Participants.

To ensure a comprehensive search, all health professions, in various workplace settings were considered for inclusion. Studies involving non-allied health professionals (e.g., doctors, nurses), students, or other general community members were excluded during the screening and selection process, as they did not align with the focus on allied health professionals (AHPs). Additionally, studies that exclusively involved psychologists and/or counsellors were excluded. This decision was based on the fact that psychologists and counsellors typically specialize in mental health, which is central to their practice. In contrast, other AHPs often do not have mental health as a core component of their professional training and scope of practice [26]. Furthermore, studies where AHPs worked solely in community or school-based settings were also excluded to maintain the focus on broader workplace contexts, as these environments may involve different dynamics and interventions.

Concept.

This review considered all types of suicide prevention training delivered to AHPs, regardless of the mode of delivery (e.g., online, in-person) or the duration of the program. The primary focus was on training that aimed to enhance suicide prevention knowledge, skills, or practices among AHPs.

Context.

No limiters were applied during the search regarding country of origin or publication language. This allowed the capture of all relevant studies that outlined suicide prevention training delivered to AHPs as CPD or in-service training.

Types of sources.

This scoping review focused solely on empirical studies that met the inclusion criteria. Specifically, only studies that provided suicide prevention training to AHPs and measured its impact, were considered. To maintain the empirical nature of the review, non-empirical sources such as reviews, protocols, policy documents, and opinion pieces were excluded. The rationale for excluding these types of sources is that they often do not provide original data or measurable outcomes regarding the effectiveness of interventions. Policy documents and opinion articles, in particular, may offer valuable insights into broader frameworks or perspectives but do not typically present empirical evidence on the impact of suicide prevention training. Therefore, these were excluded to ensure that the review focused on measurable outcomes directly related to the research questions.

Types of suicide prevention training.

The types of training reported in the studies varied significantly. Skill-based training (n = 9) was most widely used, followed by gatekeeper training (n = 8) and competency-based training (n = 8). Other forms of training included means restriction (n = 2), role-play, needs- and strengths-based and assertive case management (n = 1 each).

The predominant mode of delivery for the training programs was face-to-face workshops (n = 27), which commonly comprised of lectures, video presentations, group discussions, role-rehearsal, case study analysis and printed resources. The duration of the training programs was also widely varied, ranging from 1 to 20 hours. The most common duration of the face-to-face workshops was 4–6 hours (n = 8) and 2–3 days (n = 8). Studies with online delivery varied from 6–20 hours of content, with 1–4 weeks available for participants to complete all modules.

Allied health disciplines targeted for training.

Most of the included studies reported a mixed cohort of participants (n = 29), while the remaining were designed for participation by single disciplines including social workers (n = 3) and pharmacists (n = 1). The mixed cohorts were diverse; however, five did not report on the specific participant professions, and one only partially described specific participant professions included. The predominant allied health professions of interest represented in the mixed cohort studies were social workers (n = 21) and occupational therapists (n = 8). The number of mixed cohort studies specifically targeting AHPs only was small (n = 6), as most of the studies were aimed at health professionals more generally and commonly included nursing and other medical professions.

Underpinning frameworks and constructs.

The frameworks, models, tools, and approaches adopted by the included studies were varied (Table 2). These were grouped into the following seven categories and constructs: (i) Knowledge – epidemiology, risk and/or protective factors, intervention, lethal means and cognitive behavioral therapy (CBT); (ii) Skills – risk assessment, identification, psychoeducation, crisis management, intervention and postvention; (iii) Behavior – attitudes, responses and clinical practice; (iv) Cultural considerations – epidemiology, risk factors and context; (v) Standard of care – therapeutic alliance, engagement, documentation and liability; (vi) Reflective discussion – open group discussions, participant questions and concerns; (vii) Self-care – debriefing and workplace safety.

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Table 2. Summary of training frameworks and constructs.

https://doi.org/10.1371/journal.pone.0326738.t002

Skills-based training.

