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"I learned to ask" : suicide intervention training for school personnel 2002

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"I L E A R N E D TO A S K " : SUICIDE INTERVENTION TRAINING FOR SCHOOL PERSONNEL by C H E R Y L L Y N N E JEFFS B.A. , The University of British Columbia, 1989 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF M A S T E R OF ARTS in THE F A C U L T Y OF G R A D U A T E STUDIES Department of Educational Studies (Adult Education Program) We accept this thesis as conforming to the required standard THE UNIVERSITY'OF BRITISH C O L U M B I A July 2002 © Cheryl Lynne Jeffs, 2002 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University ot British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of c^Jjjj/Jot\3y^J^ ^j^JuLo The University of British Columbia Vancouver, Canada Date Tl UOtU&C A . 3C0z\ DE-6 (2/88) Abstract Considering the abundance of continuing professional education (CPE) there is a paltry amount of research on the application of learning following these programs. Every year programs are developed and implemented with the main purpose to improve, change or update performance or practice in the professions, especially in education. In this study, 21 school personnel from two school districts in British Columbia were interviewed three years after participating in the suicide intervention CPE program, A S K ASSESS ACT. Two research questions guided this study: From the participants' perspectives, 1) what learning did they apply following the A S K ASSESS A C T program in the context of their school setting?; and, 2) what were the factors that facilitated or hindered this application of learning in the context of their school setting? This qualitative study adapted Cervero's (1985) framework which was developed to help understand the complexity of application of learning. Identified in the framework are four factors that are considered to influence application of learning: (1) the program; (2) the proposed behaviour change; (3) the individual learner; (4) and the social system or context in which the individual works. For the purpose of this study, the proposed behaviour change is suicide intervention - this is the evidence of application of learning; the CPE program is A S K ASSESS ACT; the individual characteristics are those of teachers, school counsellors and youth care workers; and the social system is the classroom, school and school district in which the participant works. Participants were interviewed and asked about their experiences following the CPE program. Data were coded and Atlas.ti was used to assist with the analysis. It was evident that the concepts of suicide intervention, in most cases, had been retained and applied several years after the training, especially how to "ask directly about suicide. " Application of learning is a complex process. It appears that certain elements of the four factors in Cervero's (1985) framework influence application. Participants reported a desire and need to learn suicide intervention skills, thus, motivation can influence application. The title A S K ASSESS A C T appears to have a mnemonic effect as some participants used it as a suicide risk assessment model. It also appears that the program relevance and realism influence application: all participants reported the program was relevant to their work and that the program was realistic. Certain characteristics of the learner seem to influence application, especially perceived level of confidence, readiness to learn, belief that suicide can be prevented, and a sense of responsibility to prevent suicide. Administrative support, opportunity to apply learning, and changes in the school after the CPE program also seem to facilitate application of learning. The importance of this CPE program cannot be underestimated. Suicide intervention is not intuitive nor are these specialized skills modelled in society. The implications of these findings for future program planning, policy, and practice are discussed. i n Table of Contents Abstract i i List of Tables vi List of Figures vii Glossary vii i Acknowledgements ix CHAPTER 1 INTRODUCTION Training Day 1 Youth Suicide 2 What is Suicide Intervention? 3 The Problem Statement 5 Research Questions 5 Purpose and Significance of this Study 6 How this Thesis is Organized 6 CHAPTER A N A N A L Y S I S OF THE A S K ASSESS A C T P R O G R A M Background 8 A S K ASSESS ACT: The Program 9 Planning the A S K ASSESS A C T Program 10 Sork's (1997) Question Based Workshop Planning Model 13 An Analysis of the Planning Context and Identifying the Client System.. 14 Justification and Focus of the Planning Process 15 Clarifying Intended Outcomes 16 Formulating the Instructional Plan 16 Formulating the Administrative Plan 18 Development of a Summative Evaluation Plan 19 Constraints to Application 20 CHAPTER 3 LITERATURE REVIEW The Conceptual Framework 22 Characteristics of the Proposed Behaviour Change 25 Application of Learning 26 Adult Learning Theory 28 Suicide Intervention 29 Continuing Professional Education and the School System 30 Teacher and School Counsellor Characteristics 33 The School Environment 35 Summary of the Literature Review 37 CHAPTER 4 S A M P L E , D A T A COLLECTION A N D M E T H O D O L O G Y Research Design 39 Sample 40 iv Interview Instrument 42 Data Collection 44 Data Analysis 48 Limitations of This Study 48 Validity, Credibility and Corroborating Evidence ..50 Summary 53 CHAPTER 5 FINDINGS Factor 1: Characteristics of the Program 56 The elements of realism and relevance 58 Factor 2: Characteristics of Learners 60 Readiness for learning ...62 Beliefs about suicide intervention responsibility 63 Factor 3: Characteristics of the Proposed Behaviour Change 64 Factor 4: Characteristics of the Social System 65 The schools 65 Alternate education programs 70 What Learning Occurred 71 Learning to A S K about suicide 72 How did learning occur? 73 Did the mnemonic strategy help learning? 75 Opportunity to Apply Learning 75 An example of application of learning 76 Summary 78 CHAPTER 6 DISCUSSION Overview 80 The Program 80 The mnemonic strategy 81 The significance of the program 82 The Learners 83 Readiness for learning 85 The Proposed Behaviour Change 85 The Social System 86 Summary of Factors that Appear to Facilitate or Hinder Application 89 Summary Comments about Application and Learning 91 Implications 91 Suggested Further Research 97 REFERENCES 100 APPENDICES Appendix 1: A S K ASSESS A C T Program Outline 108 Appendix 2: Invitation Request to Participants 109 Appendix 3: Interview Questions 110 v List of Tables Table 1. Selected School Districts that Granted Permission 40 Table 2. Characteristics of Participants by School District 42 Table 3. Pilot Test of Interview Questions 43 Table 4. Responses of the 48 School Personnel Invited to Participate in this Research 45 Table 5. Elements of the Four Factors of Cervero's Framework 55 Table 6. Suicide Intervention Knowledge and Skills Desired by Participants 65 Table 7. Understanding Participants' Learning 74 vi List of Figures Figure 1. Cevero's (1985) Framework (adapted) and the Four Factors Considered to Influence Application of Learning 23 Figure 2. Elements of the Four Factors that Appear to Facilitate Application 90 vii Glossary The following terms are commonly found in suicide literature and have been adapted from Before-the-fact interventions: A manual of best practices in youth suicide prevention (1998). I have added the subheadings * Philosophical Belief and Educational Purpose for further clarification of these terms as they relate to this study. These philosophical beliefs are not necessarily held by all of society. Completed suicide - death resulting from self-inflicted, intentional injury [the preferred term, rather than the popular term successful suicide'] Gatekeeper - refers to someone in the position of a caregiver, for example, an administrator, teacher, counsellor, community worker, youth leader, coach, etc. who works with youth Protocol - a formal school or district policy that describes the responsibilities of school personnel and the steps to be taken if there is a possible risk of suicide. Typical protocols include details about informing the counsellor, administrator and parent(s), where to get help, and how to establish a follow-up plan. Protocols also include procedures to follow in the event of a suicide death. Suicidal behaviours - suicidal gestures, threats and attempts (verbal, nonverbal and written) Suicide ideation - thoughts about suicide Suicide intervention Philosophical Belief that individuals can and should actively intervene with someone who is potentially suicidal Educational Purpose is to train or teach individuals how to actively help or get help for someone who is potentially suicidal or who is thinking about suicide; it is not counselling or therapy Suicide prevention Philosophical Belief that life is valuable, and suicide prevention is possible Educational Purpose is to try to prevent individuals from considering or attempting suicide through health promotion and awareness campaigns aimed at the general population Postvention Philosophical Belief that the aftermath of damage can be contained following a suicide Educational Purpose - activities or policies that take place after the event of a suicide and designed to provide factual information to the survivors - family, friends, classmates, colleagues, fans and groups; establish order and provide comfort; and to prevent further suicides viii Acknowledgments There are numerous people to acknowledge for their support and encouragement during the process of writing this thesis. Thank you to my thesis advisor Lesley Andres, and the committee members Shauna Butterwick, and Tom Sork, and the external examiner Dante Lupini. I also extend great appreciation to Carol Matusicky, executive director of B C Council for Families for her support throughout this research project. Thanks to my family and friends for their belief in my work, especially to my brother who didn't hesitate to lend me his car as I collected my data, my many nephews and nieces who kept me from "all work and no play," and to my mom and dad, my siblings and my friends for listening to my many theories and thoughts about this research. Finally, to the busy people in the schools who helped me locate participants and provided directions, and who gave me their time to pilot test my questions and be interviewed. On behalf of all the students, thank you. ix Chapter 1: Introduction Training Day It's predawn and the program facilitators are driving east on Highway 1 on a cold February morning. The trunk of the car is filled with the training materials needed for the day- long suicide intervention program. On arrival at the teacher education centre, the familiar routine of preparing the classroom begins. Tables and chairs are moved to accommodate small groups, handouts are arranged, Lifesavers™ candy and brochures are placed on each table, posters are tacked to the walls, and the video is cued in the VCR. A l l is ready. The participants begin arriving, some with anticipation, some with doubts, some with anxiety, but all with their coffee cups and at precisely 8:45 am the Professional Development Day host introduces the facilitators and the name of the workshop. Lecture, discussion, pen and paper exercises, role plays and a video are the mainstay of this purposefully planned and standarized continuing professional education program. At the end of the day, all of the participants dutifully complete evaluation forms and then are given a certificate of attendance and a suicide intervention handbook. The host thanks the facilitators and offers them a gift in appreciation as the participants applaud. The next day the participants return to their schools and hopefully they will begin to apply what they learned. I return to my office in the city and there is no further contact with the participants. Ottoson (1997) expresses concern that "this cutoff point is problematic for policy, program, and practice decisions in adult and continuing education" (p. 93). This "cutoff point," also my concern, is where my research begins. As an employee of the BC Council for Families, I have been the program director of a suicide intervention program since 1990. The original program began with the development of 1 the Let's Live! School-Based Suicide Awareness program for grades 8 to 12 (1992). After several years of delivering in-service training to introduce school personnel to the curriculum it became apparent that there was a greater need to provide a different level of continuing professional education. The identified need was suicide intervention training and I have been involved in the development, implementation and evaluation of this continuing professional education (CPE) program since it began in 1997. The A S K ASSESS A C T Suicide Intervention Program was designed to provide school personnel with skills to identify and respond to potentially suicidal students. M y curiosity to find out what learning is applied, and how it is applied in the school setting following this CPE program is the focus of this research study. Youth Suicide Youth suicide is the second leading cause of death in BC and produces traumatic impacts on families, schools, and communities. In 1999, the B C Coroners Service reported 26 suicides in the 15-19 age group (Lifenotes, 2001, p. 15). However, completed suicides reflect only part of the problem and under-reporting is common. Suicidal behaviours are more prevalent and estimated to "be as much as a hundred times that of suicide" (Ramsay et al., 1999, p.24). An illustration of suicidal behaviour in BC youth is reported in the 1999 McCreary Centre Society Adolescent health survey of 25,838 grade 7-12 students: 14% had considered suicide in the past year; 11% had planned a suicide in the past year; and 7% had attempted suicide in the past year. Ramsay et al. (1999) warn us that individuals who attempt suicide increase their chance by 40% to die by suicide, and often "within two years of an earlier attempt" (p. 35). The most often cited solution to many social problems, including suicide and suicidal behaviour, is the recommendation of a continuing professional education (CPE) program. This is one of the recommendations given to the problem of youth suicide as reported by the Children's Commissioner in British Columbia (1998). The Province of British Columbia, Ministry for Children and Families implemented a suicide prevention strategy which includes, among other projects, a CPE program on suicide intervention for school personnel. In 1997, the BC Council for Families, a non-profit provincial organization, was contracted to develop, implement and evaluate such a CPE program which was subsequently named A S K ASSESS ACT: Suicide Intervention Training for School Personnel. What is Suicide Intervention? To clarify the boundaries of this research it is important to understand what suicide intervention is and what it is not. The term suicide intervention usually evokes a common emotional reaction. Most frequently the statements I hear when I'm introducing the topic of suicide intervention are "this is such a good thing - it is so needed" and "it is important that counsellors, therapists and psychiatrists know about it." I agree with these statements but suicide intervention skills are not just for the helping professionals. Counsellors, therapists and psychiatrists do need suicide intervention skills, plus extensive specialized knowledge and training to treat suicidal individuals. However, it has been demonstrated that suicide intervention is a skill that anyone, not just counsellors, can learn. As with basic first aid, suicide intervention can be a first response to a potentially life-threatening event and individuals can learn warning signs, how to respond and where to get help. Casucci and Powell (1982) offer this description of suicide intervention and demonstrate the difference between counselling and intervention: "Our goal is to halt the distressed person from harming himself [sic], not to remake his personality. 3 We throw a lifeline to the drowning individual, but do not worry about teaching him to swim or to improve his stroke" (p. 29). To further explain the context of this proposed research, in the CPE program the participants (teachers, school counsellors and youth workers) are being trained to do something (suicide intervention) as opposed to teach something in the classroom. While this research focuses on a suicide intervention CPE program it is important to note that this is only one component of a comprehensive suicide prevention strategy. A comprehensive approach, as defined in the Glossary, includes three levels, including prevention, intervention and postvention which considers life-span and community wide approaches. White and Jodoin (1998), Leenaars (1997), and Leenaars and Wenckstern (1991) emphasize in their discussions the importance of primary prevention and health promotion; which are designed to enhance the general physical and mental well-being of all individuals and to promote safe and healthy environments in our society. Bernier (1994) argues that a true suicide prevention program will not look like a "mental health program" nor "have a [mental health] name." Examples of prevention programs include clubs and community activities, parenting and family development programs, and nutrition and fitness promotion. An example of intervention includes the A S K ASSESS A C T (CPE) program. Other examples are crisis centres, and medical and policing emergency services. These programs or services are designed as an intervention to a potential suicidal crisis. Postvention occurs after a suicide death and its purpose is twofold. First, to bring some order to a chaotic time, and second, to prevent any further suicide deaths. Unfortunately, this is often the level at which schools and communities recognize the problem of suicide and move from this point to a more comprehensive strategy. 4 The Problem Statement The focus of this research is on the problem of not knowing what and how learning is applied following a CPE program. The CPE program A S K ASSESS A C T was developed to provide school personnel with the knowledge and skills of suicide intervention. The program has been implemented and some outcomes have been measured (Haw & Andres, 1998; 1999). However, the next step is to develop a better understanding of how the program participants apply what they learn. Therefore, the purpose of this study is to gain further knowledge and insight about the factors that facilitate or hinder the application of learning following a CPE program. Research Questions This research focuses on the application of learning following one specific CPE program: A S K ASSESS A C T Suicide Intervention Training. The program is designed for the continuing professional education of school personnel and has been implemented in several school districts in British Columbia since 1997. My inquiry into what happens following the program is guided by the following research questions: from the participants' perspectives, 1) what learning did they apply following the A S K ASSESS A C T program in the context of their school setting?; and, 2) what were the factors that facilitated or hindered this application of learning in the context of their school setting? 5 Purpose and Significance of the Study This study contributes to two bodies of knowledge: one, the broad field of continuing professional education and the specific field of application of learning; and two, the broad field of suicidology and the specific field of suicide intervention training. Cervero's model adapted for this study could be useful in other research projects on the application of CPE programs, not just suicide intervention training. With regard to the field of suicidology, there are usually more questions than answers. This research has added some knowledge about application of a suicide intervention program in the school system. In addition, there are implications for program development and delivery of this and other CPE programs, and school policy and protocol. This study also adds to the research findings of Cervero (1984; 1985) and Ottoson (1995; 1997) on application of learning and contributes to the broader field of adult education and adult learning. The primary significance of this research is that there are few follow-up studies which combine application of learning and a CPE suicide intervention program. Finally, this study contributes to the understanding of what and why (or why not) learning is applied. How This Thesis is Organized In this first chapter, the background of the study, links to the concepts of suicide intervention and CPE, specifics of the problem and its significance are discussed. Chapter 2 consists of a description and analysis of the CPE program and how the planning and delivery facilitate application of learning. Chapter 3 includes a description of the conceptual framework and a literature review which supports the proposed research. Chapter 4 describes the sample, data collection and research methodology and Chapter 5 presents the findings followed by 6 discussion and recommendations in Chapter 6. The appendices contain an outline of the A S K ASSESS A C T CPE program, a sample of the invitation letter, and the interview questions. At the beginning of each chapter, I have included a story told to me during the interviews I conducted for this research. I have looked at all of these stories, word by word and sentence by sentence, identified patterns and themes, and then tried to make sense of the meaning. The questions I asked were structured but they also allowed for freedom and spontaneity of answers. The participants told me about their experiences following the CPE program in their own words and at their own pace. Some told me a lot, some just a little. These stories about suicide and suicide intervention were not specifically asked about, except in the example in Chapter 5; they just became part of the dialogue, as examples, as frustrations, as hope. The stories I have selected illustrate the rationale for this CPE program, and all the concepts of suicide intervention (ask, assess, act, warning signs and risk factors), and the day-to-day challenges of real life in the school system in British Columbia. A l l of the participants' comments are italicized. 