Form TSA Consent to Con TSA Consent to Con TSA Consent to Contact

Training Skills Assessment- Phone Simulation

Consent Form [to be sent in advance]

This consent form describes a research study, what you may expect if you decide to take part, and important information to help you make your decision. Please read this form carefully.

Purpose of Study. The purpose of this study is to examine the effects of suicide prevention training program on knowledge, attitudes and skills, and to learn about the impact of practicing interview skills with standardized patients on suicide prevention skills.

Description of Study Procedures. We are inviting you to take part in this study because you participated in a GLS funded training. Your consent permits us to analyze your data.

Standardized patient interactions. As part of the phone simulation, you will engage in a virtual 30-minute interaction with a highly trained actor/standardized patient who will present as your patient experiencing distress and suicidal thoughts. The actor will provide you with immediate feedback about your responses and their experience as an at-risk patient at the end of the encounter.

Survey data. You will also be asked to complete a web-based survey at 6 and 12 months after the initial training you attended. Your data from the baseline survey (immediately following the training), and the two follow-up surveys will be linked to your phone simulation data.

Data Storage and Security. We will securely upload and store audio recordings of interactions with the SP over the course of the study. Only qualified research personnel/staff will have access to the videos for analyses.

Risks of Participation. As part of the experience mild emotional discomfort may arise when interacting with the standardized patients during an interview focused on suicide risk. A mental health clinician is available if you wish to speak about your experience.

Payments. Participants will receive a $50 gift card for their participation.

Questions. If you have questions about your participation in advance of the phone call, you may reach out to the study lead, Jessie Rouder at ICF at jessie.rouder@icf.com

Voluntary Participation. Taking part in this study is voluntary. You are free to not take part or to withdraw at any time, for whatever reason. No matter what decision you make, there will be no penalty or loss of benefit to which you are entitled. In the event that you do withdraw from this study, the information you have already provided will be kept in a confidential manner.

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Subject Consent

I have read the contents of this consent form and have been encouraged to ask questions. I have received answers to my questions. I agree to participate in this study. I have received (or will receive) a signed copy of this form for my records and future reference.

Subject Name (Printed by Subject)

Signature of Subject Date

Facilitator:

Welcome to this opportunity. My name is ______, I’m the coordinator for today’s session. I believe you received the student’s backstory that was sent to you prior to this. Now I will introduce you to your student in a few minutes. You will meet with her for up to 30 mins. However, you are not required to use all 30 mins. Please set your own timer /phone to keep track of that time. When the interaction is over, DO NOT LOG OFF. You’ll have 6 min for a break while the actor-educator prepares feedback for you. Just turn off your camera and mic but please stay close by and I will call you back when the actor is ready. You’ll then have 7 min to discuss feedback with the actor-educator. And you’ll be finished by the end of the hour. As you know the interaction is recorded.

Any questions you have for me before we proceed? Don’t forget, this is just an opportunity to practice.

Let [STUDENT] into room “[STUDENT] is here now” (let her into the room; turn off your camera/mic)

PUT SIDE BY SIDE MODE (Gallery mode)

HIT RECORD!!!!! Don’t stop until the call is completely complete.

