Religion & Spirituality

A Nationwide E-learning Program in Suicide Prevention for the Nurses in Taiwan

Purpose: The majority of baccalaureate-prepared nurses may not be well-educated with fundamental skills to care for patients with suicide risks. However, the nurses play a crucial role as gatekeepers for suicide prevention. As such, the Taiwan
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  J Med Education Vol. 19 No. 1 2015   31 A Nationwide E-learning Program in Suicide Prevention for the Nurses in Taiwan Chia-Yi Wu, 1,2  Ming-Been Lee, 2,3  Shih-Cheng Liao, 2,3 Heng-Shuen Chen 2,4   &  For-Wey Lung 2,5 Purpose:  The majority of baccalaureate-prepared nurses may not be well-educated with fundamental skills to care for patients with suicide risks. However, the nurses play a crucial role as gatekeepers for suicide prevention. As such, the Taiwan Suicide Prevention Center developed an online suicide education program for the practicing nurses. The present study aimed to evaluate the use of e-learning as an ef  Þ cient way to teach gatekeeper strategy and suicide prevention knowledge and skills for the nurses. Methods:  Between June 2013 and December 2014, twenty e-learning courses were presented online for the target population of 137,026 practicing nurses in Taiwan. Each course lasted for about 40-60 minutes, followed by questions inquiring about the nurses’ satisfaction, overall positive feedback from the course, and their willingness to be a gatekeeper or to promote the “Mood Thermometer” (i.e., Þ ve-item Brief Symptoms Rating Scale, BSRS-5) after finishing related courses. The degree of satisfaction and learning feedback were assessed using a 5-point Likert scale and the results were analyzed by descriptive statistics (i.e. number of hits; mean, standard deviation and  percentage of scaled items). Results:  In total, there were 12,966 persons who participated in the 20 online courses during the study period. The number of participants for each course was ranged between 2,818 and 9,333 nurses. All the courses received 4.36-4.58 points of ratings on satisfaction and learning feedback (5 point as the highest score) from participating nurses. As a whole, over 90% of nurses were satis Þ ed with each course and would promote the BSRS-5 or act as gatekeepers in the future. The pro Þ le of the average number of the learners per course by month indicated a three-month peak usage, which effect was in accordance with the promotion of nursing license renewal policy. Conclusion:  E-learning suicide education is highly recommendable for nurses working in different areas, and the utilization of online media would be more widespread under policy promotion. Further assessment method is needed to comprehensively evaluate the effectiveness of e-learning media for suicide  prevention training. Key words: e-learning; gatekeepers; nursing education; suicide prevention; Taiwan.( J Med Education 2015; 19: 31  41 )DOI: 10.6145/jme201504 1 School of Nursing, National Taiwan University College of Medicine; 2 Taiwan Suicide Prevention Center; 3 Department of Psychiatry,  National Taiwan University College of Medicine; 4 Department of Family Medicine, National Taiwan University Hospital; 5 Taipei City Hospital, Songde Branch.Received: 5 February 2015; Accepted: 11 March 2015.Correspondence to: Ming-Been Lee. Department of Psychiatry, National Taiwan University College of Medicine. No. 1, Jen-Ai Rd., Sec. 1, Zhongzheng Dist., Taipei City 10051, Taiwan. E-mail:  32   Chia-Yi Wu, Ming-Been Lee, Shih-Cheng Liao, Heng-Shuen Chen &  For-Wey Lung 32   J Med Education Vol. 19 No. 1 2015 INTRODUCTION Suicide is a global challenge for medical and nursing professionals. The chance for suicide completers to have made medical contact in the  prior month of their death was twice likely than the general population, indicating the importance of risk identification and case referral for suicide  prevention in the medical settings. [1]  Most  physicians and nurses failed to perform suicide risk assessment adequately due to their lack of awareness, knowledge, or attitudes toward suicidal  behaviors or their low motivations to engage in suicidal patient care. [2]  Appropriate education about suicide prevention for healthcare professionals in different medical settings may have great impact on case finding and proper management of the  people at high-risk and consequently prevent suicide.  Nurses are major professional workforce in the hospitals across the world. The issues of adequate manpower and care quality have received much discussion in the nursing field. [3]  Apart from the influence of burnout on patient care quality, the knowledge and attitudes of nurses in  providing comprehensive psychosocial care may also affect patient satisfaction and mortality. [4]  According to the statistics from the Taiwan Union of Nurses Association (2014), there are 231,559  people holding registered nurse license, while only 137,026 (around 60%) of them working in the nursing field. [5]  The turnover rate of nurses in 2010 was as high as 20.1% according to the above source of information. These numbers suggested that the nursing profession itself has  been experiencing difficulty in providing enough manpower and services. However, nurses are first-line gatekeepers of the patients’ mental health problems and suicide risk. [6]  The method of continuing education with the medium of internet plays an important part in updating health care knowledge for the nurses to provide comprehensive care. [7]  Indeed, e-learning provides an effective way of knowledge acquisition and credit earning in continuing education, particularly when it comes to nursing license renewal. With the advantages of flexibility, accessibility, liberty of course selection, and unlimited space