rural Aboriginal community, there was an overall increase in knowledge about suicide, greater levels of aiming to help community members and an overall increase in confidence in the recognition of suicide. This shows that gatekeeper training does enhance the knowledge of trainees, even if the trainees are not skilled health professionals who have already had experience around the area of suicide. This is supported by Cimini et al. (2014) who outline the increase of knowledge in university students after suicide prevention training and also an increase in comfort of students talking to their peers about suicide. This is a very effective tool as Cross et al. (2010) stated that among university students, they are more likely to talk to their own peers if they have suicidal thoughts or intentions. It is evident that it is very important to target the correct group of gatekeepers for the targeted suicide prevention population to have the most effective gatekeepers.
Implications for Practice
Various sources (as discussed above) have claimed that gatekeeper training programmes are an effective tool for a trainee in suicide prevention. From these programmes trainees enhance their knowledge around suicide prevention, improving skills to assess for and recognise suicidal thoughts, and changing attitudes of trainees so that the best support can be provided and early intervention can take place. This leads us to believe that gatekeeper training for suicide prevention could possibly be an effective way of addressing the concerning rural suicide rates in New Zealand because of the results seen in the above literature. The specific group that could be targeted to train as gatekeepers in a rural New Zealand setting is the ‘emergent’ group. This group consists of community workers such as stock agents, farm advisors, accountants etc. These workers are in a prime position to recognise and intervene early with rural community members experiencing suicidal thoughts and could be trained to refer appropriately (Walker, 2012). Gatekeeper training could result in better care for rural New Zealand clients with suicidal thoughts or behaviours and with a strategy put in place could improve early intervention in the community. With this newly gained knowledge, effective skills and a new attitude regarding suicide, emergent suicide prevention group members could play significant roles in the New Zealand rural community. Isolated members of the community could be screened through normal visits by rural workers, which could be an effective way of suicide intervention as suggested by Hossain, Gorman, Eley, and Coutts (2010).
There are some limitations of these utilised articles, which include the limited training of gatekeepers. Most gatekeeper suicide prevention programmes that have been published consist of short training programmes which include a presentation, followed by a short discussion to conclude. In most cases this does not seem to be substantial enough to develop the long-term skills required for suicide prevention, however attitudes that change towards mental health have shown to significantly change after a suicide intervention training programme (Cimini et al., 2014; Cross et al., 2011). Currently no randomised controlled trials alone to prove that gatekeeper training affects the suicide rates and very few research papers show the effect gatekeeper skills have on the suicide rates. Schmidt, Iachini, George, Koller and Weist (2014) outline the importance of further research needing to be completed and an increase in the evidence-base around the effectiveness of gatekeeper training. They also state that different training will be needed to be modified to ensure effectiveness for the specific target population.
The Ministry of Health (2015) focuses on the fact that with appropriate and accessible support, resources and knowledge suicide can be prevented. From reviewing various literature on the suicide prevention technique of gatekeeper training, it has shown that these programmes effectively enable the trainee to develop the knowledge and skills required, and also change the attitudes of the various types of trainees, to be ready to deliver effective suicide prevention in different settings. From this review of the literature some limitations prompt two main recommendations.
The first recommendation is that suicide awareness training should be an essential educational element for all health care professionals and incorporated into all health degree programmes (Tsai et al., 2010; Kawanishi et al., 2006). This could be further applied to be a requirement for all workers in a rural setting that a rural community would have contact with, such as stock agents, farm advisors and accountants. This would enable this ‘emergent’ group of rural workers to notice signs of suicidal thoughts and behaviour in the isolated community among community members. Gatekeeper training for community members in a rural New Zealand setting could be a very effective way of empowering the rural community to look out for one another and have the knowledge and skills, and an accepting attitude, required in the prevention of suicide (Walker, 2012).
The second recommendation is for refinement of community gatekeeper training workshops to ensure that gatekeepers continue to be trained effectively for the specific audience that they will be targeting (Deane et al., 2006; Cimini et al., 2014). This is very important for a rural New Zealand community because gatekeepers need to be able to develop a level of trust and understanding with the client and be able to act and refer appropriately as required by the client.
In conclusion, gatekeeper training for suicide prevention has been shown to enhance the skills of trainees and allow them to develop the knowledge required for effective suicide prevention (Cross et al., 2010). Research has shown that attitudes of gatekeeper trainees towards people with suicidal thoughts and displaying suicidal behaviour have changed remarkably post-training (Cross et al., 2011). Research from the literature suggests that audience-specific programmes are most effective in targeting a specific population where suicide prevention is required (Cimini et al., 2014; Cross, Matthieu, Lezine, & Knox, 2010). From this in-depth literature review I am led to the conclusion that overall gatekeeper training does effectively enable the trainee to develop the knowledge and skills required for suicide prevention. This technique could possibly be utilised within a rural New Zealand setting, to target the current high suicide rates that are being seen, because of farming stressors and isolation, to recognise signs and behaviours of suicidal clients, to increase knowledge and awareness in the community and to ensure gatekeepers have the right attitudes for working with potentially suicidal clients.
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