Character Introduction

Name
Demographics: age, gender, sexual orientation, race and ethnicity
Interviewer Objectives	Portray an adolescent in high school facing adjustment issues (unsure about ability to go to college and uncertainty about what comes next) and recent relationship break-up (first partner after coming out as LGBTQ), questioning self-worth and whether things would be easier if she were dead
Trainee Objectives	Conduct appropriate, patient-centered interview in 30 minute encounter to assess mood and risk using Commitment to Living for Primary Care Providers framework, ascertain the patient is not an immediate threat to herself but is at some risk, and engage in collaborative safety plan, including risk and protective factors, reasons for living, coping skills (increase activities, distress tolerance, social engagement), and arriving, at minimum, at removal of pills from patient’s possession (willing to have provider discuss with mom), drawing on more supports (connect to LGBT group at school, spend more time with friend from animal shelter), and maybe considering talking to school counselor, or school nurse. Bring patient back within a week. Check in by phone the next day. Provider gives numbers for Mobile Crisis/Lifeline
Patient Symptoms	Cry all the time, irritable, grumpy and angry (especially toward mom) Quiet and withdrawn around peers Trouble falling asleep at night Eating more often (especially junk food) and have gained weight Tired and less energy to do homework, trouble concentrating at school Hopeless, feel like there is nothing good in life Distraught about the break-up and being lonely /alone
Onset	Three months ago, following a breakup
Pattern	Nearly daily
Quality/Intensity	Sometimes you wish you could just “get it over with” and end your life because nothing feels good anymore and no one understands you. (Say this about 5 min in if not yet asked about suicide). And probably no one likes you anymore either. You think about being hit by a car or bus or driving your moms’ car off the road. You also think about taking pills and ending it all. This morning you took stock of what pills were in the home because since your girlfriend broke up with you and is no longer responding to your texts, you feel like you can’t go on.
Treatments Tried	In therapy in the past for a few sessions due to some ‘friend stuff’ in middle school, don’t remember much & not currently in therapy.
What makes it better	Nothing really. Calling / texting girlfriend – and other friends – helped, but now that girlfriend broke up with you, you’re not sure who is your ‘friend,’ never mind your lover. Used to draw/ do art/take pictures a lot, go to hear music, party, post photos on Instagram. Used to talk to mom sometimes but angry at her currently because of parents’ divorce.
What makes it worse	Looking at pictures of girlfriend now because you’ve broken up, seeing girlfriend and old friends on social media, arguments with mom, school, looking in the mirror/weighing self, calling/texting old friends and getting no response, seeing other with their friends, feeling misunderstood by mom re: sexual orientation (mom thinks it’s just a phase and dad barely acknowledges her) TRIGGER – seeing girlfriend Jessica with another romantic partner on Instagram and Snapchat
Medical History
Current medications	Ibuprofen PRN (as needed) and Acetaminophen PRN (as needed) for headaches, menstrual cramps.
Past medical history	Frequent headaches Took Percocet for pain following appendix surgery at age 15
Family health history	Mother: Depression, anxiety; Takes some medication for it. (“starts with C – Celexa maybe?”). Though you might not know the specifics, the provider might. Father: High blood pressure Siblings: Older brother, NAME, is barely around. You know he broke his ankle playing ball. You know your Aunt (mom’s older sister) attempted suicide, according to family rumors, but the details are not clear or known. You weren’t born yet.
Social history
Living situation	Lives with mom who works long hours as a nurse. Dad is not really around. You think he is dating someone new, but you have never met her. Brother (age 22) who attends college out of state; he comes home for breaks, but they don’t talk very much
Education	11th grader in high school; it is a big high school in the next county. You are an average student-- you (used to) want to go to college but you are not sure now. It is so expensive, and your mom can't help, so what’s the point? You don’t know what you would study. You have not been able to visit any schools and you aren’t sure if your mom can take time off to take you. You tried to fill out some applications, but you didn’t finish them. You don’t know many of the teachers at your school very well, but you do like your art teacher who has encouraged you to join the art club at school
Employment	None
Hobbies	drawing & art, volunteering with local animal shelter (not currently doing so), dance
Relationship status	Girlfriend of 6 months who broke up with you
Spiritual or religious beliefs
Substance Use
Alcohol use	You drink
Drug use	You smoke weed after school sometimes because it helps you fall asleep
Tobacco use	None
Demeanor	Tearful, talking about girlfriend and details of your breakup and all of the fighting that lead up to break up Hopeless – “I don’t think I can go on without Jessica; things were really bad before but now there’s nothing to live for”; “I’ve been thinking she’d find someone else - I bet she already HAS.” “All of my friends picked her over me”