7 Chapter 2: An Analysis of the A S K ASSESS A C T Program There was one student that I knew that committed suicide, at the school, he hung himself on the swings, and it affected the whole community profoundly. It was a horrendous thing. I don't know if there was that much of a warning sign but some of the kids knew, the kids that he had befriended they told me that he said things - like, about their shoes - did they want a pair of shoes like his, more specific kinds of things that were close to when his death happened. He was 14. It was a huge, huge impact and I don't think anyone has forgotten it. A S K ASSESS A C T Participant May 2001 Background As already established, the BC Provincial Government, Ministry for Children and Families provided funding to develop, implement and evaluate a suicide intervention CPE program for school personnel. Several years before the development of the A S K ASSESS A C T Suicide Intervention Program, the B C Council for Families, in cooperation with community partnerships, delivered suicide awareness CPE programs to several school districts throughout the province. These programs were well-intentioned but lacked a solid foundation of program planning, co-ordination, content and delivery. After reviewing participant comments and feedback it became evident that a new program should be developed and more clearly defined, organized and consistently delivered. This is a good example of what Sork (1991) refers to in his article "Learning about planning from success and failure" (p. 5). The funding was secured to plan, develop and test a new program specifically for school personnel in British Columbia. The program was developed over the course of a year, with guidance from an advisory committee, and pilot tested by two adult education consultants and me. In this chapter I present an outline of the A S K ASSESS A C T CPE program content and then discuss the planning process using Sork's 8 (1997) Question Based Approach to Workshop Planning Model as a template for this analysis and the program elements intended to influence the application of learning. ASK ASSESS ACT Suicide Intervention Training for School Personnel: The Program The goal of the A S K ASSESS A C T Suicide Intervention Training program is to improve the overall competency of school personnel in the recognition and crisis management of potentially suicidal youth. A l l school personnel, including teachers, counsellors, administrators, nurses, first aid attendants and support staff are candidates for this training. Dyck (1995) recommends training "is essential" for these key personnel "in whom students confide" (p. 8). He also recommends the training be extended into the community to individuals and groups that are involved with the students. The program was developed for school personnel working in junior and senior high schools. However, several elementary school counsellors have participated, including one in this study. The A S K ASSESS A C T trainers hold graduate degrees in adult education and are certified through the Living Works Education Program in Alberta. Established over 17 years ago, Living Works is the only program in Canada that offers specialized suicide intervention training-for-trainers and provides ongoing support and evaluation. The A S K ASSESS A C T trainers have several years of experience. Developed in 1998, the A S K ASSESS A C T five-hour program consists of three modules: (1) Attitudes; (2) Knowledge; and (3) Skills. An evaluation component is built into each module and each module builds on suicide intervention concepts and concludes with skill practice. Participants (15 to 20 per training session) experience discussion, pen and paper exercises, viewing of a video, small and large group work, and role-plays. On the day of the training, immediately before the CPE program commences, a pre-test questionnaire is administered. The 9 program is then introduced with facts and statistics about youth suicide and participants comment on their experience with suicide intervention. Module 1 provides participants the opportunity to explore their personal and societal attitudes towards suicide intervention and how attitudes are related to their practice. In Module 2, participants focus on teen stressors, suicide warning signs and risk factors, and then they are presented with the risk assessment model. The CHOICES video is shown which demonstrates a suicide intervention in a school setting and is followed by discussion. Module 3 consists mainly of practice of the risk assessment model. Participants work in groups and are given scenarios to role play a suicide intervention. A participant from each group observes and records the role plays and the trainer provides encouragement and support. The entire process is debriefed and each group presents their experiences with the risk assessment model. A list of additional resources, programs and contacts are distributed as well as a copy of the Suicide intervention handbook. Finally, a post- test questionnaire is administered which includes a program satisfaction component. A detailed program outline is included in Appendix 1. Planning the ASK ASSESS ACT Program Before the analysis can begin, it is important to acknowledge the "technical, social- political and ethical considerations" that were present prior to and during the planning process (Sork, 1997, p. 14-15) which are discussed in this section. With foresight, good leadership and adequate funding and resources the A S K ASSESS A C T program was developed on a solid foundation. However, this process did not happen in seclusion or overnight. The BC Council for Families had contracts with various Ministries over the years and had developed a reputation of quality work. The contract to plan the A S K ASSESS A C T program evolved over the years 10 and was the result of some key bureaucrats within the Ministry working with the vision that a suicide intervention program could be offered throughout the province. Throughout the planning of this CPE program I experienced what Sork (1997) refers to as "the messy, unpredictable, social-political dynamics that unfold during the process" (p. 6). Similarly, Cervero and Wilson (1994) refer to these dynamics as the "noise" in the "organizational and social contexts" of program planning (p. 3). Some of the challenges included facilitating the process for the funders to trust the judgement of the adult educators on the content selection and instruction methods, and to convince the adult educators to build in precious time for the evaluation component. As chair of the committee, I had to deal diplomatically with funders, community members, school personnel - representatives of the "client system" (Sork, 1997), the program planners, and consultants. Each had his or her agenda, and interest and speciality, while I had a deadline and the task to co-ordinate the project. One of the biggest challenges facing the planning process was, and still is, that of time. Every person on the advisory committee and the consultants were overwhelmed with work and their own social-political pressures, and at times it was difficult to schedule meetings and meet deadlines. As the chair, this program development was my primary responsibility in the workplace, but at the same time, I was also responsible for other projects. At times, the focus of the planning was primarily technical and to some extent more practical - to meet the deadlines. For example, questions to the funders about long-term financial sustainability or implementation plan for the project were never adequately answered. The program planners were well-equipped with the knowledge and experience in writing curriculum and instructional techniques. However, the practical aspects of office technology available at the time seemed to fail at the most critical time: the printer would jam, the photocopier would break down, and the transfer of data from disk to computer had its problems. 11 In addition, each person involved in planning used different software programs and had various levels of expertise with email correspondence. Overall, it was a fairly smooth process despite the usual delays and challenges, and I believe it was a successful project. The program was planned, tested in two school districts, implemented and evaluated, within the budget and on time. Another level of planning, the "ethical", is considered by Sork (1997) "as the deepest level" and the "the one least often considered" (p. 15). In this case, ethical issues were considered but the day-to-day pressures and real-life time constraints left little time for in depth discussion. One issue that has always been at the discussion table is "who gets suicide intervention training?" This is as much a socio-political issue as it is an ethical issue. The program planners argue that this program should be available to anyone working with youth, not just school personnel. In fact, suicide intervention concepts are transferable to most ages, just like basic first aid. The socio-political dimension of unions, funders and gatekeepers, influences who gets this particular program. Therefore, it is frustrating for the planners to know that this program is only reaching a few "chosen" individuals. Another ethical concern that is rarely discussed is that, as Rosenman (1998) and others argue, programs designed to identify and "treat at-risk individuals" are not as effective as true prevention programs (p. 101). He believes that a lifespan "population-based approach" will ultimately be more effective: examples are restricting access to firearms and other means of suicide, reducing the incidence of family breakdown, and addressing other socio-economic concerns such as umemployment, substance abuse and alienation (p. 101). Rosenman (1998) describes prevention as "the diligent, unspectacular work in the population which mitigates those factors which lead, among other things, to suicide (p. 102)." The reality in our province, and 12 many others, is that true prevention is marginally supported with funding and resources. Prevention is a term often used by politicians and funders but the reality is that intervention and treatment programs receive the funding. An notice in The Globe and Mail on July 13, 2002 announced a campaign that would raise three million dollars for the establishment of an endowed chair " to improve diagnosis and treatment" of "major depressive disorders" with the rationale that there is a suicide everyday in BC ( A l 1). A similar announcement about an endowed chair on prevention would be a welcome notice and the commitment needed. So program planners and non-profit agencies take the funding to produce programs that we believe are the best they can be, but, i f we had a choice or even more funding, the programs would possibly look different. That said, it is possible to use the funding of treatment and intervention programs as leverage to keep the issue on the agenda, and continue on with the prevention message. Sork's (1997) Question Based Approach to Workshop Planning Model Since I was involved in every stage of the planning, implementation and evaluation of the A S K ASSESS A C T program, I can offer a retrospective account to the analysis of this process. No specific planning model was intentionally used. However, the process that occurred resembled Sork's Question-Based Approach to Workshop Planning Model (1997), and will be discussed here using this model. The elements of Sork's (1997) model include 1) Analyze Planning Context and Client System; 2) Justify and Focus Planning; Clarify Intended Outcomes; 3) Formulate Instructional Plan; 4) Formulate Administrative Plan; 5) Develop Summative Evaluation Plan and Formative Evaluation. Throughout the planning process, formative evaluation occurs as plans are reviewed and improved (p. 14). Indeed formative evaluation did 13 occur during the planning of A S K ASSESS ACT. A l l of these elements were incorporated into the planning but in no particular order. I can only suggest that this process was influenced by the fact that the planners were graduates of the adult education program where Sork taught. They also had many years of experience in both the content and planning of adult education programs. An Analysis of the Planning Context and Identifying the Client System As mentioned in the previous section, it was clear from the beginning of the process that this program was for school personnel in British Columbia. The Ministry had contracted with the BC Council for Families to develop and deliver a program on suicide intervention and had made specific requests that the project include an advisory committee and an evaluation component. At the earliest stage of the planning process, an advisory committee was assembled that consisted of several members of the "client system" including potential consumers of the program, as described by Sork (1997). In this case, the client system included teachers, school counsellors and administrators. Several other members of government, the funders, and community agencies were selected to be part of the advisory committee due to their expertise in suicide intervention and vested interest in the program. Financial, staff and time limitations constrained the size of the advisory committee, but ideally, parents, students and suicide survivors should be included in such a committee, or at least a method to obtain their feedback would be established in the planning process. The context in which the program was planned included a hopeful shift in government support of suicide awareness, education and intervention. A provincial suicide information program (SPIRC) was established and it began to bring together community agencies that were delivering suicide awareness and intervention programs. At about the same time a plan for youth suicide prevention was developed which also guided this work 14 (White, 1998). In addition, SPIRC produced^ manual for best practices in youth suicide prevention (White & Jodoin, 1998). This was an important document because of the diversity in agencies (programs for students or gatekeepers, and regional or provincial focus) and the fact that in some cases they had the same funders. Nonetheless, it was crucial to have the community agencies involved, not only for their expertise, but to further the mission of the program and to hopefully alleviate any concerns that we were encroaching on their territory. To further the input and involvement from the "client system" at the point where the program was in the penultimate draft stage it was also extensively reviewed and feedback was obtained from several school personnel from around the province. Justification and Focus of the Planning Process As previously stated, the goal of the A S K ASSESS A C T Suicide Intervention Program is to improve the overall competency of school personnel in the recognition and crisis management of potentially suicidal youth. The planners were experienced in developing programs and they were able to take the time to build the foundation. The first step included an extensive review of current literature on program planning, suicide intervention, and evaluation, including a 1997 BC survey on Suicide prevention training needs (White, Rouse, & Jodoin). In 1997 I also conducted a focus group at a B C provincial conference for Career and Personnel Development (CAPP) teachers. Counsellors, teachers, and youth workers had the "floor" for 90 minutes to tell me their ideas about what they wanted and needed in a suicide intervention training program. As mentioned elsewhere in this paper, youth are at risk of suicide, most youth are in a school system, and suicide intervention skills can be taught to school personnel. 15 Clarifying Intended Outcomes The intended outcomes of the A S K ASSESS A C T suicide intervention program are that participants will learn suicide intervention skills and then apply what they learn in their school setting. Program objectives are as follows: (1) to increase the likelihood that participants will adopt attitudes favourable to intervention, including adoption of non-judgemental approaches, demonstration of willingness to make referrals, and the foresight to seek consultation; (2) to increase participants' knowledge in suicide warning signs and their school's suicide intervention protocols; and (3) to improve participants' skills in initiating intervention, assessing risk and developing actions plans. (Dafoe, MacCallum & Haw, 1997, p.l). Formulating the Instructional Plan In this section, I will provide details about the instructional planning and how the program links to application of learning. One of the factors identified in Cervero's (1985) framework which influences application of learning is the CPE program itself. Cervero stresses that "educators must take into account the constraints and opportunities within the working environments of learners in planning programs that are intended to improve not only their competence, but also their performance" (p. 86). Influencing application of learning was foremost on the minds throughout the "instructional" planning. Indeed, even the title reflects application: A S K ASSESS A C T are action words that accurately reflect the intended application. The planning was done with the intent that the CPE program was developed specifically for the "client system" of school personnel. Several constraints of the school system and school personnel were considered during this stage of planning including the length of the program (it had to be delivered within a professional development or regular school day), the examples 16 (handouts and case studies had to refer to schools, teachers, and students) and as much as possible, British Columbia data would be used. The consideration of these variables when planning the program would positively influence the application of learning (Cervero, 1985). Ottoson (1995) stresses that the goal of application is a "complex, multidimensional process" that takes more than a "good idea" (p.24). The belief that individuals can learn suicide intervention skills and help prevent suicide is indeed a "good idea" based on a solid foundation of research and practice and is the propelling force to the planning and delivery of this CPE program. This belief forms the foundation of how the exercises, resources, and content of the program were selected and how carefully the timing and instructions were detailed. One of the assumptions of this CPE program is that learning will occur. Fogarty (1999) explains how the theory of constructivism helps us understand learning. He states that we learn by constructing knowledge and making meaning of new concepts by "searching for a pattern that connects a seemingly random series of dots" (p. 76). This is an accurate representation of the learning experience during the A S K ASSESS A C T program. During the presentation, the participants are reassured that the concepts will make sense by the end of the program. Throughout the program the facilitators and participants help one another to "connect the dots." Lecture, video, role playing, practice and discussion are all designed for participants to learn the concepts of suicide intervention. To further facilitate learning and application, the program planners intentionally use concepts or examples with which most individuals would be familiar. For example, one of the key concepts in the program is assessing the risk of suicide. The risk assessment model in this program was adapted with permission from Living Works Education and uses the acronym CPR. CPR stands for current suicide plan,prior suicidal behaviour and resources (Ramsay, et al, 17 1999). Although CPR in suicide intervention has a different meaning, most adults can relate to the first aid acronym CPR. They are familiar with the acronym CPR and then more likely to apply it to the new model as a memory device. Carney and Levin (1998) support this notion of using memory aids in their discussion on "Mnemonic strategies for adult learners." To provide realistic situations, the planners scripted several scenarios about potentially suicidal students. These scenarios were given to participants to role play the parts of the teacher and suicidal student. Coaches or recorders from each group made notes and encouraged the suicide intervention process. This exercise provided the school personnel with an opportunity to explore the concept of suicide intervention in a somewhat realistic and safe manner. In addition the environment in which this practice took place was often a similar environment in which the participants regularly worked: a classroom or other school facility. The realism of the examples and the environment all encourage application of learning and are an integral and intentional part of the program. Most importantly, a suicide intervention protocol from the school district is obtained prior to the CPE program being delivered. A protocol describes the responsibilities of school personnel and the steps to be taken if there is a possible risk of suicide. Typical protocols include details about informing the counsellor, administrator and parent(s), where to get help and how to establish a follow-up plan. This protocol is used by the participants to simulate what they would actually do in the event of a potentially suicidal student. Formulating the Administrative Plan While Sork (1997) emphasises the importance of formulating an administrative plan, only a part of this element was active during the planning process. Funding had been secured, the client system was ready for the training and eager to participate, there was no direct cost to the 18 client system, and B C Council for Families had adequate staff and resources to support the accounting and other needs of the program. The administrative aspects of the A S K ASSESS A C T program included finding school districts interested in participating in the pilot tests and co-ordinating two of these events. Since some time has elapsed since the original planning, it is interesting to note in recent years, the administrative plan has become more important as the funding for the program implementation has gradually been reduced. More recently a marketing plan has been developed and for the first time in the program history, the client system has been asked for a fee-for-service. This is a dramatic change in not only how the clients plan for professional development but how the BC Council for Families manages this program. The client system is not used to paying for the program and the workshop providers are not used to charging for the program. Only time will tell i f the program will survive. Development of a Summative Evaluation Plan Another significant commitment to this program was the evaluation component. Mentioned earlier was the challenge to the program planners to build in the time for the evaluation as part of the instruction design. This was challenging because it was an unknown element as we had never worked on a contract where evaluation was a required element. Almost all program planning models have an evaluation component but in the real world of practice it is often the most neglected element, not because planners do not want to include this element, but because it is time consuming, and there are up-front costs in the initial stages of planning. Often budgets do not allow for an evaluation component, other than what is often referred to as "happiness sheets" - gauging the participants' immediate reactions following a workshop as to their satisfaction with the presenters, materials, environment, refreshments, etc. (Kirkpatrick, 19 1994, p. 27). However, once an evaluation process has been developed, as in this case, the data collection is relatively simple. The ongoing cost is related to the data analysis and report writing, but once a template is constructed, again this is cost effective and adds value to the program. A plan was developed during the planning phase to conduct a summative evaluation. An expert consultant was invited to participate in the evaluation planning, analysis and final report. It was decided that the program objectives could be measured using several techniques, including a pre-post test, a questionnaire and participant observation, by collecting all of the data on each training day. This process was cyclical in that the objectives and measurement tools were developed, debated, assessed, reviewed, revised and then eventually pilot tested. The evaluation data were collected during the first year of pilot testing. After the initial analysis, the instruments were revised. Data were again collected the following year using the revised instruments. Two reports were written detailing the immediate program outcomes and participant satisfaction. It appears that the program objectives were met and overall the participants were satisfied with the training. No follow-up data was collected due to budget constraints. Details of these findings can be found in the reports by Haw & Andres (1998; 1999). Constraints to Application The reality of working as a contractor to the school system has some limitations. We can never be truly effective in facilitating application because we are not in the system on a day-to- day basis. We show up for one day, present the program and then leave. Rarely do we hear from anyone in the school system again, except occasionally to schedule another training session. It has been established that application of learning needs to be encouraged, especially by the school administration. Very few administrators attended the program and I can speculate 20 at this time that only a few are really aware of the intent of the CPE program. If administrators were more aware of A S K ASSESS A C T there might be greater support for the program. It is difficult working on the outside of the school system to convince administrators to take an active part in suicide intervention. However, a good place to start would be providing information to the principals and vice-principal associations. There seems to be a tendency to expect outside or expert advice on issues especially like suicide and because we are non-school personnel we have established what I believe is a reputation for an excellent program. However, it is reinforced during the CPE program that school personnel are the frontline caretakers and can be proactive in intervention and relying on the experts when needed. This comes back to the definition of suicide intervention and the comparison to first aid. Individuals can be trained to be first responders in a crisis or potential crisis situation. Facilitating the entire process of planning, implementation and evaluation led to my interest in the research study. What happens after all of this work? Did we develop a CPE program that will lead to application of learning and more effective suicide intervention? Can this research influence the socio-political decision making of suicide intervention program delivery? 