for the audience, among other benefits, learning web- based healthcare materials online have become a feasible and popular strategy of promoting better levels of personal cognitions, attitudes, or nursing  practice. [8]  However, e-learning effectiveness for health care professionals is determined by multilevel factors including organizational, economic, pedagogical and individual aspects, with positive e-learning experience linked closely to various supports. [9]  Thus, evaluation of e-learning effects should consider multiple factors as well.E-learning is regarded as a specific training method in suicide prevention for medical students and healthcare professionals in recent years. [10]  Several newly-developed e-learning modules have been currently under evaluation, while the effectiveness of most modules remains to be tested. [8]  Web-based suicide prevention programs have offered great opportunities for the public to access a wide range of information about treatment resources, self-help and resources for helping others, and anonymous counseling services for the high-risk group for suicide. For the nurses who work in various sectors throughout a country, repeatedly viewing and reviewing e-learning suicide prevention materials by selecting contents of their need can facilitate self-learning and reflective thinking. As the most important gatekeepers in clinical settings, nurses should all equip with fundamental knowledge and skills in assessing and managing suicidal risk through  Nursing E-learning on Suicide Prevention   33 J Med Education Vol. 19 No. 1 2015   33 e-learning.The present study aimed to investigate the outcomes of an e-learning suicide prevention  program designed by the research team in the Taiwan Suicide Prevention Center (TSPC).The prevalence of hit, learners’ satisfaction, and willingness to promote the use of BSRS-5 for suicide screening and to be a gatekeeper after finishing their learning were analyzed in the 20 courses of suicide-related topics. We also presented the most popular course and the time of reaching the peak in terms of the participants’ number by month for each course after its presentation online in order to inform future course design. MATERIALS AND METHODS Online courses design In the era of high-tech utilization, e-learning has become the most convenient way of knowledge sharing on the internet. In response to this trend, the TSPC has developed an online platform, the Cherish Life Digital Learning Website, for the  public and healthcare providers to access a broad range of information about suicide prevention. Between June 2013 and December 2014, there were 20 courses presented online. The 20 online courses can be grouped into four modules by the research team, with major topics covering the following issues: (1) fundamentals of suicide  prevention; (2) suicide and medical conditions; (3) suicide risk assessment; (4) treatment modalities of suicidal behavior. The first module mainly introduced national statistics, facts about suicide and key concepts of suicide prevention such as stress management. The second module was related to contents instructing the relationship  between medical conditions and suicide, including depression, medical illnesses, and multiple morbidity in the elderly. The third module  presented topics related to suicide risk assessment; while the fourth module broadly covered topics about treatment aspects of suicidal behavior. Course launched and promotion The 20 courses were launched periodically in a package at three different period’s time points; all courses were approved in advance as 1 credit hour for each course by the Taiwan Union of  Nurses Association (TUNA). The Þ rst package of 10 courses was presented on-line in June 2013, followed by the second package of 5 courses in January 2014 and the third package of 5 courses in July 2014. The Þ rst package of courses mainly centered on the concept and skills of gatekeepers focusing on risk assessment, early identi Þ cation of high risk groups and adequate necessary referrals (i.e., the Selective Strategy). The second package contained updated treatment and collaborative care for depressive disorders. The third package of courses highlighted the Indicated Strategy regarding the aftercare providers’ skills such as interviewing and supportive skills, crisis intervention, guideline for inter-professional referrals and adequate usage of resource networks. While the new package of courses was provided, the TSPC worked closely with the TUNA to  promote the courses to the nurses through all available channels. Participants The study targeted at all the practicing nurses in Taiwan who were attracted by TSPC website e-learning courses about suicide prevention. In order to promote suicide e-learning courses for the nurses, the TSPC collaborated with TUNA in offering all practicing nurses opportunities to get access to the online courses free of charge. The TUNA is responsible for issuing the nursing license for nearly 140,000 registered nurses in  34   Chia-Yi Wu, Ming-Been Lee, Shih-Cheng Liao, Heng-Shuen Chen &  For-Wey Lung 34   J Med Education Vol. 19 No. 1 2015 Taiwan. All the nurses are required to receive continuing education for 150 credits every 6 years.  