Disclosure guidelines	Depressed, overwhelmed Only when asked directly about suicidal thoughts or plans reveal that you have thought about suicide; you feel like no one cares about you, no one understands you, things aren’t going to get better, nothing is working out If asked about ‘hurting yourself’ say, “I don’t want to be in any more pain” (ideally they will ask directly about suicide/killing yourself) When asked about having any thoughts as to how you might do it, you say you have thought about taking pills; today while mom was at work you took stock /counted the pills that are in your room and in their medicine cabinet – there’s lots. If asked how many, you don’t know exact number but “it was a handful…probably enough.” When asked about driving car off the road/getting hit by a car, you state “It’s just a fleeting thought. I wouldn’t really do that – I wouldn’t want anyone else to get hurt.” When asked about guns in the home, you say that your dad hunts and he has a gun; you know where he keeps it but you don’t know if it is loaded; you wouldn’t use it If asked directly “Do you have plans to kill yourself?” express some ambivalence – “I don’t know; I mean, I know my mom would miss me but she doesn’t make any time for me” “I’m so fat and ugly now I don’t think I’ll ever have another girlfriend so I don’t really see the point of being here” “Jessica is the only one who really understood me, now I feel so alone” If asked on a scale of 1(low) to 10 (high) how sure you are that you want to kill yourself, you rate yourself a 4 If asked as to any other methods considered, such as cutting, tried cutting a few times in past in middle school but you didn’t like it, don’t like blood; and you didn’t do it to kill self If asked as to any prior suicide attempts, you say only that you have thought about it off and on, but never did anything. When answering questions regarding duration of symptoms, symptoms have been intermittent but present most days and overall worsening over past 3 months. Sense of worth issues includes feeling ugly and fat because of weight gain; not having friends at new school Used to get good grades (A’s or B’s) but can’t concentrate anymore – feel stupid and behind, but you’re not failing – more so getting a few C’s Feel like you won’t ever have another girlfriend like Jessica – “she made me feel like life was worth it” Sleep issues: Trouble falling asleep most nights, usually takes an hour; feel tense and angry at bedtime; take naps after school most days Concentration issues: Can’t focus at school – thinking about what old friends and ex-girlfriend are doing; at home, keep checking phone to see if anyone has texted When asked about anxiety, worried that ex-girlfriend is going to start dating a friend (Naomi) of yours If asked about eating habits, you’ve been eating a lot more junk food, especially when home after school and feeling bored. Last doctor’s visit was 4 months ago. They did all the usual tests and everything was normal except you had gained 5 pounds and today’s visit indicates another 3 pound gain. If asked any mental status questions, date, place, calculations, drawing diagrams, all are responded to appropriately. Be dismissive though. If asked about persistent worries or thoughts, you do spend a fair amount of time thinking about what you are missing at your old school and how your friends have moved on without you. Today you can’t stop thinking about who Jessica will ask out next. And fall in love with. If asked about impulsiveness, you’ve occasionally done things your parents thought were stupid, like getting a belly button piercing with Jessica; and sleeping outside one night because you didn’t want them to know you had missed curfew (of course they figured it out) If presented with diagnosis of depression, you acknowledge, “Of course I’m depressed, who wouldn’t be?” If asked if you will keep coming in to see the doctor, “yes if I’m still here.” If asked about telling your mom about your symptoms and suicidal thoughts, you are initially angry and don’t want them to know – “It’s their fault I feel this way.” But then you acknowledge they’re probably worried about you and it could be helpful for them to know – you would agree if the provider encourages you to have your parents move medications so that you don’t have access to them. But you don’t suggest that yourself. Provider may want to call parents while you’re with them. You pout but say, “OK I guess” You may be willing to take meds for depression – could we talk about that next time? You are open to try the art club at school and see if you can check in with your art teacher occasionally You would be interested in joining a group for LGBT youth – but you also have been thinking about the Gay Alliance in town You aren’t sure you would want to talk to a therapist – it would have to be someone young, hip, liberal You are hesitant about talking to your school counselor or school nurse but agree it could be helpful You are open to try talking more frequently with your older brother and calling him if you feel more serious about ending your life – you miss him! You are willing to make a plan to come back soon or have a check in call
Flow of conversation	You are quite hopeless that things will get better. You felt like things were really bad before Jessica broke up with you, but now you feel like things are ten times worse and you can’t imagine living your life without Jess because she was so perfect for you. You wish you could go out more with friends, but they are all taking Jessica’s side. Your mom works all the time so it’s hard to get access to their cars to drive to see friends. Argue a lot with mom recently. But you have a solid relationship history; you used to be close to brother but he is away at college; you call and text him but not the same as talking to him. You are close to your grandmother but she has Alzheimer’s and recently moved into a nursing home. You have one friend (Olivia) from another school who works at the animal shelter; it would probably be good to see her more often
Appearance	Hair a little unkempt; animated when talking about how angry you are at parents; frequently check cell phone to see if anyone has texted you
Clothing
Props/Makeup