21 Chapter 3: Literature Review We had received a note, you know somebody intercepted it and it was a suicide note and looking at all the different risks I thought I don't think there was a huge risk but I mean she might have been going to commit suicide when she thought that we were going to tell her parents. You know that was more serious to her than anything else [telling her parents], and she thought it was just one more problem you know. So we worked out this method for her to go home and that by seven that night she would phone either myself or the principal. After she left for home we sat there wondering are we okay, you know, are we okay to do this. She did phone and we had a long talk with her and her parents and it was okay. A S K ASSESS A C T Participant April 2001 The Conceptual Framework This research is primarily informed by the work of Cervero (1984; 1985). First, he conducted an exploratory study and then he proposed a framework to specifically research the application of learning following a CPE program. The framework was influenced by his perceived need for a better model to study and therefore understand the complexity of application of learning. Cervero (1984) argues that we need to shift from "determining effectiveness" to "analysing the effectiveness of CPE" programs (p. 135). In other words, a program can be determined effective but we need to understand and analyse why it is effective. We need a model to help explain application of learning and this is the main reason I have selected this framework to adapt for this study. It provides a model that guided my research and helped answer the questions: what learning was applied and what facilitated or hindered application of learning? Cervero's (1985) framework was influenced by the communication of innovations work of Rogers and Shoemaker (1971) and is expanded to include the factors that appear to influence application of learning. This framework uses the term "proposed behaviour change," and in the 22 case of this study it refers to application of learning following a CPE program. As illustrated in Figure 1, (adapted from Cervero, 1985, p. 86), the factors identified in the framework include the following characteristics: (1) the program; (2) the proposed behaviour change; (3) the individual learner; (4) and the social system or context in which the individual works. For the purpose of this study, the proposed behaviour change is suicide intervention - this is the evidence of application of learning; the CPE program is A S K ASSESS ACT; the individual characteristics are those of school teachers, counsellors and youth care workers; and the social system is the classroom, school and school district in which the participant works. Figure 1. Cevero's (1985) Framework (adapted) and the Four Factors Considered to Influence Application of Learning 23 Although beyond the scope of this study, Cervero also included "client outcomes" in his model after application of learning. The "client outcomes" in this situation refer to what happened in the school or to the student after the suicide intervention. Ramsay et al. (1999) provides the following suggestions to determine "client outcomes": "What was the outcome of the intervention? How do the parties feel about it? If a referral was made, was it appropriate? What was the long-term outcome of the intervention?" (p. 92). I will further discuss these recommendations in Chapter 6. The A S K ASSESS A C T program presents numerous challenges to the adult educator. The program is designed for school personnel to learn basic suicide intervention skills which require participants to learn how to watch and listen for potential suicidal behaviour or symptoms and inquire directly of the potentially suicidal individual i f they have concerns. Suicide is often considered a taboo topic and some of the concepts of intervention are generally new information, abstract and often misunderstood. For example, the risk assessment model considers three variables, (1) current plan, (2) prior suicidal behaviour, and (3) resources that are used to estimate suicidal behaviour. The acronym CPR is used to teach this concept. In addition, four other variables are introduced to help learn this concept. It is a complex and time consuming process because some of the variables are often associated with common misconceptions such as males are at higher risk, and seniors are not at risk. The facts are males complete suicide more but females attempt more, and seniors are at a high risk of suicide as youth are. Another challenge to the learners is the term "resources." Automatically, most participants think of community "resources" such as counselling and mental health services to help the suicidal individual. This model refers to individual "resources" such as friends, family, work, pets, or whatever can help the suicidal individual through the crisis. Participants struggle with this 24 model, which seems a necessary component of the learning. A few hours are devoted to teaching the somewhat complex concept of suicide intervention and practicing assessment skills. To further understand how learning is applied and how it is connected to Cervero's framework, it is necessary to review several bodies of literature, including application of learning, continuing professional education and suicide intervention, teacher characteristics and the school environment. Each of these bodies of knowledge inform and support this research. Characteristics of the Proposed Behaviour Change At first glance one might question how the proposed behaviour change can influence behaviour change or application of learning. The key to this statement is the word proposed. What behaviour, change or learning is expected that participants will apply? In this CPE program it is expected that participants will apply suicide intervention skills in their workplace. Cervero (1985) explains that individuals will more likely adopt the proposed behaviour change, or apply the learning, i f the desired needs of the participants are met. Despite some of the negative connotations of suicide, it is probable that participants want to learn intervention skills to use in their workplace. In the 1997 BC survey on school personnel training needs, it was reported that 51% of the 1446 respondents felt that suicide intervention skills were a priority (White, Rouse & Jodoin). Furthermore, King et al. (1999) alert us that high school counsellors feel that suicide intervention is their responsibility, yet in their study, only "38% believed that they could recognize a student at risk for suicide" (p. 464-465). Furthermore, while few reported a recent CPE program on suicide intervention in their school, 79% felt that such a program was "one of the most important things a school system could ever do" (p. 462). This demonstrates 25 the need for a CPE program and the desire to learn about suicide intervention. These elements will be further explored in the findings and discussion sections. Application of Learning There is a paltry amount of research on the topic of application of learning following a CPE program. However, research has provided an abundance of information about immediate outcomes of programs including changed attitudes, improved knowledge and skills and participants' satisfaction (Cervero, 1985; Eraut, 1994; Ottoson, 1997). Each of these same authors in turn encourages more studies on application of learning. While a great deal of time, effort, and human and financial resources are devoted to CPE programs there is little known about if, and how, what is learned during a CPE program is applied in practice. Few researchers have conducted follow-up studies and there is even less known about the application of learning following suicide intervention programs (Tierney, 1994). Furthermore, "unless adult educators know more about the circumstances of how [the CPE program] matters, they are not likely to have much effect on social policy, their own practice, nor the lives of adult learners and their communities" (Ottoson, 1995, p. 18). This statement emphasises why this research is so important. This research is located within the field of continuing professional education on the topic of suicide intervention. Lives are literally at stake and we are not sure how and if the learning from a CPE program is applied in practice. Some of the key findings in the application of learning research are the factors that facilitate or hinder application (Cervero, 1984; 1985) and multiple influences on practice (Ottoson, 1995). Both of these researchers stress that there is no single variable or reason that explains the application of learning. Cervero (1985), as mentioned previously, identified four 26 factors and proposed a model for research. The four factors (the program; the expected behaviour change; the individual learner; and the social environment in which the individual works) are all linked to application. Similarly, Ottoson (1995) found the multiple influences on application of learning to be the education program, the learner, and resources and support in the workplace. The difference between Cervero and Ottoson's research is that Cervero developed a model from an exploratory study and Ottoson used an existing model to explain application of learning. I have selected Cervero's model because it provides a useful framework, adapts well to this qualitative research study (it was originally developed based on a quantitative study), and emphasizes analysis to understand application of learning. Ottoson's (1997) writings and research are useful, and supportive of this research: I was informed by her ideas of "enabling" application to consider the factors that facilitate or hinder application in this study (p. 99). Like Cervero and Ottoson, Peirson and Prilleltensky (1994) demonstrate how individuals and schools can implement change and apply learning. Perison and Prilleltensky developed a model after they conducted research on school change and primary prevention: programs that "both reduce deficits and enhance strengths" (p. 128). Their model identifies several components that facilitate change or application such as community ownership, attention to human factors, and proper implementation (p. 136). This model has an emphasis on support from the community and school administration. This concept is similar to the factor Cervero refers to as "social system" and Ottoson as "enabling and reinforcing." Another challenge facing the application of learning research is the finding that some "common sense" or easy solutions to a problem are not applied after a CPE program. This finding adds to the complexity of understanding and researching application of learning. Rogers and Shoemaker (1971) found that sometimes a worthy cause or a simple solution to problems is 27 not always adopted or applied. Ottoson (1995) also argues while the goals may be a "good idea" there is no simple explanation of what occurs after the program and that "application is a complex, multidimensional process" (p. 24). The goal of the A S K ASSESS A C T Suicide Intervention Program is to improve the overall competency of school personnel in the recognition and crisis management of potentially suicidal youth. It is a "good idea" based on the belief that individuals can learn suicide intervention skills and help prevent suicide, and more than a "good idea" in that the program was developed on theoretical concepts of suicide intervention and adult education. Adult Learning Theory The very nature of the research on application of learning assumes something has been learned. Adult learning theory is influenced by interdisciplinary contributions from the social sciences including education, sociology, psychology, and the physical sciences, especially in the area of brain research including cognition and memory. Numerous authors have contributed volumes of texts written about learning theory in adult education and how learning occurs, including the classic works of Merriam and Caffarella (1991; 1999). For the purpose of this study I have drawn on the writings of Johnson and Pratt (1998) and Fogarty (1999) for guidance on how the participants' learning occurred within the confines of this CPE program. Their writings on how we search for patterns, and use past experiences to learn new concepts best fit with the learning situation faced in this CPE program. Building on this concept of searching for patterns, Johnson and Pratt (1998) explain that adults have multiple and previous learning experiences upon which they draw on to learn. These are referred to as "schemas" or "maps" or "templates" that help adults make sense or meaning of concepts when they are faced with new 28 information (p. 84-85). This is exactly the situation school personnel face when they are participants in the A S K ASSESS A C T CPE program. Most have experience teaching, guiding and counselling students and are all graduates of a formal education system. Many are faced with the concepts of suicide education for the first time and have to rely on their past experiences, as well as the guidance of the trainers, to learn new concepts. Suicide Intervention It is important to understand the context of this CPE program within the field of suicidology. Suicidology refers to the study of suicide and suicidal behaviours and its related concepts of prevention, intervention and postvention (which are defined in the Glossary). There is a vast body of knowledge on the topic of suicide and a large industry servicing and supporting practitioners and educators. It appears that there are more questions than answers with regard to suicide even though there is a great deal of knowledge about the topic. In fact, suicides still and will continue to happen. At the Conference on Suicide Prevention: New Considerations, Dyck (1993) offered an example based on the Alberta experience, that even though funding, programs and policies had been in place for several years there had not been a decline in suicide rates. He suggests we need to "stop developing programs and begin focusing on the results those programs are designed to achieve" (p. 1). Although there have been some additional contributions to the literature on outcomes of CPE programs, they have mainly been in the area of school-based programs (Kalafat & Elias, 1994). Other researchers (Drabek & Yutrzenka, 1991; Tierney, 1994; and Turley et al., 2000) report on the effectiveness of CPE suicide intervention programs. They indicate changes in attitudes, knowledge and skills immediately following the program. Drabek and Yutrzenka 29 conducted a study on retention of learning following a suicide prevention program. Five months after the training, participants were administered a post-test and results suggest the "ability to recognize suicide lethality" had improved (p. 136). McConahay (1991) found in his follow-up study that there was limited application of learning six months after a suicide intervention program, mainly because of the lack of opportunity. He describes this as chance but also wonders if this was a result of the training in that "they did not make a suicide generalization as frequently" (p. 134). In other words someone trained in suicide intervention may be more likely to identify a potentially suicidal individual and less likely to make a false-positive judgement. His reasoning is that participants were able to more accurately identify potentially suicidal individuals and therefore apply application of learning more selectively. This research will contribute to a greater understanding of how suicide intervention programs are applied in practice and this, in turn, will have implications for policy, programming and practice. Continuing Professional Education and the School System In British Columbia, The BC Teachers' Federation has a history of offering CPE programs and supporting professional development. The BCTF offer this description: "Professional development consists of programs, services, and activities designed to build and strengthen a body of professional teachers" (BCTF, 1998). Another common term used in the school system is "staff development" when referring to CPE. In her work with the Vancouver School Board, Hunter (1986) identified personal needs, professional needs and school/district needs as goals of staff development with the main focus on changes or improvement for students. She reports that the best outcomes in professional development are when the individual and institutional needs are met. This fits with the concept that schools and school personnel must 30 work together on a common goal to facilitate application of learning. For the purpose of this study, the common goal is suicide intervention. To further the argument that CPE programs are valuable to the school system, Houle (1980) wrote "everyone must expect constant change and with it new goals to be achieved and new understanding and skill to be mastered" (p. 75). His foresight demonstrates the need for CPE programs, especially for school personnel. Constant change in the BC school system has placed demands on administrators and school personnel. Budget cuts, labour disagreements, and technology demands are concurrent with the pressure on school personnel to increase academic performance and be sensitive to the social and emotional needs of their students. The recent McCreary Centre Survey (1999) demonstrates the turmoil and non-academic realities facing youth in BC. Suicide, teen pregnancies, sexually transmitted disease, drinking and driving, drug use, injuries, violence, bullying, and family problems are some of these issues. School personnel cannot ignore the realities of these social issues and the impact in their classrooms. This is where CPE programs can help school personnel keep up with "constant changes" as expected by Houle (1980). Fortunately, in British Columbia, the BC Teacher's Federation (BCTF) and the Ministry of Education are committed to supporting continuing professional education (BCTF Professional Development Policies and Priorities, 1999). In turn, the BCTF state in their 2001 Handbook for New Teachers "it is the responsibility of the individual teacher to make a continuing effort to develop professionally.. .on a voluntary basis" (BCTF, p. 52). Because of the immense negative impact of youth suicide, a great deal of research has been devoted to help eliminate or reduce the incidences of suicide and suicidal behaviour. One of the arguments for a suicide intervention CPE program in the school system is that it has been demonstrated that significant numbers of suicide attempts and completed suicides involve 31 school-aged youth. Therefore, school personnel are a logical choice to participate in a CPE program on suicide intervention. The Centers for Disease Control (1992) argue that professional development of school personnel "may help prevent suicides" (p. 11). Leenaars and Wenckstern (1991) and Tierney (1994) also support this reasoning because once trained in suicide intervention skills, "caregivers can detect those who may be at risk" (p. 69). In the late 1990's the BC Ministry of Education and the Ministry for Children and Families supported the rationale for suicide intervention at two levels. First, they formally recognized that teenage suicide is a social problem and second, they provided funding for the development and implementation of a suicide intervention CPE program for school personnel. However, much work still needs to be done to coordinate a comprehensive suicide intervention strategy and until then CPE programs are a logical choice. While much of the literature on CPE or staff development in the school system focuses on the academic curriculum, teaching methods, and classroom control there has been a heightened awareness that schools and classrooms are not immune to the problems facing society. To this end, non-academic CPE programs are generally offered and prescribed to throughout the school year (BCTF, 1998). The A S K ASSESS A C T CPE program is one of the non-curriculum subjects that continue to be in great demand. In Creating Learning Communities: The Role of the Teacher in the 21st Century, Jalongo (1991) explains this shift as a necessity. She gives examples of how some teachers have made an impact on the well-being of students through non-academic pursuits. Jalongo (1991) stresses that besides teacher intuition and experience, there is also a need for adequate training and continuing professional development. 32 Along with the recognition that school personnel are key players in this complex issue there are other considerations besides just a CPE program. According to some legal advice with regard to youth suicide, school districts have adequate warning that they may someday be held liable for a suicide (Oaks-Davidson, 1996; Noonan, 1996). Part of the liability is created because of the greater awareness of the issue and the fact that some school personnel are trained in suicide intervention, thus putting responsibility on the professional body that stands "in loco parentis - ie. to exercise the care and supervision of a careful and prudent parent over students in their care" (Noonan, 1996, p. 191). In other words, CPE programmers, in collaboration with the "client system," need to exercise caution in their planning and implementation and need to consider the ethical implications of a suicide intervention program (as discussed in the previous chapter). Teacher and School Counsellor Characteristics How can teachers and school counsellors be asked to do one more task when they are already overloaded with responsibilities? Suicide intervention is probably the last skill anyone wants to learn or use but like first aid it has become a necessary part of life. There are legal and ethical implications for the school systems when students are in their care and are their responsibility. In this section, I will explore some of the characteristics of school personnel and relate how these elements have implications for application of learning. One of the myths of suicide is i f you talk about it you will put the idea in someone's mind. The fact is that almost everyone thinks about suicide at one time or another, from a moment's thought to obsessive rumination. It has been well demonstrated that at any given time some students are thinking about suicide or planning their suicide (Leenaars & Wenckstern, 33 1991; McCreary Centre Society, 1993; 1999). Unfortunately, it is often after a student suicide that schools recognize they need to be more proactive in training, program development or prevention strategies. Central to the concept of application of learning are the characteristics of the learner. The objective of the A S K ASSESS A C T Suicide Intervention Program is that school personnel will apply suicide intervention skills. Therefore, the factor to consider in this research is how certain teacher characteristics may influence application of learning. Personal and societal attitudes towards suicide are generally well documented and can influence application of learning. It is generally found that i f individuals have a positive attitude towards suicide intervention, that is, they believe they can prevent suicide, they are more likely to intervene (Tierney, 1994). Therefore, i f an individual has a negative attitude towards suicide intervention or believes that she/he cannot prevent suicide, it is likely she/he will not adopt or apply learning from a suicide intervention program. In addition, in this study, data about education levels were collected to see if there is any relationship between higher education, and application of learning. Cividin and Ottoson (1997) found "active, intrinsic motivations of participants" were linked to application (p. 54). In other words, participants who voluntarily attended a program that they perceived as beneficial to them were more likely to apply what they learned. While these findings may appear obvious it is nonetheless important to consider this when developing policy about who should attend a CPE program. The A S K ASSESS A C T CPE program is part of a provincial strategy for suicide prevention and almost all participants voluntarily attended. 