Nurses can earn credits from various lectures or online courses that are recognized as valid for license renewal. The nurses chose to click on videos based on their interests from a list of 20 courses on TSPC website. They can ß exibly view any course with free access and unlimited time frame. Attendance to the e-learning modules was anonymous; however, the TSPC recorded each registration account to calculate the numbers of learners. Since the account is unrecognizable to the researchers, there is no violation to the ethical regulations. In this study, all the participants who viewed more than 90% of the length of the session for each course and completed the post course questionnaire were recognized as eligible to get the credit and recruited as our study subjects for analysis. Post-course survey and statistics After finishing each course, the learners were asked to fill out four surveyed questions online including the satisfaction with the course, overall learning feedback, and their willingness to  promote the BSRS-5 as suicide screening tool and to become a gatekeeper for suicide prevention. [11]  The global assessment of satisfaction and learning feedback was self-rated by the learners based on a 5 points Likert scale (5= the most agreeable response; 1= the least agreeable). The ratings of willingness were expressed as “yes” or “no”. All the surveyed questions were analyzed by descriptive statistics for each course (i.e. number of hits; mean, standard deviation and percentage of scale items). The trends and distribution of the number of learners for each course were displayed as a pro Þ le with mean number of participants per  package of courses by month during June 2013 to December 2014. RESULTS Between the study periods of June 2013 to December 2014, there were 12,966 practicing nurses contributing to a total of 142,205 times of the online courses (Table 1). Thus, every nurse took part in an average of 10.97 times of course viewing among the list of 20 courses. The majority of the learners were females. Among all the courses, stress management drew the most attention of the nurses (9,333 hits) within a 2-year  period. The following four prevalent courses were gatekeeper Ask-Persuade-Refer (APR) skills introduction (8,910 hits), application of BSRS-5 (8,812 hits), combined treatment of medication and psychotherapy for depressive disorders (8,759 hits), and hospital quality improvement for elderly suicide prevention (8,594 hits).Regarding the trends and distribution of learner numbers by month across two years, as shown in Figure 1, at the Þ rst six months after the Þ rst package of 10 courses was lunched, the mean number was steadily below 200 persons per course for each month; however, with biggest efforts of more active and comprehensive promotion and announcement of the deadline of nationwide license renewal (June 2014) at the time point of December 2013, the number was increasing steeply to the peak in March 2014 for both the first and second package of courses. In a word, with respect to the Þ rst two packages for the Þ xed target population of TUNA members, the mean number of participants per course reached the peak level within three months, and decreased steadily in three months. For the third package of courses launched immediately after the deadline of license renewal, the average number of participants was 706 per course per month at the second month and then decreased steadily.  Nursing E-learning on Suicide Prevention   35 J Med Education Vol. 19 No. 1 2015   35 Table 2 showed the degree of agreeable responses to the questions inquiring about the  participants’ overall learning feedback, i.e. whether the learner had much positive learning from each course. Among all the 20 courses, the learners consistently agreed that they have gained much knowledge about suicide prevention, with the mean scores over 4.6 for each course in the 5-pointLikert scale. We also found an overall assessment of  positive learning feedback by the learners was over 96%. Likewise, Table 3 demonstrated that over 96% of the learners reported to satisfy with the course presentation for the 20 courses, with a mean score over 4.5 points as a whole. Furthermore, Table 4 revealed that more than 90% of the learners expressed their willingness to promote the use of BSRS-5 as a screening tool after they had browsed the eight courses regarding this scale. Similarly, more than 93% of the learners agreed that they would act as gatekeepers of people with suicide risks after viewing the aforementioned courses. These two findings indicated that the Table 1. The browsing record of the 12,966 nurses who attended the online courses for suicide prevention  between June 2013 and November 2014 Topics of courseTotalcountsHit*/Mon. 1. Gatekeepers APR skills introduction (18)8910495 2. Stress management and SP (18)9333519 3. Active application of the Mood Thermometer, BSRS-5 (18)8812490 4. Psychological reactions and crisis of the suicide survivors (18)8449469 5. Health care for the elderly with neuropsychiatric disorders (18)8295461 6. SP and depression (18)8277460 7. SP in hospitals (18)8341463 8. Quality improvement of hospital SP for the elderly patients (18)8594477 9. SP gatekeepers and suicide risk assessment (18)801044510. Social networks and resources (18)821245611. Psychotherapy for depressive disorders (12)857271412. Collaborative care for depression in the primary care settings (12)839970013. The mechanism of depression and its treatment (12)812167714. Current trends of pharmacotherapy for depressive disorders (12)828769015. Combining drug treatment and psychotherapy for depressive disorders (12)875976016. National strategies for SP and their implementations (6)323954017. The current status and associated factors of suicide (6)291748618. Communication skills for aftercare providers of suicide attempters (6)291448619.Crisis intervention, referral and resource link in suicide aftercare (6)281847020. Communication and continued care for the survivors (6)2946491Total1,142,205 * This shows the number of hits per month for each online course. The parenthesis shows the number of duration in months after course presentation online. APR: Ask-Persuade-Refer; SP: suicide prevention; BSRS-5: The Five-item Brief Symptom Rating Scale
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