The skills-based training programs included content to enhance suicide prevention knowledge; however, there was a stronger focus on risk identification and assessment, crisis management and psychoeducation. This type of training also commonly had components designed to influence the behaviors and/or attitudes of participants towards suicide. Four of the six that had face-to-face workshops were delivered across 2–3 days [33,39,41,44], while the other two were 6-hour programs [45,46]. Two training programs were delivered online, one allowing 2 weeks for completion [47], with the other not describing the time provided for completion [48]. One training program had blended online delivery with a 2-day face-to-face workshop [49].

Of the eight studies that used skills-based training, five were non-specific (i.e., designed specifically for the study) [33,44–46,48], while the remaining studies each utilized a different approach. These included the Decision Tree model [47], Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) [39], Recognizing and Responding to Suicide Risk (RRSR) [49] and the Skills Training on Risk Management (STORM) model [41]. Additionally, one study taught participants how to use the Suicide Risk Decision Tool (SRDT) [45] and another the CASE Approach [49] to support their clinical suicide risk assessments.

Gatekeeper training.

The gatekeeper programs typically aimed to increase knowledge and skills in identification, assessment, and management of suicidal behaviors; cultural context and risk factors; and therapeutic alliance. Question, Persuade, Refer (QPR) and/or content based on QPR was the most widely used gatekeeper program (n = 6), which is typically delivered in 1–2-hour workshops. One study compared QPR with Applied Suicide Intervention Skills Training (ASIST), a different gatekeeper program delivered across a 2-day workshop [37]. Two other non-specific gatekeeper training programs were reported that were specifically designed for the studies [50,51]. One study also exposed participants to the QPRT Suicide Risk Management Inventory used in clinical practice to aid suicide management [52].

Competency-based training.

The competency-based programs targeted learning around the core competencies of suicide risk assessment and management, including understanding suicide, risk/protective factors, therapeutic alliance, management of responses to client, formulation of risk, crisis intervention and safety planning. Seven of the eight programs were delivered in face-to-face workshops ranging from 3 hours to two days in length [34,43,53–57]. Cramer et al. [58] opted for online delivery, allowing participants 30 days to complete 20 hours of content.

Four of the programs were non-specific, using prior studies and/or professional guidelines to design training content [34,53,57,58]. Both studies conducted by Mirick et al. [43,55] delivered the Suicide Assessment and Intervention Training (SAIT) program, whereas Pisani et al. [56] provided Commitment to Living (CTL) training, and La Guardia et al. [54] used the Zero Suicide Model multi-level framework. Wharff et al.’s [57] was the only study from this category to teach participants the use of an additional tool called the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) procedure, often utilized in hospital settings to quickly assess level of suicide risk.

Other types of training.

The means-restriction program Counselling on Access to Lethal Means (CALM) was adopted by two studies, delivering content in brief face-to-face workshops that aim to increase knowledge of epidemiology and risk factors pertaining to lethal means; skills in identification, assessment, and intervention; and a strong focus on therapeutic alliance and client engagement [59,60]. One study utilized an assertive case management approach, which addressed psychoeducation, client engagement and intervention skills across a 2-day workshop [61]. Another study adopted the needs- and strengths-based framework Care.Collaborate.Connect, comprising 8 online modules emphasizing therapeutic alliance, positive attitudes and responses to suicidal behavior, and psychoeducation [36].

Three studies did not utilize any specific frameworks, but instead tailored the training for the context or targeted participants. One was designed for face-to-face delivery (1-day) to participants that worked in remote communities, with many engaging with indigenous populations [42]. This covered suicide prevention content specific to the region, including a lived experience component, and aimed to increase participants’ confidence in addressing suicidality in their practice. Another was a 3-hour workshop designed for emergency department personnel and included exposure to the Basic Suicide Assessment Five-step Evaluation (B-SAFE) Protocol, a tool administered to assess immediate risk and provide brief intervention strategies [35]. The third compared brief and enhanced training programs (1-day versus 3-day workshops), that delivered content regarding suicide crisis identification and intervention [50].