34 As would be expected, it is more likely that school personnel would intervene if they have participated in previous suicide intervention training or a CPE program. Hall and Hall (1996) found this to be true in their study on application of learning following a CPE program. They found that over time the least experienced group caught up to the experienced group. Their explanation cites workplace "opportunity" and encouragement. Again, i f there is not the opportunity to intervene or i f suicide intervention is not encouraged or supported by administration or others it is less likely to occur. Finally, Knowles' (1980) contribution to adult learning was based on characteristics of learners. His term "andragogy" includes assumptions about adults and how their learning is different from children. His assumptions about adult learners, include (1) being a self-directed human being; (2) their readiness to learn; (3) they accumulate a growing reservoir of experience; and (4) immediacy of application, are all applicable to this study when considering characteristics of school personnel (p. 44-45). A l l of these aforementioned elements were considered during the development of the interview questions and will be discussed further in this thesis. These assumptions also connect to the next section on the social environment or system in which school personnel work. The School Environment Although individual characteristics and attitudes influence application of learning, the other factor closely linked is that of the environment in which school personnel work. Several authors suggest how schools and school districts can be proactive in suicide prevention (Tierney, Ramsay, Tanney & Lang, 1990; Poland, 1989; Davis & Sandoval, 1991; Leenaars & Wenckstern, 1991). Their work establishes guidelines that schools can adopt to further 35 prevention efforts. A comprehensive school suicide-prevention strategy consists generally of: coordination and commitment of both the school and community, including all staff (teaching and non-teaching), students and parents; development of a suicide intervention policy and a crisis response team (with community members); and training and education opportunities at all levels. In order to develop or move a strategy along, it only takes one individual. However, "the key to whether a suicide intervention program is implemented in a school is whether the top administrators' support the program" is argued by Poland (1989, p. 60). Peirson and Prilleltensky (1994) also write about the importance of administrators and how their support is "a contributing factor in the success or failure of a new program/change" (p. 129). One of the questions, in this study, posed to the participants is their perception about administrators' support. These findings are reported further on in this paper. Individuals can be well trained and have a positive attitude towards suicide intervention but i f there is no support from the school system, then it can be hypothesised that application of learning is less likely. So "unless there are incentives or at least not disincentives within the working environment for the proposed changes, the CPE program is unlikely to be successful " (Cervero, 1985, p. 87). Another crucial element of suicide intervention in the school system is the development and implementation of a suicide intervention protocol. The school protocol is a policy that directs and guides school personnel in the event of a potential suicide. This protocol is important for several reasons. First, by the mere fact that it exists it will have endorsement from the administrator, and often district level administration, thus indicating support. Second, it means the community has been involved with the school at some stage of the planning. Third, it clearly spells out the duties and responsibilities of school personnel, and hopefully eliminates confusion 36 of roles, and decreases anxiety. To gain an understanding of the participants' school environment, in this study questions were asked about suicide intervention protocols in each school district. Also, I have observed that the schools with a current suicide intervention protocol seem more involved in planning for the training, partly because the school coordinators had to do some work prior to the CPE program, such as, identifying the need for training, liaison with potential participants, reviewing the protocol for accuracy, and engaging in an active dialogue with me prior to the training. In other words, they are not just booking the A S K ASSESS A C T to fill in a slot during a professional development day with a program that is available and free of charge. In addition, Johnson and Maille (1987) suggest the schools be proactive by connecting to community agencies prior to any crisis and organizing activities that promote the well-being of both individuals and the school environment. They believe these efforts will create "an atmosphere conducive to effective ongoing personal problem solving and stress reduction" (p. 17). Summary of the Literature Review In this chapter, I have explained Cervero's (1985) framework and identified characteristics of four factors, (1) the program, (2) the learner, (3) the behaviour change, and (4) the social system that will be considered throughout this study as to there influence on application of learning. I have presented and discussed findings in the literature that are central to this research on application of learning and that are connected to the framework. Each of the topics identified, the proposed behaviour change, application of learning, adult learning theory, 37 suicide intervention, continuing professional education, the school system, characteristics of school personnel and the school environment are interconnected and provides guidance throughout this study. In the next chapters I will present the research methodology, the findings and conclude with a discussion including implications, recommendations and suggested further research. 38 Chapter 4: Sample, Data Collection and Methodology One of the reasons I got involved in this [the ASK ASSESS ACT training] I had an experience with a grade 12 student. Straight As. She spent a couple of months out in the hallways not going to classes, crying her eyes out and the reason was she was pregnant. She couldn't get it together to go to class she was so distraught. There was nobody she could talk to, she couldn't trust her friends, she didn't trust the counsellor and she didn't trust whoever. So she didn't have anybody she could talk to and nobody knew she was out there doing this. In this school she sat in the hallways crying, not going to classes and nobody knew or if they had a hint they didn't follow up on it and of course she considered suicide. She was at a loss as to what else to do, and that's where I think it happened to me, which just boggled my mind. The reason I found out was she decided that the only person she might talk to was her old teacher, which was me so she came to me and I was able to direct her in the right direction and we made a plan to salvage the rest of her school year so she could go to university and it all worked out and she's okay and she's graduated from university. A S K ASSESS A C T Participant May 2001 Research Design A qualitative research design was selected and in-depth semi-structured interviews were conducted with school personnel in two school districts in British Columbia. A l l interviews were conducted in person. The criteria for inclusion in this research are individuals who had participated in the A S K ASSESS A C T Suicide Intervention Program in 1998 and who had continued to work in the school system. It is crucial that the research be conducted after a period of time to allow application of learning to occur. Hall and Hall (1996) report a "sleeper effect" after a CPE program for teachers and the necessity to wait before collecting data. The timing for this study was to give participants enough time for opportunities to apply their learning. The data were collected approximately three years after the CPE program, between January and June, 2001, thus allowing time for participants to apply learning in their workplace and to reflect on 39 what factors facilitated or hindered the process. The following sections outline the sample, instrument and process for collecting, analysing and reporting data. Sample This CPE program was delivered to 156 junior and senior secondary school participants at eleven locations in British Columbia between January 1998 and February 1999. Three school districts were selected as sites for the research: two urban school districts (USD) and one rural school district (RSD). School districts were selected rather than individual schools because only one or two participants were trained from each school. The school districts selected to participate are identified in Table 1. Table 1. Selected School Districts that Granted Permission to Conduct the Research Study SD Schools in District Training Date(s) # Participants USD 55 January 12, 1998 11 USD 117 March 6, 1998 & April 17, 1998 29 RSD 22 November 30, 1998 20 A "purposive sampling" technique, as described by Miles and Huberman (1994, p. 27), was selected to recruit participants from the three school districts for the following practical reasons. First, the permission process, involving contacting superintendents to conduct this study in their school district and three school districts, was a manageable task. Second, in the event that permission was not obtained, there were enough other districts to select from. Third, two of the districts had a high number of participants, which would increase the chance of a 40 higher number in the sample. Fourth, one district was rural and the other two were urban so there was an opportunity to determine if there was a difference between districts. A l l of the interviews were conducted in person and the selection of the three districts above made the interview process more practical with regard to access to transportation, travel time, ferry costs, and long distance charges. Permission was requested and granted from each of the three school districts to conduct the research on agreement that a written report about the study would be delivered to each school district after completion. Forty-eight school personnel were invited to participate in this study and 21 were interviewed: 12 in USD and nine in RSD. The sample consisted of 14 female and seven males with an age range from 33 to 57 (average age 45 years). The A S K ASSESS A C T program was designed for the secondary school personnel, and all participants, except one elementary school counsellor, worked at the secondary level. Length in occupation ranged from 5 to 28 with an average of 16 years working in the school system. The average age of males is 46.5 years and the average age of females is 44 years. These average ages are close or identical to school teachers in BC. The Ministry of Education (2001) reports the average age of male teachers is 45 years and the average age of female teachers is 44 years. While there were twice as many females as male participants this was expected since two-thirds of teachers in B C are female (Ministry of Education, 2001). Occupations consisted of school counsellors (N=7), teachers (N=7), and youth care workers (N=7). Corresponding with all of the 21 participants, seven had graduate degrees, seven undergraduate degrees, and seven a certificate/diploma. Table 2 provides a breakdown of select characteristics of these participants. 41 Table 2. Characteristics of Participants N=21 by School District Characteristic USD RSD Sex Females 8 7 Males 4 2 Age Age Range 33-53 35-57 Average Age 45.5 45 Occupation Counsellors 4 3 Teachers 5 2 Youth Workers 3 4 Education Level Graduate Degree 4 3 Undergraduate Degree 5 2 Certificate/Diploma 3 4 Twelve of the 21 participants worked in an alternate education program within their districts. The BC Alternate Education Association describes the population of these programs as: "a diverse group of at-risk students who have complex social, emotional, behavioural and academic needs" (British Columbia Alternate Education Association, 2002). In the next two chapters I will further discuss the sample of participants from alternate education programs. The actual number of school districts that participated in this research was two. Only participants from one USD and the one RSD consented to an interview. Interview Instrument Interview questions developed specifically for this study were used to collect data. The questions were developed on the basis of the four factors identified by Cervero (1985) and his proposed research model on application of learning following a CPE program. Specifically the 42 questions were designed to explore elements of the four factors: (1) the program (ASK ASSESS ACT); (2) individual characteristics of the participants (school personnel); (3) the proposed behaviour change (suicide intervention); and (4) the environment or social system (school & district) in which the participant works. The interview questions were semi-structured with allowances for open-ended responses. A copy of the interview questions are included in Appendix 3. Pilot testing of the interview questions was done during November and December 2000. Several participants who had taken the A S K ASSESS A C T training, from two school districts other than the ones included in this study, were contacted to be part of the pilot test and three agreed to be interviewed (Table 3). Table 3. Pilot Test of Interview Questions # Occupation Interview Date 1. School Nurse/Educator November 28, 2000 2. School Counsellor December 7,2000 3. School Counsellor December 11,2000 A l l pilot interviews were audio taped. The participants were then given the opportunity to provide feedback about the interview process and to query any of the questions asked. Some of the questions were subsequently revised for clarity and continuity. The pilot testing was a useful exercise in that it also provided me an opportunity to practice asking the questions and to gain confidence in my interviewing ability. Indeed, ten Have (1999) in his book, Doing 43 Conversation Analysis, recommends this practice to improve interviewing quality and to sharpen analysis skills. Following the interviews, thank you notes and Starbucks™ coffee gift certificates were sent to each of the pilot test participants, as a token of appreciation for their time and expertise. Data Collection During November 2000, forty-eight participants were mailed a letter, response card, and a self-addressed stamped envelope, with a request for a personal interview (Appendix 2). Some responses, both negative and affirmative to the request, were received that same year. In January 2001 a reminder card was sent to those who had not responded. This second mailing prompted several more responses. In total nine "yes" responses and five "no" responses were received via mail, and two "no" responses were received by email. I began phoning the individuals who had not responded and as a result of this process and additional 14 consented to an interview and an additional eight did not consent. The most frequently given response from the participants who did not consent to an interview was "too busy." Other reasons included "don't remember the training", "not interested", "no experience with suicide", and, "going on sick leave" and simply, just "no. " Several did not respond to the follow-up reminder that was mailed, nor the phone calls. In total, twenty-three participants consented to an interview. Twenty-one were interviewed and two interviews were not conducted due to scheduling conflicts. Table 4 is a summary of responses. The interviews were scheduled at the participants' convenience as to the time and location. 44 Table 4. Responses of the 48 School Personnel Invited to Participate in This Research Responses Number * Consented to an interview (responded by mail or phone) Declined an interview 23 13 (too busy, not interested, don't remember, etc.) Away or planning on leave (medical, maternity) No response to follow up requests (mail & phone) 4 8 48 TOTAL *Unable to interview due to conflicting schedules 2 Overall there were many barriers to scheduling interviews mainly because of the nature of the school system: time pressures on school personnel, exam time, holidays, professional days, and illness. Most participants informed me the only way to connect with them was via the telephone. I talked to each participant to book a date, time, and location and then I did a follow- up phone call a day or two before to confirm the meeting. A l l of the participants could only respond to phone calls during their breaks, and some had district jobs which meant they were at different schools each day and therefore more difficult to locate. On one occasion I had arrived at a school for an interview and the teacher met me and said he had to cancel because he was leaving for a field trip because the regular teacher was sick. Another school had been shut down on a day when I was trying to contact a participant, because the students were "on strike" and about a dozen fire alarms had been pulled. Fortunately my schedule was flexible enough to accommodate most of the scheduling challenges. Of the three school districts, none of the participants from one of the USD consented to an interview. Therefore, the data collected in this study are from two school districts only. I 45 followed up with two administrators as to the reasons for this non-participation rate. One administrator stated that she didn't believe anyone was "philosophically opposed to participating in the research" but that most school personnel were in a "time crunch" (personal communication, December 12, 2001), therefore confirming some of the "too busy" responses. The other administrator felt that pending job action might have influenced the non-participation rate. In addition, he said his district seems to get a lot of requests due to its close proximity to the University of B C which, in turn, could contribute to research fatigue (personal communication, March 12, 2002). The other factors that might have influenced the response rate included a very public suicide in one of the USDs, and the brewing of labour unrest within the schools. Both topics were front page stories in the Vancouver Sun and The Province over a period of several months. On March 11, 2000 a grade nine student jumped off a bridge and left a suicide note blaming his action on bullying at school (McMartin, Fong, & Skelton, 2000). One of the participants of the A S K ASSESS A C T program worked at the school where the student had attended. There was no response from the participant to either the letter, follow up card, or phone call. In the summer and fall of 2001, prior to any official labour action, newspaper headlines predicted some of the changes forthcoming and the conflict between the Ministry of Education and the BC Teachers' Federation (Hauka & Lazaruk, 2001; Kines, 2001). Official labour action began in September 2001 at which time school teachers withdrew any volunteer activities. Fortunately, all of the data for this study were collected during the 2000/2001 academic school year. However, the brewing labour unrest may have contributed to a few participants not responding to requests for, or consenting to, an interview. 46 Interviews were conducted at the convenience of each participant and usually in their school setting, which included offices, classrooms, and labs. Most of the meeting spaces were quiet and we were uninterrupted, but on a few occasions it was noisy and distracting. Teachers generally do not have offices so we found classrooms or meeting rooms that were not in use. Two of the participants had pets in the room and on one occasion workers were boarding up the windows of the portable as I was conducting the interview (it was the last week of school). A l l of the participants, except one, were welcoming and keen to participate. Often it was the participants that said they did not have much to contribute that talked the most. Participants worked in portables, old and new and small and large schools. In total, 14 locations were visited to conduct 21 interviews, 11 in the USD and nine in the RSD. Most of the interviews were scheduled either during the regular school day, during a lunch break, or immediately after the last class. To accommodate schedules, three participants invited me into their homes after school hours for the interview. Prior to the start of the interview, I explained the interview procedure and asked for written permission to continue the study: all consented and all completed the interviews. As previous with the pilot, following each interview, the participants were sent a note of thanks and a Starbucks™ gift certificate as a token of appreciation. During the winter of 2001, the SD administrators who had granted permission to conduct the study were informed about the research progress and expected completion date. The interviews took on average 36 minutes, with the shortest time of 20 minutes and the longest being 60 minutes. During the shortest interviews the participants did not choose to elaborate on their responses, and during the longer interviews participants told me many of their stories and gave examples. Interviews were audio-taped and I took written notes during the 47 interview. In addition, a log book was kept with notes, comments, observations and travel experiences throughout the process and following the interviews. Data Analysis I transcribed the data from 21 interviews verbatim using a tape recorder and word processor. Data were then entered into the qualitative software program ATLAS. t i to assist with the analysis. A coding system was developed, informed by the qualitative work of Miles and Huberman (1984). The primary focus of this research was to determine what learning was applied following the CPE program and what factors facilitated or hindered the application of learning. Themes and "patterns" as described by Miles and Huberman (1984, p. 216) are "productive as an analysis strategy" with the caution that the researcher needs to be clear that a pattern is indeed apparent and to be open to data that do not fit a category as predicted. With these cautions in mind, it was expected that there would be other "patterns" or factors that were not predicted using Cervero's framework. These other factors might further explain application of learning. Limitations of This Study There are too many variables and complex situations related to application of learning to fully understand the process. Besides the four factors identified, according to Cervero's framework, it is not possible within the confines of this study to discover and explain every psychological, environmental, political, or societal factor related to the CPE and application of learning. The study contributes to a greater understanding of application of one particular CPE program, and hopefully will encourage others to research this under-studied problem. This study 48 has attempted to explain and analyse what learning was applied following a CPE program and to identify some of the factors that facilitated or hindered application. These findings will be directly related to this study but they may also provide insight, through extrapolation, into other CPE programs. The purposive sample of participants is small and the findings are limited to two school districts in BC. The sample included an equal number of teachers, counsellors and youth workers and over half of the participants worked in an alternate education setting. At the time of this research almost 500 school personnel had participated in the A S K ASSESS A C T suicide intervention program, and their experiences following the training are unknown. Several participants who declined to be part of this study gave reasons such as "I don't remember the program, " and "I've had no experience with suicide since the training, " and some "didn't feel they had anything to share." These participants did not volunteer but 21 others did, and even some of those protested they did not have much to offer. There might be certain characteristics of the learner, not identified in this study, that would influence their decision to volunteer as a participant in this research. In addition it was expected that some barriers to application would be identified, and none were found. This perhaps was due to the characteristics of the participants or other factors that were unique to those that volunteered for this study. It may also be expected that this research will offer some insight into the impact of this training on suicide rates. It is not the intention of this study nor is it generally possible to link specific prevention or intervention efforts to reported suicide rates. This argument is best explained in the Suicide Intervention Handbook (1999) and is supported by the facts that suicide rates and reported suicide acts are not necessarily accurate or standardized and suicide intervention training programs are not directed at potentially suicidal individuals, but at possible 49 caregivers. Ramsay et al. (1999) argue that "some aspects of suicidal behavior are subject to factors over which you can have no control" (p. 91). They suggest to further the understanding of application following suicide intervention training programs, data should be collected on "the number of interventions and referrals being made" and "the number of crisis situations receiving a response" (p. 92). These suggestions are achievable and would provide additional data and information about suicide intervention programs: I will further address this recommendation in Chapter 6. Validity, Credibility and Corroborating Evidence Most qualitative research texts include a chapter on validity (Miles & Huberman, 1985, 1994), Woods (1999), and Silverman, (2000). Marshall and Rossman (1995) use the term credible qualitative research and Dey (1993) refers to the validity concept as corroborating evidence. Whatever the term, the challenge to justify what is trustworthy and what is real faces qualitative researchers. McMillan and Schumacher (1997) and others suggest a "combination of strategies" to "enhance design validity" (p. 404). The following outlines the steps taken in this research study to best ensure validity. The research questions were developed with the use of a framework (Cervero, 1985) and then each question was rationalized based on previous research findings. For example, when considering questions regarding individual characteristics, it has been demonstrated that attitudes and beliefs about suicide intervention can influence application of learning. Questions of this nature were then included in this research. Once the questions were developed, three pilot tests were conducted which allowed for participant feedback and revision of some questions. The subsequent set of semi-structured questions were used in each of the 21 interviews. 50 McMillan and Schumacher (1997) recommend "prolonged and persistent field work, mechanically recorded data, member checking, and negative cases or discrepant data" (p. 405). In this study it took six months to interview the participants in a dozen different locations throughout two school districts. Interviews were conducted at the convenience of the participant and I ensured (to the best of my ability) that the environment was comfortable and distraction free. Each participant offered informed consent and I was considerate of the time we agreed upon for the interview. I used a tape recorder, with permission, and it was unobtrusive during the interviews. During each interview I had a paper copy of the questions and I took notes throughout. I later referred to these notes for accuracy during transcription. During the interviews participants asked for clarification of questions and I asked for clarification of answers. Immediately after the interview I marked the cassette tape with the interview ID, date and location and I made additional notes on the question sheets. After one of the interviews I asked the participant i f I could send him a copy of the transcription for feedback and a check for accuracy and he agreed. He had provided some confidential information and we mutually agreed that he would look at the transcription before I included it in this paper. I received the transcription back with no changes other than deleting a reference to a community agency to ensure anonymity. McMillan and Schumacher (1997) recommend this "participant review" (p. 407) technique for all transcripts. However, I experienced such difficulty in obtaining interview time from the participants that I felt this step would overburden them. Therefore, I did not ask for more participants to review their transcripts. I would recommend this technique in future research. In addition, all of the data that were contrasting or discrepant were recorded and reported on in this study. For example, one participant out of 21 did not apply learning and there were contradictions in how participants' perceived administrative and school district support. 51 Each interview was transcribed verbatim into a word processor. During the transcription I played and replayed any word or phase that was not clear until I could accurately identify it. At this time I also referred to my written notes I had taken during the interviews. After each document was transcribed I checked it for accuracy before it was prepared for input into the qualitative software program, ATLAS. t i . A code book was developed and before I began coding in ATLAS. t i I coded the transcribed documents by hand. As I was coding in ATLAS. t i I rechecked the coding and made corrections or adjustments as necessary. Woods (1999) suggests to check on findings that are not clear or complex (p. 103). Throughout this process, beginning from the preliminary stages of data analysis, I began to record some early thoughts on the findings. I talked to a colleague about some of the themes, patterns and links I was finding in my data. She offered me thoughtful feedback and helped me process my ideas. I was able to think about and rethink my ideas by drawing and redrawing graphs, circles, boxes, arrows, and words. I had the opportunity to talk to several other students and recent adult education graduates who were interested in my work. Their feedback and comments were useful and challenging throughout this time. I also submitted three proposals to different scientific meetings on the preliminary results of my research. This task deepened my understanding of my findings and further challenged me to re-think some of my analysis. Dey (1993) prompts researchers to consider how we "observe" and were the data "unprompted, or in response to a question?" (p. 224). In this research I collected the data directly from the participants, and I was responsible for the tape recording and transcription. The participants responded to a set of semi-structured questions and there was opportunity for unprompted responses. Indeed, one participant asked me how much "room" I had on the tape 52 recorder. He was anxious to tell me about his frustrations with the school system and why he was leaving the school district. Once all the data were collected, I began "counting" as recommended by Miles and Huberman (1994) to "see what's there" (p. 245). It was easy to see when 21 out of 21 said the same thing or when one responded "no" to a question and all the other 20 reported "yes." What was more difficult was to determine meaning when the numbers seemed meaningless. This challenge was met by looking more closely at the data, and then by stepping back and further processing the findings. Summary In this chapter I have discussed the following details about the qualitative research design including; the length of time between the CPE program and data collection to provide an opportunity for application of learning; the purposive sampling technique of CPE participants; how the sample was invited to participate in an interview; the development of the interview instrument based on the four factors of Cervero's (1985) model; details about the interview process; coding and analysis of data using the qualitative software program ATLAS. t i ; the limitations of this study; and the process I undertook to best ensure validity. In the next two chapters I will report the findings and discuss my interpretations. 53 Chapter 5: Findings I'm advised usually by a student or staff member that there is a problem with a student who is considering suicide to some degree or another and they require my help. At this point I will discuss with the student what may be of concern to them, try and settle them down and see... make an assessment as to whether or not I should intervene by calling in an outside agency. So I act as kind of a gatekeeper to the process. I am able to walk away from this job each day knowing that life has improved for somebody because of my abilities or my concern and I know I've been instrumental in turning some kids lives around. A S K ASSESS A C T Participant May 2001 The primary focus of this research was to determine what learning was applied following the A S K ASSESS A C T CPE program and from the participants' perspective what factors facilitated or hindered the application of learning. In this section, I will present the findings based on the characteristics of Cervero's (1985) framework, adapted for this research, of the four factors: (1) the program, (2) the learners or individuals, (3) the proposed behaviour change, and (4) the social system. While Cervero has provided the framework, he does not specify which elements to consider that would influence application of learning: these elements are specific to the content of each program. In this study, the literature search was utilized to identify the elements that would most likely influence application of learning as either a facilitator or barrier. In turn, several elements were derived for each factor and were used to develop the interview questions. The elements of each factor, shown in Table 5 are: (1) the program - involvement in program planning, handbook use, motivation to do other activities as a result of taking the program, ordering additional materials, realistic scenarios, and relevance; (2) the learner - age, sex, occupation and length in occupation, additional training after the CPE program, personal belief in suicide prevention, personal responsibility for intervention, confidence level, voluntary 54 attendance at CPE program and an unexpected element, readiness for learning; (3) the proposed behaviour change - skills, knowledge and information; (4) the social system - accessibility of services, perceived administrative and school district support, change after the CPE program, parental involvement, having a suicide intervention protocol and opportunity to apply learning. Table 5. Elements of the Four Factors of Cervero's (1985) Framework Factor Element Factor 1. The Program Factor 2. The Learner Factor 3. The Proposed Behaviour Change Factor 4. The Social System Involved in program planning Handbook use Motivation to do other activities Ordered additional materials Realistic scenarios Relevant program Occupation & length in occupation Additional training after the CPE program Personal belief in suicide prevention Personal responsibility for intervention Confidence level Voluntary attendance at CPE program *Readiness for learning Skills Knowledge Information Accessibility of services Perceived administrative & school district support Change after the CPE program Parental involvement Suicide intervention protocol Opportunity to apply learning *unexpected element 55 Factor 1: Characteristics of the Program It was expected that certain elements related to the program would influence application of learning. In Chapter 2, the CPE program A S K ASSESS A C T was analysed and discussed regarding its content and instructional techniques and how these were designed for learning and to influence application of learning. In this section, the elements of participants' involvement in program planning prior to the course, handbook use and motivation to do other related activities following the CPE program, and their perceptions of how realistic and relevant the program was, are considered. The other elements considered to influence application were how participants used the handbook given out at the time of the training, how the participants perceived the realism and relevance of the program, if participants ordered or obtained additional resource materials, and if the program motivated any other involvement in the school or community related to suicide intervention or awareness. Such activities include additional training, joining or establishing a committee, or working on the school protocol. Approximately one-quarter of the participants (N=5) were actually involved in an aspect of the program planning activities prior to the workshop, which included the selection of the topic and more detailed planning such as booking the facility. Seven reported they did not receive the suicide intervention handbook. Eleven participants reported using the handbook, and how they used it was limited to perhaps once in the three years since the training. One participant commented "I haven't even looked at it, typical, when do you have time to do that? " Only three participants were motivated to do other activities as a result of the workshop. The activities mentioned were working with a community group and working with peer helpers on suicide awareness. One participant attempted to form a school committee but: 56 Basically nothing happened - overcoming inertia in the school is really difficult, when you talk to people it's yes, yes, yes it's really important that you 're okay and when can we get together and do this, well, I'm pretty busy. When asked if they had ordered any additional materials or resources related to suicide intervention most had not. Some responded by saying there were already "brochures right at the entry to our program - they 're right on the wall outside the counsellor's office. " Others mentioned they brought resources from other jobs, or "I've xeroxed a few things, " and "I was going to order the CHOICES video but I ascertained that the district had it anyway." One participant said "we don't even try because we believe there is no budget. " Of those who responded they had bought or obtained resources two were at no or low cost such as "I made my own, " and "I get as many as I can through the community program — I often go raid their walls. " Finally one participant summed it up as "we seem to be having a problem with monetary support." For many participants this was the first time they had taken a suicide intervention training program. Sixteen years was the average length of time in their respective occupations and many had been in the school system for a much longer time. In addition, specific suicide intervention training is not necessarily part of any professional program for school personnel. In the University of British Columbia teacher education program, students get "very general information" about suicide and often the topic becomes part of the curriculum because of student interest (personal communication, July 10, 2002). Therefore, for the first time, some experienced counsellors had learned and were applying a systematic suicide intervention model. One participant commented on how this had changed his practice: "the need to ask the question 'are you planning on killing yourself,' that was major, that was a major turn around for me, big time." 57 Furthermore, the program appeared to alleviate some fears about the topic of suicide and the intervention process. Indeed, one A S K ASSESS A C T participant made the statement during the training that asking about suicide is "just not natural." Several participants in this study made similar comments, such as: I have learned to ASK and to have no qualms about doing that and knowing how to do that I think something the program has done for me is made me not afraid to ask ASK ASSESS ACT, the steps, validation, courage to do that, it took the fear away, I'm not afraid of asking the question During the interviews, others seemed humbled by the magnitude of the issue. Several commented on how the program covered such "an important issue, " and several mentioned how "big" an issue it was "because it's not like anything else - it can be the end right? " Although not specifically asked about, several participants compared their positive experience with the A S K ASSESS A C T program with previous negative professional development experiences. "I've taken workshops that have nothing to do with my job...aromatherapy 101 ...I need to be doing something relevant, " and "I never went to Pro D Days. " Somehow the topic of this program encouraged these participants to register. The elements of realism and relevance. The elements of realism and relevance support the notion that learning and application will more likely occur is connected to Knowles (1980) assumptions about adult learners. He proposes that "adults are motivated to learn to the extent that they perceive that it will help them perform tasks they confront in their life situations" (p.57). In this study, seventeen participants perceived the program scenarios as realistic and 20 rated the program as relevant to their work. 58 The question asked during the interviews was "Did the A S K ASSESS A C T program portray realistic school scenarios?" Seventeen of the 21 participants answered affirmatively and four responded that they didn't remember. Some of the comments given about their perceptions include "the video was great and the role playing too ", "I remember the conversation and the dialogue was helpful, " and "I remember thinking it was useful, and yeah, oh yeah, absolutely. " When asked the question "Was the A S K ASSESS A C T program relevant to your work in the school system?" all, except one of the participants responded "yes. " The one participant that responded "no " gave the reason "because boundaries, professional boundaries are set in our program very, very stringently. " As a teacher she could not ask a student directly about suicide. However, her obligations, as defined by "professional boundaries " were to report or refer a potentially suicidal student to the school counselor. She went on to say that she did use the risk assessment tool "outside of the school" and that no one could stop her from asking questions "walking to the bus or whatever then I can talk to them anyway I want and you know, I've had a kid say to me well, you tried to make me feel better 'cause I was about to kill myself. " Many of the comments reflected the reality that teenagers can be at risk of suicide and 12 out of the 21 participants worked in alternate education programs which may have more "at risk" students. Statements included: "I deal with high risk students "; "I was working with very high risk age groups "; and "there's always kids having suicidal ideation." Others commented on the fact that the program provided them with tools or skills for their work: "it was a practical application and practice "; "it provided a model for me "; "it helped me through a few situations with some kids who have wanted to commit suicide"; and "relevant in a sense that yes, with regard to being prepared and having knowledge. " Others reported using the suicide intervention skills immediately or soon after returning to their classrooms. Further in this section, I will 59 demonstrate how the program elements of realism and relevance, combined with the learner element of readiness for learning facilitate application of learning. When asked about the "one thing" participants identified they took away with them from this CPE program the following items were mentioned: assessment tool; warning signs, better prepared; confidence; encouragement; and, heightened awareness. Others added these comments: "It made me not afraid to ask and to not be afraid of suicide per se or suicidal ideation or someone else's angst that would bring to a place that they might be feeling suicidal, " and finally with optimism "there is something you can do. " It is likely that all of these elements would facilitate application. Factor 2: Characteristics of Learners In Chapter 3 it was suggested that certain characteristics of school personnel, such as experience (length in occupation), would influence the application of learning. The number of years in their respective occupations ranged from five to 28 with the average length of 16 years. However, one participant commented that she had worked in the school district "oh, forever." This interview took place on a Friday afternoon at the end of the school day and she appeared tired and frustrated. Several participants expressed frustration and I will discuss this in Chapter 6. Other characteristics considered in this study include additional training, belief in prevention, confidence level, readiness for learning, responsibility for suicide prevention and voluntary attendance at the CPE program. The characteristics of participants in both the USD and the RSD are very similar. As expected, all participants had post secondary education including undergraduate degrees, followed by graduate degrees and a certificate or diploma. In addition, two teachers were in the 60 process of obtaining a graduate degree. There were three characteristics of learners that all participants shared: they all responded "yes " to the questions "Do you believe there are things you can do to prevent suicide?" "In your position do you believe suicide intervention is your responsibility?" and "Did you attend the CPE program voluntarily?" The elements of beliefs and responsibility are expanded on further in this section. With regard to voluntary attendance, the following comment sums up most responses "It was a voluntary thing, I wanted to be there. " Most participants, reported they felt as a result of the program confident, very confident or extremely confident that they could identify warning signs, assess the risk and get help for someone who was suicidal. Some of the comments included: A feeling of confidence that I would be able to actually help. There was more confidence, a self confidence to do risk assessment, I believe that. Ifelt a lot more confident and comfortable in dealing with suicidal youth. It made it more comfortable to know that you had a little bit more, a little bit more competence. With regard to additional suicide awareness or intervention training since the A S K ASSESS A C T CPE program, 13 of the participants did not take any further training, five took a half-day workshop and three attended two additional days. The additional training was taken "at a conference", "in the district" and "in the community. " "No, because it hasn't been offered" was a common response and most expressed a desire for additional training and that they would like their school district to offer it. Again, without specifically asking, 18 comments were recorded with requests and suggestions for additional training or a refresher course on suicide intervention. Some of the suggestions are as follows: 61 You need to keep going back for the refresher that's what I think about the suicide prevention, because you don't use it enough that it's like second nature to you. I think it should be a constant updating. Like, there should always be, we should be accessible to a workshop at least once every six months or one a year because a lot of it you forget or just kind ofpass over you get busy right, I always feel it needs to be updated. Even if it's a half day thing that we 're up to date and brought around to it again, even like six months, eight months, or even you know beginning of the year - September. In the next chapter, I will compare these comments, which I perceive as a need, to the reality of what additional training is occurring or is currently available in the school system. Readiness for learning. One unexpected characteristic observed during the data analysis is what I will refer to as "readiness for learning." It became apparent after nine participants mentioned how, during the CPE program, they had been thinking about a student who might be suicidal, or who had been suicidal. Some of their comments included: It was a hot topic in our district because of things that had happened recently. I had been involved with children who were expressing suicidal inclinations... I had dealt with them and I felt almost overwhelmed by it... not quite sure what to do and so I took the training. All the time we were doing the [ASK ASSESS ACT] program I was thinking, Ijust gave myself more permission to admit out loud what I'd already been witnessing and seeing. This element appears to be connected to application of learning because of its link to the learner characteristic of "motivation." In addition, seven participants indicated that they had applied the learning almost immediately upon return to their school: "Istarted incorporating right the next day, " "it was right after I experienced a very severe situation, " and "we came back right away 62 and started you know listing off people that we thought were actually in the zone. " I will discuss this element, readiness for learning, further in the next section. Beliefs about suicide intervention responsibility. Another characteristic of these participants is their attitude or belief that they can prevent suicide. As mentioned, all of the 21 participants stated "yes " they could do things to prevent a suicide. Related to this attitude are participant beliefs that suicide intervention is their responsibility. This finding is similar to King et al. (1999). Again, all of the participants felt it was their responsibility but a pattern emerged that seem to differentiate the responses, into two categories, as follows. Nine participants made comments, without hesitation, which I will refer to as altruistic responsibility: this concept appears to demonstrate a level of commitment to their work and exceeds the responsibility of a job description. A sample of these comments include: / think it's my responsibility as a conscious, caring human being. I would say just in a general social being it's your responsibility. I think it's one of those things like people that take CPR courses...it's something that everybody should be able to know and try and be at least on the alert for. I believe it's every adult's responsibility, yes absolutely. Well, I mean it's like giving blood. You know, if I can save somebody's life, you know, by all means. The other participants qualified their responsibility in suicide intervention with a "yes, but" and were more cautious in their responses. For example, this group mentioned it was a shared responsibility as part of a team, "as far as I am mandated, there is only so much we sometimes can do, but certainly it is a very important part of my job. " 63 Factor 3: Characteristics of The Proposed Behaviour Change What behaviour, change or learning is expected that participants will apply? In this CPE program it is expected that participants will learn suicide intervention skills and apply them in their workplace. As previously demonstrated, there are suicidal youth in the school system. Dealing with a potential suicidal student or wondering i f a student might be at risk of suicide has been the experience of many of the participants. Despite some of the negative connotations and fears of suicide, and as one participant mentioned "it's a hard topic to sell," it appears that the participants want and need to learn "practical skills, professional practical skills " of suicide intervention as evidenced by the following statements: To alleviate the fear of the unknown and to give me a better understanding and to augment my participation as a member of this team. I wanted it to be better skilled, skill development and working with the kids, and not just the kids, working with the other professionals, very important and I thought if we came up with the same language around this then we would be so much clearer. In total, 16 participants made comments about their need for suicide intervention skills and I have summarized all comments into two components: (1) knowledge "data, statistics, and information (suicide warning signs) "; and (2) skills, "tools and strategies " as the motivation for taking the program. Participants identified "skill development" as a reason for taking the A S K ASSESS A C T CPE program to "keep the kids safe" and "to be more effective with the students. " One participant had not taken any professional development on the topic of suicide for several years and he wanted to be brought "up to a current standard. " A summary of these two components are shown in Table 6. 