Reported effectiveness of training.

A diverse range of measurement tools were used in the studies (see Table 3 for a summary), with many using more than one measurement tool (n = 17) and/or a combination of developed and study-specific measures (n = 9). Twenty-seven studies developed their own tools, which included questionnaires, documentation exercises and interview questions. Fifteen studies administered previously developed tools, including 24 validated measures and 3 not validated. Of the validated tools, only 5 were used in more than one study: Suicide Behavior Attitude Questionnaire (SBAQ) [33,44,47,54,58], Suicide Competency Assessment Form (SCAF) [54,58], Attitudes Towards Suicide (ATTS) [51,61], Attitudes toward Self-Harm Patients (ASHP) [54,58] and Suicide Interventionist Response Inventory (SIRI-2) [45,61]. Many of the developed tools were adapted and/or only a portion of the tool was used (e.g., one subscale) to suit the needs of the study.

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Table 3. Summary of measures and results.

https://doi.org/10.1371/journal.pone.0326738.t003

The effectiveness of training is outlined below based on the most common domains measured. Thirty studies used questionnaires to explore both the changes as perceived by participants (n = 24) and quantitatively measure change across the different domains (n = 28), while three studies used only interviews to subjectively determine training efficacy with study-specific questions [41–43].

Knowledge and attitudes.

Knowledge (n = 23) and attitudes (n = 18) were among the most common domains measured. Statistically significant improvements in total knowledge were reported by 12 studies, of which the training types included three skills-based [39,44,48], three competency-based [53,54,56] and three gatekeeper programs [40,62,63]. The remaining three were non-specific [50], means-restriction [60] and needs- and strengths-based training [36,50,60].

Gryglewicz et al.’s [52] was the only one of seven studies that declared an increase in knowledge of risk factors to produce a significant result (p < 0.001), while Levitt et al. [62] reported a significant increase in knowledge of prevention strategies (p < 0.001). Though Adrian et al. [45] reported increased applied knowledge, and four studies reported improvements in overall suicide prevention knowledge [36,40,44,58], none of these results were statistically significant and, therefore, represent only weak associations. The mixed-method study by Slovak et al. [60] involved a follow-up focus group which outlined that the training increased their knowledge about firearm access, signs and symptoms of suicidality and acquisition of skills and strategies. These findings supported the quantitative findings, where five of the survey items regarding knowledge, strategies and relevance increased significantly (all p < 0.05) from post-test to follow-up.

Three studies declared statistically significant increases in general attitudes towards suicide (all p < 0.001) [36,61,64], and two studies reported a significant reduction in negative attitudes towards suicidal individuals (p = 0.002 and p < 0.001, respectively) [44,49]. Adrian et al. [45] and Hawgood et al. [53] reported significantly increased positive attitudes towards intervention/prevention (p = 0.01 and p = 0.014, respectively) while da Silva Cais [44] reported significant increases for attitudes towards suicide right (p = 0.02). Stuber et al. [48] also reported significant improvement in attitudes to intervention post skills-based training, particularly with regards to conversing about firearms and medication storage (p=<0.01). Cramer et al. [58] declared improvements in 18 of the 21 items on the SBAQ following delivery of a competency-based program; however, significant results were recorded for only 3 subscales: suicide right (p= [0.02); negative attitudes (p = 0.002); and professional capacity (p < 0.001). Additionally, Gryglewicz [49] and colleagues [52], who delivered QPRT gatekeeper training, and Duvivier [47], who delivered a skill-based program and was the only RCT in our sample, did not record significant improvements in attitudes towards suicide prevention.

Skills.

Suicide prevention skills were measured by several studies (n = 16), with a number of those reporting overall skill improvement (n = 7); however, only Scott [39], who delivered competency-based training, declared a significant increase (p < 0.000).