64 Table 6. Suicide Intervention Knowledge and Skills Desired by Participants Knowledge Skills Data Statistics Information (warning signs) Better understanding The same language Strategies Practical skills Tools To keep kids safe To work with others Factor 4: Characteristics of the Social System Cervero's (1985) model refers to the working environment (school and district) as the social system. In this section, elements of the participants' social system are considered that might influence the application of learning. Based on the premise that this system (school and district) is perhaps the "most powerful yet overlooked variable," a series of questions were designed to ascertain how the participants perceived their social system (Cervero, 1985, p. 87). The responses to these questions are woven throughout this section and contribute to the analysis of how the elements of this factor facilitate or hinder application of learning. Participants were asked to "describe the school you work in - your first thoughts please." Four participants, all from the RSD, responded immediately with laughter, and then proceeded to describe their school. I will attempt to interpret this laughter in the next chapter. Once the interviews were concluded a pattern emerged that these descriptions seemed to fall into one of The schools. 65 two categories, either (a) descriptive which included factual information about their work or their school or (b) affective, participants feelings about their school and students. Comments ranged from "it feels like a family" to "fairly low morale, " and from "the kids seem quite happy" to "some days it's very high anxiety and violent. " The descriptions of the schools are almost as varied as the participants. The following comments offer some insight into the school system in which the participants of this study work: (a) descriptive It's an 8-12, 1700 students, low socio-economic, high ESL, inner city high school. It's a treatment program with a school component. We do a lot ofpreventive stuff at this school, at the beginning level, right at the beginning. I'm on the road a lot, I'm in between all the communities and I have a pager and I go, I do a lot of crisis intervention type stuff connecting with kids who have dropped out. The school serves 18-20 children who for reasons are unable to function in the mainstream who exhibit learning problems or disabilities or and/or exhibit behavioural challenges and that don't Jit in the mainstream. (b) affective It's a comfortable community, the kids seem to be quite happy you know it's just a nice school environment. I'm really proud of what we do, I'm really proud of the school. Friendly administrative team who put kids first. The really great thing is that it's small, warm and caring. I work in a school in which there is very little collaboration and fairly low morale. We've suffered from years ofpoor leadership, there is a general apathy, people basically do the minimum and then go home. It's awesome, I think it fulfils a huge amount of needs. 66 I really enjoy it here. I've been given a choice of moving, and I've chosen to stay here and work with the staff and administration because I think it's a great place. We have a lot of good people in our school, it's a great place. It's safe and very caring and stable. The kids are very appreciative - a lot of them, the kids want guidance, the staff really seem to care. Overall, participants seem to like their work and one described how her school acts as a positive role model for students: Immersion, appropriate behaviour. They come in and they constantly see people treating each other with respect, we 're all role modelling just our appearance, how we speak to each other, our organization, things are tidy, things are clean, so just like French immersion, you 're immersed in French, well you 're immersed in good behaviour, preventative measures, if we dish out 200% and they take 20 away then that's a win win. It is within these school settings, all participants, except one, applied learning and were involved in various degrees of suicide intervention. It was predicted that accessible services, administrator and school district support, parental involvement and a suicide intervention protocol would all positively influence application. Two-thirds of the participants reported their services for potentially suicidal youth as "accessible " to "extremely accessible " and the other third, all from the RSD, reported services as "somewhat accessible. " Participants from the RSD were also most frustrated with this situation in contrast to participants from the USD who were mostly satisfied. Some of the comments from USD participants included "there's nobody " and "we don't even have a child psychiatrist here. " Most perceived their administrator was supportive of suicide intervention efforts in their school, a few did not know and one responded that the "principal is not supportive." While the majority of participants (81%) perceived that they had administrative support, fewer participants (62%) perceived that they had school district support. Administrative support was most often 67 described as "resources to go to the [ASK ASSESS ACT] training, " and "providing resources to hire a TOC [substitute teacher] and pay for a course. " Others mentioned their administrators had confidence in their abilities and "would ask our opinion " and "support decisions " with regard to potentially suicidal crises. Three participants responded they "didn't know" i f their administrator was supportive of suicide intervention efforts, and seven responded they "didn't' know" i f their school district was supportive. Typical comments regarding these responses were: "they don't hold me back"; "no one's really pushed it"; and, "they 're not standing in my way. " One of the questions asked of the participants was if they had noticed any change in their school after the CPE program. Fifteen said "yes, " four said "no " and two didn't know. Most of the change seemed to be in the area of "heightened awareness " and "more open to make sure we weren't missing things", "people talked more consciously about it" and "things have improved. " The following comment illustrates some change in the school after the CPE program: Yes, people talked more consciously about, what do you think? Do you think this is ... ? We did a lot more assessment and then we encouraged one another to ask, right from that time on, has anybody asked? That's like part of our language now, has anybody asked directly, have you talked to this child directly? We do it all the time, it's really neat. In contrast, one participant said "well I don't think it was business as usual, but I don't think that the earth moved either." This element of change at the school level may have implications for understanding application beyond the individual level, which I will discuss in the next chapter. Parental involvement in the schools was generally reported as none to low except in a few of the alternate programs, where there was "high involvement with our parents, we have contact with our parents almost daily. " The importance of parental involvement in a suicide intervention is demonstrated in an example at the end of this section. Parental involvement, or at 68 least informing the parents is part of all school protocols and policies in BC. Participants were questioned if their district or school had a suicide awareness and intervention program for parents. Four said they "didn't know " and the rest responded, "no", "not that I'm aware of", and "I don't believe so. " When questioned further about their opinion i f there should be a program for parents many responded "there should be" and offered the following reasons: / think that parents definitely need a little bit more awareness. I think it's a good idea. It shouldn't be for just the parents but for the community out there. Others were not as optimistic and stated that "They won't come -1 think we have to work with what we've got and that's the kids " and "you know so few parents would likely take advantage of it is what my concern is. " One gave an example of a typical Parent Advisory Committee meeting where "5 parents out of1300" attend. Two other participants felt it would be a good idea with the provision that a program for parents be carefully planned and implemented as outlined in the following comments: / really want to be cautious about introducing a school culture to suicide but simply because of raising the awareness and some of the consequences of that -1 don't think it's a bad thing it has to be done in the right way. I don't know if any parents would go to a training on that, like, that's like admitting that you 're not being a good parent because your kid wants to die, like why would you go. I think it has to be community based, it would be far better if it was community based - awareness for all people. At the time the interviews were being conducted in the USD there were a series of suicide prevention forums being offered to community and school members. Notices of these events were posted on the school bulletin board. The participants seemed unaware of these events. It was proposed that having a suicide intervention protocol (either district wide or within the school) would likely influence application of learning. The number of participants who 69 reported having a current protocol was five, three responded "no " and 13 "did not know. " The number of participants who reported having a protocol at the time of training, was three, eight responded "no " and ten "did not know. " Several participants expressed frustration at not being able to participate in the development of a suicide intervention protocol: "It's like there is no time, there is more and more loaded on the curriculum. " Another participant mentioned: "I have talked many times you know we should really look at the protocol but there's no time, we 're always getting into crisis about a kid, we need to, I wish we could do something this summer when we 're not working with kids, I wish we could get paid to spend time doing stuff like this. " The fact is most participants do not know or believe there is a current protocol and this has stayed constant since the initial CPE program. Alternate education programs. As reported earlier, over half of the participants worked in an alternate education program. Some of the participants described their work in the alternate settings and the challenges to them and their students: They are moderate to severe behaviour, not all of them are severe behaviour, academic, at risk students. It's day to day life coping skills for the kids. The alternate program doesn't fit into the regular school - they try to but it really doesn't because what we 're working on with our kids in here they can't access in the school because in the school it's strictly academic and learning. In here we are trying to get them to work on how to fit in a group. It's really hard. I've noticed from discussing it with other alternate programs and not just in this district, generally speaking everybody is getting more disturbed, at risk dysfunctional kids and families. One participant expressed his views and experience in the alternate education program as: "The current system as it is very destructive to children and we 're seeing more and more signs of that. 70 What I do in here [alternate program] is mostly make up for the mistakes of the system." He further stated that "these kids are not the real problem." Another participant made a similar comment "nine out of ten times when there is a problem in the school or with the kids it's the problem originating at home. " He strongly believed that parenting information and additional education and support for parents was needed. In the next chapter I will discuss some of the implications of the alternate education program on application. What Learning Occurred? Did the participants in this study learn the concepts necessary to apply the proposed behaviour change? It appears they did learn the basics of suicide intervention. This was determined by first asking them to describe the term 'suicide intervention,' and then asking them to describe what they remembered about the A S K ASSESS A C T CPE program. Upon careful coding and analysis, it became clear that the concepts, in most cases, had been retained several years after the training. In this section, what learning occurred and how was it learned will be discussed. The main learning objectives of the A S K ASSESS A C T Suicide Intervention Training Program (outlined in Chapter 2) are to identify potentially suicidal students, ask about suicide intent, assess the level of risk and seek appropriate help. It is expected that this learning will be applied and this is what Cervero's framework refers to as the proposed behaviour change. Part of this research is based on the assumption that learning did occur after the A S K ASSESS A C T program and findings in the 1998 and 1999 program evaluation reports indicate that there were immediate learning outcomes (Haw & Andres, 1998, 1999). Increased knowledge, observable suicide intervention skills, and a shift in attitudes were all measured (throughout the training) 71 using pre and post test questionnaires and participant observation. The challenge in this follow- up study was to record participants' responses about content presented at the workshop three years prior, and to identify what learning had occurred. A l l of the concepts of suicide intervention that were taught during the A S K ASSESS A C T CPE program were mentioned several times during the interviews. The concepts include: asking about suicide; assessing the risk of suicide; responding to a potentially suicidal student; suicide warning signs; and suicide risk factors. To further illustrate what learning had occurred, the following statement made by a participant demonstrates the CPE program content of A S K ASSESS A C T . This statement was made when the participant was asked to recall the workshop and to define suicide intervention: ASK Essentially that you investigate the situation by asking what the circumstances ASSESS are, and then you assess the situation by noting certain flags that go up in terms ACT of the severity of the situation and then follow through to an outside agency or if there is not a significant threat to the student's life I would monitor the situation. Another participant described dealing with a potentially suicidal student who had made the statement "I wish I wasn't living." She found out the student had a suicide plan and she continued with, "yeah, I do feel that the training helped with that [asking about the plan] but when you 're saying reflect back what did I get from that day well I did get that. " Learning to ASK about suicide. One of the salient components of the A S K ASSESS A C T curriculum is teaching about the importance of asking directly about suicide. Twelve out of the 21 participants highlighted this component as key learning for themselves, and how the program had given them "courage " to "ask the question, are you planning on killing yourself? " One participant believes that her 72 V "confidence in asking direct questions probably saved those three kids. " A typical example of what happens in a school is explained in this comment: It was the question, ask the question, I think it was the most important thing you learned, I mean everybody kind of pitter patters around it, and in the end after you've pitter pattered around it you must need to ask it and really call it really straight. Another participant made the comment: "I've learned to ask and have no qualms about doing that and knowing how to do that and doing it. " She further explained that one of the changes in her school, following the CPE program was: We encouraged one another to ask, right from that time on, has anyone asked? That's like part of our language now. Has anybody asked directly, have you talked to this child directly? We do it all the time, it's really neat. How did learning occur? In this section, I have drawn on the discussion from Chapter 3 about learning theory to help explain how learning occurred. During the interviews the participants talked about their learning and how they recall the learning. Some used a metaphor to describe what they had learned, for example, "itputs a better card catalogue in my head" another compared learning as "added to a bank of information " and others described how they built upon past learning and experiences. I have categorised the comments into general themes that seem to best fit their experiences of learning using their own words as "schemas" or "templates" (Johnson & Pratt, 1998, p. 84-85) such as "bank of information " and "card catalogue " as a way to "connect the dots" to construct knowledge as described by Fogarty (1999, p. 76). From these statements, I have identified the following categories or themes, in Table 7, as banking information, building blocks, cues, internalized learning, and past experiences/practice. 73 Table 7. Understanding Participants' Learning Theme Participant's description of learning Banking I guess it's probably like a lot of things that I do, I take it in and Information it's added to my bank of information. Building Blocks 'Cause there's a lot of information and every time you have it you get new information out of it and you learn something new. I've done a little bit of reading here and there over the years and it's sort of like just a compilation of whatever I've perceived as important. Cues When I hear actual stories it puts a better card catalogue in my head so when a situation does arise I'm able to pull out certain cards, if you will, on how to react or how to read what a kid is reading when they are at risk. When you say the ASK ASSESS ACT, then I go wait a minute you know, I know that it's there. I internalized whatever it was that was there. When it's personalized and it's your stuff, right, your stories or whatever then it's more meaningful. I think that actually the information passed on through the workshop itself is integrated into mental thought processes that we have. There's just stuff that just sorts of sits in your head. To sit down and do a role play through a situation I find kinda fun to do, cause that takes all your past experiences and talents and you get to reapply them to what you just read. We can always imagine things that are perhaps more accurate but you know you don't need to have it absolutely correct in order to transfer that knowledge to our own environment here. I've had lots of training in suicide intervention including when I worked for victim services and they've all sort of run together. I've picked up little bits of training everywhere and this just sort offit in with other stuff I'd learned. Internalized/Personalized Learning Past Experiences/ 74 Did the mnemonic strategy help learning? As mentioned in Chapter 2, a memory device used in the A S K ASSESS A C T program was the first aid acronym CPR. This concept was borrowed, with permission, from another suicide intervention program and it was expected that most participants would remember and use this risk assessment tool. In actuality, not one of the participants interviewed mentioned the CPR concept. It was evident that the participants were referring to a risk assessment model but not by the mnemonic used at the time of the training. References were made to plan, resources, and assessment, all components of risk assessment, but no one made a specific mention of CPR. What participants seemed to use the most as a memory aid for risk assessment was the title of the program, A S K ASSESS ACT. The program title was not intentionally used as a mnemonic strategy but it appears to be so in many cases. The following are some of the participants' comments: "Definitely the title, excellent because I remember that, " and "what I remember the most important and I've kept is the title ASK ASSESS and ACT. " Opportunity to Apply Learning With regard to application of learning, which Cervero (1995) refers to as the proposed behaviour change, and in this case, suicide intervention, all but one of the 21 participants indicated that they had experienced an opportunity to apply the learning. Previously I reported one participant claimed the program was not relevant to her work in the school system because "professional boundaries " prevented her from asking students directly about suicide. She could and did, however, refer students to counselling i f she believed they were suicidal. In addition, she reported applying suicide intervention skills in her community work with youth. This participant has been included in this section as reporting "frequent" opportunity to apply 75 learning. The question asked regarding opportunity to apply learning was "Since you have taken the A S K ASSESS A C T program how often were you in a position to respond to a potentially suicidal youth?" One participant reported "no never" and all others reported an opportunity. The participants quantified their responses to their reported opportunity as follows: 1) frequently, up to 20 times per year; 2) regularly, as ten to 12 per year; 3) occasionally, approximately once per year; and 4) rarely, as once every few years. The participants who reported that they "rarely" or "never" had an opportunity to apply suicide intervention skills were all teachers or youth workers. It would be expected that school counsellors would have more opportunities because of the nature of their work, and indeed all seven counsellors reported opportunity ratings of occasionally, regularly, and frequently. Of the participants who reported frequent opportunity, two were counsellors, one a teacher, and one a youth worker. These participants also shared most of the elements of two factors: program and learner factors, including high confidence level, readiness for learning and involvement in program planning. It can also be assumed that the factor "proposed behaviour change" influenced application because all participants voluntarily registered to take this CPE program to fulfil a perceived need in their professional lives. In addition, as previously mentioned all participants believed that suicide prevention was their responsibility and that there are things they can do to prevent it. An example of application of learning. The following account of a suicide intervention in a school in British Columbia was told to me during one of the participant interviews. It has been edited slightly for clarity and anonymity. It demonstrates how the learned concepts of suicide intervention were applied. Learning a concept does not automatically mean application. As previously stated, the variables 76 of a participant's characteristics, the program (ASK ASSESS ACT), the school environment, and the expected behaviour change (suicide intervention) all work together to influence application. This following interview demonstrates how the combination of the participant's characteristics (experience as a school counsellor), practice and learning (the A S K ASSESS A C T program) facilitated a suicide intervention (application), in this unpredictable situation (within the school environment). I asked the question "could you tell me about your involvement in a suicide intervention after taking the A S K ASSESS A C T program?" The interview proceeded as follows: The situation involved a grade 12 academic student who was found - that she's cut her wrists and was in the girls' bathroom. Found by a student - the student, her friend, brought her to her classroom teacher who was distraught. She was brought to the counselling centre with her wrists that had been cut she was taken to the medical room and was quieted down The counselling intervention was to discover what was the cause - what would be the course of action. The presenting student had no stated previous hurting that the counsellor was aware of so the child was kept in the nurses' room and quiet, parents were contacted, father came and it was discovered that it was an incident to hurt herself and that she had had previous attempts at suicide before but that was the first we knew about it. A suicide intervention worker was called and a risk assessment again done and interview done and it was discovered that the nature of the self inflicted injury was a few things, pressures in school, pressures to succeed, some family difficulties but on the whole the family was a professional caring warm group that were there to support her. It did come out that she was setting high standards for herself. The counsellor from the suicide prevention team and the counsellor at the school, myself, worked with the girl to get to the root of the issue, the bleeding had stopped, it wasn't serious, she calmed down, we discovered that it was an issue with the boyfriend - a break-up, got the boyfriend, interviewed the boyfriend and at that point the dad arrived and the girl was in with the boyfriend who she'd broken up with, that was discontinued because it was argumentative, we didn't feel it was therapeutic. She was isolated and then ran - ran away. Her dad and the administrators attempted to find her in the school and did, and we worked as kind of a team, it was an interesting one, the vice-principal worked with the girl - sat her down, got her calmed down finally, the other vice-principal worked with the boy and that was quite an angry situation, and I worked with the dad with the suicide outreach worker. It was determined that she was fine, she was released into custody with her dad and he was going to take her to the family doctor. It was then discovered that she was under 11 psychiatric care. But the intervention, suicide intervention part of it was the questioning techniques and doing a risk assessment, probably that was the kernel of the whole exercise because we had to determine in a short space of time, what were we going to do: was she going to be going to the hospital, was she going to go to a community agency, or was she going to be released into custody with her dad. Certainly the training in the crisis response, the suicide crisis response gave us a format in which to ask questions to determine the level of risk. The suicide prevention worker and myself worked in tandem and it was such that, it was decided as such that it was safe and she would go back with her dad, and receive ongoing counselling and support from the psychiatrist and from the crisis response team. Short term, there was one other incident about two months after that where she was cutting her self again, and the same process was involved, she was more subdued, and it was more of a self-injury as opposed to a suicide attempt, but the same process was followed, her dad was brought in she was calmed down. Long term she's back in class, she's attending, she'll graduate and she's getting long term help. I think the number one salient point is the risk assessment - that's key - that was key right through it all and I got the letter from the parents how thankful they were for the timely and professional response that helped their daughter in the midst of a pretty difficult situation - if you can imagine in a high school a girl walking down the hall with wrists...it was like Carrie [teen horror movie]. While this example represents the application of learning at the individual level it is evident that suicide intervention relies on others in the school and district working together. Several participants have previously mentioned the need for a shared common "language " and the skills to work together in a potentially suicidal crisis, and indeed some individuals report a change at the school level. These findings emphasize the best method to facilitate application of learning is to train teams or entire schools and not just individuals within the school. Summary In this section I have presented data that were collected during 21 interviews of school personnel in British Columbia during the 2000-2001 academic school year. Cervero's (1985) framework was used to present the data based on four factors identified as facilitators or barriers to application. Within these four factors, many elements appear to influence application and 78 have been so identified. Included in these findings are several sections on what learning had occurred, how it was learned, and how it was applied. It appears that multiple factors and elements are involved in the application of learning and in the next section I will discuss these findings and attempt to interpret some of the factors which appear to facilitate or hinder application of learning. Finally, I will consider the implications of this study on program planning and practice, both at the individual and school level. 79 Chapter 6: Discussion For all the reasons, for the speed, for the confidence for the professionally, if that's a word, and for getting the needs of the kid met in a timely matter - probably just understanding the process, having role played it and then having gone through it a number of times it became a practised kind of set of behaviours that Ifelt comfortable with and the parents felt comfortable with and the administration and teachers felt comfortable with it as well. This girl would have killed herself without the intervention. ASK ASSESS A CT Participant June 2001 Overview The original intent of this research was to identify the factors that facilitated application and factors that hindered application of learning. After completion of the data analysis it appears that none of the elements are a barrier to application. A l l of the elements of the four factors tend to be facilitators, or in some cases seem to have no effect. This could be a result of the sample size or the type of sample. In this section, I will discuss the findings of each factor: (1) the program; (2) characteristics of the individual or learner; (3) the proposed behaviour change; and (4) the social system and how each is related to application. I will discuss what learning occurred, how it occurred, and how it was applied. Finally I will conclude with implications and recommendations regarding this CPE program and future research on application of learning. The Program Five elements of the program factor were included in this analysis: involvement in program planning, handbook use, motivation to do other activities as a result of taking the program, realistic scenarios, and relevant program. The elements that appear to influence application are the participants' perception that the program was realistic and relevant. Nineteen 80 indicated the program portrayed realistic school scenarios and 20 felt the program as relevant to their work. This finding is not surprising, since the realism element had been carefully considered and built into the program planning, as discussed in Chapter 2. Likewise, the fact that all but one participant identified the program as relevant indicates that the effort taken to plan a program for this specific audience was worthwhile and likely influenced application. According to Cervero (1985), the greater an individual's investment in the program, the more likely he or she is to use the program. The findings related to involvement in program planning, use of the handbook, additional training, ordering materials and resources, and motivation to do other suicide prevention activities in the school and community suggest that these elements are neither facilitators nor barriers: application of learning occurred in all but one case regardless of these activities. Few were involved in any of the program planning activities prior to the workshop, three participants were motivated to do other activities as a result of the workshop, and eleven looked at the handbook. It appears that a lack of budget prevented some participants from ordering materials, and the low report of additional training was from lack of opportunity. The investment in the program seems to be in the perceived need or motivation to attend which will be discussed in the section on characteristics of the learners. The mnemonic strategy. One component of the program designed to enhance learning, and in turn application, was the mnemonic strategy CPR used in the risk assessment model. As reported in Chapter 5 no one mentioned the term CPR, although it was evident the participants were referring to the risk assessment model. Instead, participants seemed to be using the title of the program A S K ASSESS A C T as a mnemonic device to remember the steps of the risk assessment model. This 81 was not the intention of the title. However, it further supports the original intent which was to accurately reflect the program content. It also provides support for keeping the original title as there has been some pressure to change it. The mnemonic use of the term CPR in the A S K ASSESS A C T program may have indeed confused participants. It was selected because the term CPR is well known. It may indeed have had the opposite effect because it is so well known as an emergency first aid technique. Thus the possible confusion: two meanings for one acronym. Significance of the program. Suicide intervention is not an intuitive process, nor is it modelled in everyday life - it needs to be taught. It is my belief that A S K ASSESS A C T is a significant contribution to the professional development of school personnel. Many participants reported working with high risk students and were unsure of how to deal with potentially suicidal students or crises. Comments from participants that the program "gave them confidence, " "skills and tools," and "heightened awareness " appear to have filled a gap in the CPE needs of school personnel. For many participants this was the first time they had taken a suicide intervention training program even after being in the school system for years. What seems obvious, but needs to be stated, is the importance of the CPE program A S K ASSESS A C T and it cannot be taken for granted. This supports Turley et al. (2000) findings in that there is a "beneficial impact" from a suicide intervention workshop (p. 4). Furthermore, in this study, without asking, 18 participants commented that they would like additional training or a refresher course on suicide intervention. They felt that this would add to their and their colleagues' professional development. This recommendation supports King et al. (1999) study on confidence levels in high school counsellors and that more time be 82 devoted to "training programs" in "the skills essential to recognizing students at risk for suicide" (p. 457). The Learners In Chapter 3 the question was posed: "How can teachers, counsellors and other school personnel be asked to do one more task when they are already overloaded with responsibilities?" The task is suicide intervention and this question can be answered with some of the responses identified in the findings section. A l l participants believed that suicide intervention was their responsibility. Their statements demonstrate beliefs about responsibility and the caring and commitment school personnel have to their work and students. Other characteristics about school personnel were identified as possibly contributing to learning and applying these skills and these include: occupation; length of time in occupation; additional training; belief in prevention; confidence level; readiness for learning; and voluntary attendance. A l l are discussed in this section. It was originally thought that age, sex and length of time in occupation, and additional training, may influence application. This is connected to what Hall and Hall (1996) refer to as an effect of experience, and in this case, the experience of suicide intervention. These elements do not seem to either facilitate or act as barriers to application. However, the element of experience as related to one of Knowles (1980) assumptions about adult learning is relevant in this study. Many participants commented that they used past learning experiences to learn the suicide intervention concepts. Occupation seems to be connected, and as expected, school counsellors reported the most opportunities to apply suicide intervention. The other elements that seem to 83 facilitate application of learning are belief in prevention, confidence level, readiness for learning and voluntary attendance. As previously discussed, it has been well demonstrated that at any given time some students are thinking about suicide or planning their suicide (Leenaars & Wenckstern, 1991; McCreary Centre Society, 1993, 1999). Indeed this was the reason many participants gave for attending the A S K ASSESS A C T CPE program, that they were concerned about a student or that they had already experienced a suicidal crisis. It is generally found that i f individuals have a positive attitude towards suicide intervention, where they believe they can prevent suicide, they are more likely to intervene (Tierney 1994). In this research, all participants believed that they could do things to prevent suicide. In addition, Cividin and Ottoson (1997) found "active, intrinsic motivations of participants" were linked to application (p. 54). In other words, the participants voluntarily attended a program that they perceived as beneficial to them and were more likely to apply what they learned. In this study all participants attended voluntarily. This finding also supports Knowles (1980) assumption that adults are "self-directed" in their learning choices. In contrast to "intrinsic motivations" Cividin and Ottoson (1997) suggest "extrinsic motivation" or "compulsory attendance" of participants may be connected to application, although the influence is unclear (p. 54). To ensure the "potential to influence" application they recommend encouragement of voluntary, rather than mandatory attendance (p. 54). Furthermore, they suggest research that focuses on reasons for participation. This information could also help explain why some participants did not consent to an interview. Some school personnel may have been required to take the A S K ASSESS A C T CPE program and therefore they might not be as motivated to learn, apply what they learn, and participate in follow-up research. 84 Readiness for learning. The finding that several participants were identified as ready for learning is consistent with Knowles' (1980) concept of andragogy. His assumption that readiness is associated with the "developmental tasks of their social roles" (p. 44-45) is demonstrated in the participants' roles as school teachers, counsellors or youth workers. They are faced with situations (potentially suicidal youth) that Compel them to learn. In this study, nine participants mentioned how, during the CPE program, they had a student in mind who might be suicidal. In addition, Cervero (1985) argues that "the most well-planned program will not induce behavior change in an individual who is not motivated to change" (p. 87). Motivation, based on need or a perceived deficit, can influence the first steps towards application: that is by attending the program and hopefully learning the skills. Motivation has been well established in this study. A l l of the participants wanted to attend the CPE program, most were seeking information, knowledge and skills, and most believed they could do something to prevent suicide, and again all felt that it was their responsibility to do so. The Proposed Behaviour Change What proposed behaviour change or learning was expected that participants would apply? In this CPE program it is expected that participants will apply suicide intervention skills in their workplace. As previously mentioned, the A S K ASSESS A C T program presents numerous challenges to participants. Yet despite some of the negative connotations, demands on time and sometimes lack of support, school personnel voluntarily take the training and are asking for additional training. It appears that the participants want to learn the skills of intervention because of their perceived need and the reality that suicide is part of school life. In Chapter 5, 85 there is a summary of participants' comments about their needs for knowledge and skills. This factor, proposed behaviour change, seems to facilitate application, because of the perceived need and the participants' desire to "be more effective with the students. " The Social System "Unless there are incentives or at least not disincentives within the working environment for the proposed changes, the CPE program is unlikely to be successful" (Cervero, 1985, p. 87). In the case of this study, the social system or working environment is the school and school district. Based on Cervero's premise that this system is perhaps the "most powerful yet overlooked variable," a series of questions were designed to ascertain how the participants perceived their social system. Seven elements were presented in the findings section, including: a description of the schools; accessibility of services; perceived administrative and school district support; any change after the CPE program; parental involvement; suicide intervention protocol; and opportunity to apply the learning. The school descriptions offered by the participants were varied and ranged from hopeful to discouraged. Overall the participants seemed pleased with their work environment despite the frustrations and limitations. When asked to describe their school, the four participants that laughed appeared to out of relief - it was almost as if they were thinking "where do I begin..." I did not notice this pattern until I was transcribing the audio tapes so I was unable to ask the participants about this laughter. Some of the participants described how their work in the schools was overwhelming and highly demanding. The laughter might have been a coping mechanism. This might also be the reason related to the comment made by one participant about working in the school "oh, forever. " 86 It appears that all of the elements of this factor facilitate application of learning except the level of parental involvement and accessibility of services. Again, application of learning occurred regardless of parental involvement and accessibility of services. However, in the event of a crisis, parents would be called upon and services would have to be found. Overall, there was perceived support from administrators and the school district which is probably necessary for application to occur. However, not all participants felt they had administrative or school district support in their work but they continued to be involved in suicide intervention when they needed to. With regard to change in the school post-CPE program, it seemed to be in the area of "heightened awareness " and "more open " and "people talked more consciously about it. " Indeed this element more than likely facilitated application. Out of the 21 participants, one reported no opportunity to respond to a potential suicidal student. This seems curious because all participants had approximately three years following the CPE program to apply learning. She went on to say that she felt "fairly confident" that she could identify someone who was potentially suicidal and intervene. It does appear that an opportunity to intervene did not present itself. In comparison McConahay (1991) found in his six month follow-up study that there was a decrease in suicide interventions which he attributed to mainly a lack of opportunity. It would therefore be expected that the more length in time after a CPE program the more likely an opportunity to apply learning would occur. This appears to be the case, other than the one report of lack of opportunity. To state the obvious, i f there is no opportunity, there is no application. It was also expected and reported in the findings that school counsellors would have more opportunities because of the nature of their work. However, of the participants who reported frequent opportunity two were counsellors, one a teacher, and one a youth worker. This would indicate that variables other than occupation are influencing application. 87 It appears that other elements of the social system have little influence on application of learning. A l l participants, except one, applied learning and were involved in varying degrees of suicide intervention regardless of accessible services, parental involvement and a suicide intervention protocol. With regard to community and health services available to school personnel dealing with potentially suicidal youth, the USD appears to have more services than the RSD. Although this finding would be typical of a rural district, since most services are concentrated in large urban districts, this is nonetheless an area of frustration for those in the RSD. Parental involvement was generally low, although the description of a suicide intervention in Chapter 5 demonstrates how parents must be involved during a potential crisis situation. It was proposed that having a suicide intervention protocol would likely influence application of learning. Most of the participants reported "no " or "don't know " when asked if they have a current protocol. What was identified in this finding was the desire of most participants to have a current suicide intervention protocol to further assist them in their work. There are several issues that need to be explored due to the fact that over half of the participants were working in an alternate education program. Does this element have any bearing on application of learning, and are there reasons why these people participated in this research? This element may facilitate application. Indeed, out of the two participants that reported frequent application, two were from an alternate school, and the one participant that reported "never" to a suicide intervention was from an alternate school. The element of working in an alternate education program appears to have influenced the motivation to attend the CPE program because the concern about working with at-risk students. In addition, this factor may have also influenced the higher rate of participation in this study by alternate education school personnel. 88 Summary of Factors that Appear to Facilitate or Hinder Application of Learning In summary, certain elements of the four factors identified in Cervero's (1985) framework do appear to facilitate application of learning. As identified in the findings, these were the three R's of adult learning - readiness, relevance, and realism. These elements are a combination of factors, including the program factors relevance to the learner, and a realistic program, and the characteristic factor of readiness to learn. The other elements include an individual's confidence, belief about suicide prevention and their personal sense of responsibility to intervene; a perceived need for the proposed behaviour change (suicide intervention skills); and elements of the social system, which include perceived administrative support, the opportunity for suicide intervention, and a change "heightened awareness " among school personnel after the CPE program. The elements of school district support, and a suicide intervention protocol appear to have no effect either way on application of learning: participants applied learning regardless of their perceived support or the guidance of a written protocol. Other factors, beyond the scope of this study, that may facilitate or be a barrier to application are the number of students in the school, the characteristics of the students, and environmental factors beyond anyone's control. In addition, there might be something different about the characteristics of the learners that did not participate in this study. It is clear that all factors appear to influence application in combination with one another. Figure 2 illustrates this concept. I have taken the diagram originally displayed in Figure 1 (adapted from Cervero 1985), and have added the elements (indicated by bullets) to each factor that appear to facilitate application of learning. These factors and elements include: (1) The CPE program: the mnemonic effect of the title, A S K ASSESS ACT; relevance to the participants' work; and the realism of the program. (2) Characteristics of the learner: their confidence level; readiness for 89 learning; belief they can prevent suicide; and intervention is their responsibility. (3) The proposed behaviour change: participants' perceived need/desire for suicide intervention skills. (4). The social system in which the school personnel work: perceived support from administrators and the school district; opportunity to apply the learning; and a change in the school after the training. The two-headed arrows indicate the interaction between factors and the one-headed arrow indicates how all of these factors and elements work together to facilitate application of learning. Figure 2. Elements of the Four Factors that Appear to Facilitate Application. These findings seem to support Cervero's framework and Ottoson's research on multiple influences on application. No one factor appears to hinder application, while some factors seem more involved in influencing application and others appear to have little or no influence. 