Significant improvements were found more specifically in crisis intervention and/or management skills for Gryglewicz et al. [52] and Kawashima et al. [61] (both p < 0.001), and in professional competence (all p < 0.001) for two studies that delivered gatekeeper programs [52,63], three competency-based [54,56,58] and one skills-based training [49]. Risk assessment and/or identification skills were significantly increased post training for Pisani et al. [56], who utilized a documentation exercise to measure change (p < 0.001), and for Jacobson et al. [59], who developed a study-specific questionnaire that included vignette analysis (p = 0.02). Furthermore, two studies declared significant improvements in skills regarding communicating about suicide (both p < 0.001) [36,63], and in two of the qualitative studies [42,43] participants reported improvements to the quality of, and approach towards, discussing suicide with their clients.

In contrast, fifteen studies reported positive results across various domains, including risk assessment (n = 5), crisis management (n = 6) and communication (n = 4). However, improvements were not found to be statistically significant and can thus be considered weak evidence towards skill development in those areas.

Confidence and self-efficacy.

Confidence (n = 13) and self-efficacy (n = 11) were measured by several studies, typically exploring participants’ level of comfort with, and understanding of, approaching suicide with their clients and their responses to suicidal behaviors. The greatest increases were found in perceived capacity and/or skill in managing suicidal individuals, including communication and de-escalation of crises, with five studies declaring significant results (all p < 0.001) [35,40,48,54,61]. Only one study reported significant results for increased confidence in identifying suicide warning signs and safety planning (p=<0.01) [48]. In addition, only one study identified increased confidence in responding to suicidal behavior (p = 0.008) [54]. Two studies [52,53] found improvements in participants’ perceived capability post training, though results were significant in only one of the two studies [53]. It is also worth noting that whilst Hawgood et al. detected a significant change in perceived capability, participants’ reluctance to intervene did not significantly improve, which indicates mixed evidence regarding changes in confidence and self-efficacy.

All three qualitative studies discussed improvements in confidence and self-efficacy. Gask et al. [41] reported that the skills-based training improved participants’ confidence in identifying risks and asking patients about suicidal behaviors, as well as discussing protective factors and problem solving. Jones et al. [42] reported their participants felt increased confidence working with those at risk and were better equipped to manage suicidality, particularly their responses to disclosure of self-harm and suicidal ideation. Furthermore, the participants from Mirick et al. [43], who delivered competency-based training, described feeling more comfortable in communicating about suicide and, specifically, in using more direct language and/or adjusting their questions to elicit more truthful responses.

Practice changes.

Fourteen studies measured the degree of change or intent of participants to implement learning in their clinical practice. This was typically done in the form of “yes/no” questions or using a Likert scale. A range of 43–97% of participants from 9 of the 13 studies that conducted follow-up reported implementation of training knowledge or skills [39,41–43,46,49,50,57,59], including changes to client management and communication. Notably, 97% of participants from Wharff et al.’s [57] study reported a substantial increase in the level of inquiry when conducting risk assessments, stating that they no longer took their client’s negative responses to questions about suicidality at “face value”.

Improved information exchange was also declared by Adrian et al. [45], Mirick et al. [43,55] and Slovak et al. [60], and increased referral to services by Condron et al. [37] and Huh et al. [46]. Participants from the qualitative study by Mirick et al. [43] described how they increased their focus on protective factors, conducted more in-depth risk assessments, and increased the rate of safety planning with their clients post-training.

Other.

Overall, there were no significant differences in results between the training delivery modes or duration, with many of the brief trainings producing similar results to the longer trainings. However, the two studies that compared brief and enhanced training did report large differences between the two groups, with greater gains achieved by the longer workshops. Condron et al. [37] reported significant differences in risk identification (p < 0.001) and referral to services (p = 0.009) for the enhanced training group, while Donald et al. [50] outlined significant increases in knowledge, information exchange and support (all p ≤ 0.001).

Seven studies did not obtain a baseline measurement [37,41–43,57,59,60]. Six studies reported maintenance of results at follow-up (T3), with only small decreases in outcomes compared to post-test [45,46,49,50,59,62]. Furthermore, prior exposure to suicide prevention training did not seem to moderate learning effects, with only two studies noting an impact [55,61].