90 Summary Comments about Learning and Application Upon careful coding and analysis it became clear that the concepts learned, in most cases, had been retained and applied several years after the training, especially how to "ask directly about suicide. " The challenge in this follow-up study was to record participants' responses about content presented at the workshop three years prior, to identify what learning had occurred, what concepts had been applied and to gain an understanding of this process. This finding supports Drabek and Yutrzenka's (1991), five month follow-up study which indicated retention of learning which they attributed to the CPE program. It is a concern that most of the participants have not taken additional training since the A S K ASSESS A C T CPE program and would have i f it had been offered. Indeed, most requested a refresher or additional training, which would demonstrate the participants' perceived need to either fill some gaps, improve skills, or reinforce their current knowledge. It is also reflected in this statement: "I need to see it again, even within the same workshop, because now I understand it more. " Based on the comments from participants about how they learned, and how adults learn in general, additional practice and refresher courses should be offered. It is hoped that this study has contributed to a greater understanding of how suicide intervention programs are applied in practice and this in turn, will have implications for policy, programming and practice. Implications In this section, I will explore how the results of this research have implications for program, policy, and practice. The A S K ASSESS A C T program appears to be a good foundation on which revisions and changes can be made. In 2000 the CPR acronym used as a mnemonic strategy was changed (due to copyright restrictions) and the HLP (silent e) acronym 91 was developed. No follow-up has been conducted on the 2000 CPE program so it is not possible to determine if this new mnemonic strategy made a difference. Future revisions and updates of statistics are recommended and will be necessary on a regular basis, and ongoing program evaluation should continue. A one-page quick reference handout was developed in 2000 and a copy is given to each participant instead of the Suicide intervention handbook. The handbook is still recommended as a reference in teacher resource centers and a copy should be available in every school. Not one participant recommended changes to the content or length of the program. The content of the program appears to be acceptable to participants, as they all agreed to the relevance and realism of A S K ASSESS ACT. The initial time taken to develop and test this CPE program seems to have been worthwhile. Since it was designed to be part of a professional development day, the length of the program, five hours, also seems adequate. The time is flexible enough in that if the participants move faster through the content the five hours might be reduced. This has happened on occasion when there is a small group taking the training. In addition, time can be added to the program if the group wishes to take a longer lunch and/or more frequent breaks. I had the opportunity to present a shortened version of A S K ASSESS A C T in January 2002. We were allotted a one and half hour time slot at a conference. It was frustrating for me and for the participants that not all of the concepts could be fully explained and in turn, practiced and learned. Finally, the demand for a "refresher" course should be explored. The shortened version of A S K ASSESS A C T (one and a half hours) would be appropriate as a refresher course. The implementation would need to be determined. It was evident that a suicide intervention policy for each district would be beneficial. The Ministry of Education developed and recommended a suicide intervention protocol in 2000 and 92 provided a sample to each district, but it is up to the individual district to develop and implement such a policy (personal communication, March 25, 2002). Some school districts in BC have developed a suicide intervention protocol and others are at various stages of draft documents and policy implementation. However, in light of current fiscal restraints and change, which I will discuss further, it will be a challenge for districts to commit to this process. Unfortunately, it is the reality that this suicide intervention CPE program was developed and introduced without a long-term plan and budget as to how the training was to be implemented, who receives the training, built in refresher courses, and a standard baseline of suicide intervention skills. An ideal policy, as previously stated by Dyck (1995), would provide direction for a systematic implementation of the A S K ASSESS A C T program for "selected staff including (p. 8). In the event that this will not happen in the near future, another approach could be taken to ensure at least some school personnel are trained on a systematic basis as follows. As mentioned earlier, suicide intervention is similar to basic first aid. The model that is currently used to implement first aid could provide policy guidelines for suicide intervention programs. For example, in every workplace and school in BC (with over 20 staff), Workers' Compensation Board mandate that there be a first aid person on staff at all times (Section 3.1, 1999). These first aid attendants attend training and retraining on a regular basis to remain certified. I would recommend that these designated first aid attendants also be trained in suicide intervention. Although this recommendation is not without challenges because of issues such as mandatory training and participant characteristics it would be a beginning to systematically implement suicide intervention training. Based on a participant's comment that "there's nobody" with regard to assistance and support in potentially suicidal crises, a designated suicide intervention worker in each school could be an asset. Another benefit to training first aid attendants is that 93 their function is already recognized as a legitimate and necessary part of school systems so by association, suicide intervention could also obtain a similar status. There is one more caution to this recommendation. As with the first aid model, a designated person is not totally responsible for everyone's safety - this is still a community effort, as it would continue to be with suicide prevention. With regard to practice, this CPE program was intended to be implemented in school districts throughout the province. One of the original objectives of the A S K ASSESS A C T program was to train all school personnel (teaching and non-teaching) and ideally one school at a time. In 2001-2002 the Ministry of Education reports there were 55,055 FTE staff. This number includes all administrators, teachers, counsellors, educational assistants, clerks and custodial staff (p. 18). This turned out to be fiscally impossible and the reality is that only a few school personnel per school are trained. The B C Council for Families has delivered the training to over 500 school personnel in the province and an additional 60 key personnel from each school district were trained to deliver the A S K ASSESS A C T program. It was expected that these 60 individuals would in turn deliver the training in their school districts. In principle, this is an efficient method for program implementation in combination with continued support and resources for the trainers. There was no plan to support the trainers nor to follow-up on this project so it is not known to what extent this training has occurred. One place to start systematically implementing suicide intervention skills is at the teacher training level. A S K ASSESS A C T should be included in all college and university undergraduate and graduate level programs that offer school counsellor, teacher training, and youth care worker programs. In British Columbia, university students enrolled in the education program are being prepared to teach the Career and Personal Planning (CAPP) curriculum and 94 this would be an ideal starting point to introduce A S K ASSESS ACT. This recommendation would be relatively simple to accomplish and could begin with pilot testing the program at this level. There are several other avenues for the future of practice. One, funding for these types of programs will be solicited from the corporate or private sector. Two, inexperienced trainers will deliver inexpensive programs which could result in misinformation and potentially dangerous situations. Three, it will stay the same with ad hoc, reactive implementation, for example, following a suicide in the school community - funding is found for training. Four, there will be a change in government or policy and funding will be restored or enhanced. In this study application at the individual level was determined and it would also be beneficial to know about application at the school level. There was a hint of broader application as evidenced by comments about change in schools and examples of working together during a crisis. In addition, Ramsay et al. (1999) recommended collecting data on suicide interventions, referrals and suicidal crises. This should be implemented at the school and district level and coordinated by the Ministry of Education to determine a provincial level of application. Since I have been involved in the A S K ASSESS A C T CPE program from its very inception and after completing this study, it has influenced my practice in the following ways. First, I am constantly asked to present A S K ASSESS A C T in an hour or an hour and a half and I am even more convinced that the content of the program (five hours) should not be shortened, except where mentioned as a refresher. The program was developed over the course of a year, with the guidance of an advisory committee and based on evidence of best practice, sound principles and theories and should not be revised without good justification. Keeping the statistics and current resources updated are essential. Second, this CPE program had a system of 95 quality control which I think is essential. The B C Council for Families was able to provide standardized delivery of A S K ASSESS ACT, conduct ongoing evaluations of the program, and provide support for the trainers. The Council is able to do some of this quality control as it moves towards a fee-for-service basis. However, 60 school personnel were trained to deliver the A S K ASSESS A C T program in 2000 and the quality control is unknown. There is no central coordination to determine what support there is for the trainers, program delivery and implementation. Third, at each training session the participants were given a copy of the Suicide intervention handbook and I have changed this practice. Instead, participants receive a one-page summary (printed both sides) of A S K ASSESS A C T that contains the HLP risk assessment model, additional resources and a sample protocol. This document is printed on a heavy card stock and can be used as a quick reference. Fourth, I am getting used to asking for a fee-for- service and trying to find alternate and creative funding sources. This is a personal and organizational change in practice. As I am finishing this thesis, there appears to be a high level of uncertainty in the province of British Columbia. A new government was voted in on June 5, 2001 based on the platform that there would be reform throughout the province to balance the budget. As mentioned previously, labour unrest had been brewing in the school system and labour action was escalated when legislation declaring education as an essential service was introduced in August 2001 (Ministry of Skills Development and Labour). The government "is calling for a shake-up in BC's education system" was reported by Steffenhagen (2002). Labour unrest continues with constant threats to school structures, funding and programs. Headlines in the Vancouver Sun report the Ministry of Education warning that "times will be tough for the next 96 two years" (February 9, 2002), and the unions' response: "BCTF organizing for long battle with government" (March 8, 2002). It is unpredictable how professional development will be delivered in this environment. It is reasonable to expect some professional development will continue, but more than likely, there will be reduced funding to sponsor and support CPE programs. Reduced funding also has implications for the amount of time allotted for training, resources and equipment, substitute teachers and maintaining and updating CPE programs. This in turn will have a direct effect on the A S K ASSESS A C T program since it is offered on a fee for service basis. In addition, the provincial Suicide Prevention Information and Research Centre, which was relied upon for current youth statistics on suicide, related reports and information was all but closed on February 28, 2002. A single employee remains on a one-year contract. While it has been clearly demonstrated that suicide intervention programs should be offered to all school personnel, it is even more unlikely the CPE budgets will be able to support this recommendation. One A S K ASSESS A C T participant described her efforts to implement suicide intervention training in her district: "if I was to present it as a large scale, full school blitz-training, everybody needs this I'm sure, I would hear back that there is absolutely - don't have the funding for that!" This statement was made before the change in government so it is reasonable to expect there still would not be funding from this traditional source, at this time. Suggested Further Research There are unanswered questions about application of learning that need to be further explored. It appears that characteristics of the learners, combined with the characteristics of the program, have the greatest influence on application and further exploration of this finding is 97 implicated. For example, is there something unique about the participants in this study that they all felt suicide intervention was their responsibility? Administrative support in the social system does not appear to, yet, it could have a greater effect on application: some information about this element was gleaned from the interviews, but it is difficult to determine. Another aspect of the social system that needs to be explored is the lack of funding or support for suicide intervention training programs. Schools, districts, communities and government are part of the system that determines the funding for this type of a CPE program. What is it about suicide intervention that prevents the political will from supporting these programs? Most of the data in this study focused on individual application of learning. However, since suicide intervention always involves more than individuals, a study designed to determine application at the school or district level would be beneficial. It would also be beneficial to know more about the participants who did not consent to an interview to find out i f learning was not applied for other reasons than lack of opportunity, how confident they felt after the A S K ASSESS A C T program, and if they attended the CPE program voluntarily or were required to attend. While it appeared that some learning had been applied from the CPE program, especially how to "ask directly about suicide, " it was difficult to determine exactly what learning had been retained. A longitudinal study following a CPE group could provide information about learning retention from CPE programs, and what adult education program planners can do to enhance learning, retention and application. Further studies on how application of learning occurs following CPE programs need to be conducted. 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A S K ASSESS A C T Outline A S K ASSESS A C T Suicide Intervention Training Program for School Personnel Outline & Content *Evaluation component indicated in italics Introduction Pretest Questionnaire Introduction & Program Goals Pre-assess participants BC Statistics on Youth Suicide • Handout Module 1 Attitudes Attitudes Towards Youth Suicide and Intervention - Individual and Societal • Attitude questionnaire Module 2 Knowledge Teen Stressors •Stressed out Sam & Samantha exercise Suicide Warning Signs & Risk Factors • Brochure handout Suicide Risk Assessment **CPR Living Works Model • Pen and paper exercise Choices Video Module 3 Skills Risk Assessment Practice CPR Living Works Model Participant Observation • Scenarios and role play instructions • Sample school protocol handout Wrap up Resources • Handout • Suicide Intervention Handbook Posttest Questionnaire Program Satisfaction Questionnaire *Evaluation instruments can be found in Haw, C , & Andres, L . (1999). Evaluation of the ASK ASSESS ACT suicide intervention training program. Vancouver: BC Council for Families. **CPR Risk Assessment Model used with permission from Living Works Education Inc. 108 Appendix 2. Invitation Request to Participants U B C i Department of Educational Studies Faculty of Education 2125 Main Mall Vancouver B C V6T 1Z4 <Date> <Name> <School> <School District #> <Address> <City> <PC> Dear <merge name>: Re: Invitation to Participate in the Research Study: Taking a Closer Look at Application of Learning Following a Continuing Professional Education Program. You have been selected to participate in the research study Taking a Closer Look at Application of Learning Following a Continuing Professional Education Program. Several years ago you participated in the ASK«ASSESS»ACT Suicide Intervention Training Program, sponsored by your school district. My research interest in this program is focused on what happens after participants complete the program and go back to work in their school setting. The knowledge gained from this research will have future implications for professional development programs and ultimately save lives. This research study is part of my master's thesis in the Department of Educational Studies at UBC. I would like to interview you for about one hour, at your convenience. Our interview will be audio taped. Your participation in this study is completely voluntary and you may refuse to participate or withdraw at any time. Your identity will be kept confidential and you will not be identified in any reports. I will send you a copy of the research report when it is completed. Lesley Andres, Assistant Professor, Educational Studies is the Principal Investigator and my faculty advisor. If you have any questions she can be contacted at (604)822-8943. If you have any concerns about your rights or treatment as a research subject, please contact Dr. Richard Spratley, Director of the UBC Office of Research Services and Administration at (604)822-8598. If you would like to participate in this study, please sign and date the enclosed consent form, have someone witness it and return it in the enclosed envelope. Thank you again for your consideration. Your feedback is crucial on this important topic. Sincerely, Cheryl Jeffs Co-Investigator 109 Appendix 3. Interview Questions T A K I N G A CLOSER L O O K A T APPLICATION OF L E A R N I N G FOLLOWING A CONTINUING PROFESSIONAL EDUCATION P R O G R A M • Criteria for inclusion: must have been working in the high school system since participating in the ASK*ASSESS«ACT Suicide Intervention Program. The Research Questions that Guided The Development of the Interview Questions From the participants' perspective: 1. what learning did they apply following the ASK«ASSESS»ACT program in the context of their school setting? and, 2. what were the factors that facilitated or hindered this application of learning in the context of their school setting? Prior to the interview, superintendents will have given permission to conduct this research study in their district, and all participants will have been contacted via letter and will have given consent to be interviewed. INTERVIEW QUESTIONS Introduction: Good morning/afternoon, I'm Cheryl Jeffs and thank you for agreeing to be interviewed for my research study. I expect our interview to take no more than 60 minutes. M y records indicate that your participated in the ASK*ASSESS*ACT Suicide Intervention Program at <location> on <date>. The facilitator for the day was <trainer name>. There were lifesavers on your table and you were given a handbook at the end of the training. Informed Consent: If at anytime you would like to stop this interview and withdraw from this study you may do so. Interviewer to complete: ID Sex Age Occupation Date of Interview Location of Interview Time Begin Time Finish M F 110 Background Information 1. Could you please describe what suicide intervention means to you? 2. Can you describe what you remember about the ASK>ASSESS«ACT Suicide Intervention Program? The Program - Planned for Application of Learning 3. Did you have an opportunity to participate in the planning for the ASK "ASSESS'ACT training? Eg. Selecting the ASK>ASSESS»ACT Program? Coordinating arrangements, hosting, Pro-D Day Planning, etc. yes no If yes, how did you participate? 4. Did the ASK»ASSESS»ACTprogram portray realistic school scenarios? yes please describe no please describe 5. Was the ASK»ASSESS»ACTprogram relevant to your work in the school system? yes please describe no please describe 6. Since the ASK*ASSESS»ACT training program, have you referred to the Suicide Intervention Handbook you received? If no, what is the reason? If yes, why did you look at it? 7. Did participating in the ASK>ASSESS»ACT program motivate you to do any of the following? • joined or established a suicide prevention committee • took additional suicide intervention training • worked on school protocol etc. • other Characteristics of the Participants 8. Was your participation in the ASK-ASSESS-ACT Program Voluntary (if so, what was the motivation) Mandatory (if so, who required your attendance) 111 9. Please indicate any other suicide intervention training you have taken since the ASK»ASSESS»ACT Training: 0 1-2 hrs 72 day 1 day 2 days 2 days plus 10. How confident do you feel that you could identify warning signs, assess the risk and get help for someone who is suicidal • extremely confident • very confident • confident • somewhat confident • not confident 11. What is your level of education • grade 12 plus certificate/diploma • university degree • graduate degree 12. How long have you been in this occupation 13. Do you believe there are things you can do to prevent suicide • yes • no 14. In your occupation as a <teacher, counsellor or youth worker> do you believe suicide intervention is your responsibility? • yes please elaborate on your response • no please elaborate on your response 15. Please describe the best or ideal way you learn. What is the Proposed Behaviour Change or Opportunity to Apply Learning 16. Since you have taken the ASK«ASSESS«ACT program how often were you in a position to respond to a potentially suicidal youth? 1 2 3 4 5 Never Rarely Occasionally Regularly Frequently 17. Have you observed suicide warning signs in any student since you took the ASK>ASSESS«ACT Suicide Intervention Program? • yes • no i f yes, please estimate approximately how long after the program you observed warning signs 18. If yes what part of the ASK»ASSESS»ACT program did you use? Did it work well for you? If no what stopped you from using it? 112 19. Have you used the ASK»ASSESS»ACTprogram for other purposes, eg. Give a report to your peers, parents or school board, adapted to peer helper program, etc.? Develop your own suicide awareness program? The Social System in Which the Individual Practices (School Setting) 20. Does your administrator support suicide intervention efforts in your school? • yes if yes, can you think of an example that would demonstrate support? • no if no, can you explain 21. Is there encouragement or support for suicide intervention in your school or district? • yes please give an example. • no what would encouragement or support look like? 22. How would you rate the general level of parental involvement in your school? None Low Medium High 23. Are there any suicide education programs in your school that involve parents? • Yes if yes, please describe • No i f no, do you think there should be? 24. How would you rate the services you can access for suicidal youth in your area • extremely accessible • very accessible • accessible • somewhat accessible • not accessible 25. Have you ordered any of the materials as a result of taking the program? BC Council for Family Suicide Awareness Brochures CHOICES Video Let's Live! Manual Other 26. Please describe (in 25 words or less) the school you work in - your first thoughts please. 27. Was there a suicide intervention/crisis intervention policy in place in your school or district at the time of the training? • Yes • No • Don't Know 113 28. Is there a written suicide intervention/crisis intervention policy in place in your school or district now? • Yes how well do you think everyone knows about it? • No do you think such a policy would be beneficial? • Don't Know who would you ask i f there is one? 29. Was it business as usual after you took the program, in other words nothing changed with regard to suicide intervention policy, procedure or practice? • Yes • No • Don't Know If Yes, please explain what you think would have made a difference to implement suicide intervention in your school? 30. What would you change in your school to help support your work in suicide intervention? 31. Could you please describe the one thing that you took away with you from this program? 32. Other comments or suggestions Thank you for your time. Your feedback is important. 114


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