Coding

Coding Form

Actor and Scenario		Coder
Study ID #		Coding Date
		Coding Time

Scoring Criteria

Core Competency	Skills specific to the Scenario	Score	Scoring Criteria 0 = not observed 1 = partially observed 2 = fully observed	Notes
Attitudes and reactions	Demonstration of a calm, confident demeanor	0	Frequently appeared anxious, lacking in confidence
		1	Occasionally appeared anxious or lacking in confidence
		2	Demonstrated a calm, non-anxious, confident presence for the majority of the interview
Empathetic stance towards the youth	Demonstration of patience, empathy, active listening skills	0	Lacking/ failure to reflect, be empathic or listen well; harsh, dismissive, or demeaning; several significant missed opportunities Active negative comments that create a rift or therapeutic disconnection.
		1	Some attempts at building rapport and empathy, some active listening observed; some clear missed opportunities and/or example of minor negative stance that create a brief ‘rift’ or therapeutic disconnection; only focused on problem solving.
		2	Rapport /empathic stance observed throughout with good active listening; any missed opportunities do not create obvious ‘rift’ or therapeutic disconnection.
Asked directly about suicidal ideation	Asked directly about suicide without seeming afraid or uncomfortable	0	Doesn’t use “suicide” “killing self” “ending your life” “wanting to die.” In addition, the following terms are scored a zero: “not being alive/born” “sleeping forever”
		1	Uses “hurt self” or “hurt or kill yourself,” “having those thoughts,” “do something bad,” or other euphemisms/avoidant language but also mix of at least one clear term
		2	Uses clear and specific terminology, may use “hurt self” in early assessment only but otherwise uses “suicide,” “killing yourself,” or “ending your life” throughout the remainder of the interview
Risk factors	Did the participant elicit the following: parent –teen conflict adjustment issues/stressor lack of social support /peers hopelessness, sign of depression family history of depression and likely suicide attempt history of self harm/suicide attempt		Demonstrated knowledge about risk factors and conducted interview to elicit those specific to the patient. Includes: Adjustment issues/stressor of: relationship stressors/ breakup for all, changes in school & few friends (Coding – all or nothing) Signs of depression/anxiety: not only depressed/anxious mood but also one of the following: hopelessness, sleep disturbance, low energy, appetite disturbance, social withdrawal, feelings of worthlessness, anhedonia, difficulty concentrating History of suicidal thoughts (distal to this current situation/context) History of suicide attempt (automatically score 1 if SP indicates no previous history of suicidal thoughts) Family history: of a likely suicide attempt Substance use
Protective factors	Collaborated with the patient to identity strengths, supports, and important collaterals May include: friends, family faith community interests/hobbies/activities reasons for living (family would miss.)		Collaborated with patient to identify strengths, supports and important collaterals: Includes: Social support: friends, family/partner, coach Interests/activities /hobbies – Coping strategies patient has used in the past (i.e., what made self feel better) Reasons for living (i.e., Parents/friends/partner/sibling would miss, new child on the way, specific future plans in context with scenario, such as visiting college, etc.)
Current suicidality	Identified current suicidal ideation/behaviors		Triggers: thinking about relationship stressors, checking social media posts, thinking about work/finances, studying.
			Onset: when current suicidal thoughts began, could be a statement such as “when did you start feeling like you can’t go on?”
			Duration of each episode: minutes/hours/whole day and/or frequency (e.g., every night)
			Access to medications
			Access to gun
			Rehearsal behaviors: counted or took stock of pills or checked gun ammo
			Plan 0= did not ask about plan .5 = asked questions that elicited a vague plan of HOW (e.g., “I’d take some pills”) 1= asked questions that could elicit specific details of a plan (i.e., how PLUS when and/or where plan would occur)
			Seriousness of intent to die: How likely is patient to act on it, ‘on a scale of 1 – 10’; “I think about getting it over with”; ‘how sure are you that you’ll do it?’ code 0 if they only ask, “are you safe to go home?”
Referral for gatekeeper
CLINICAL SECTION ONLY
Risk Assessment	Trainee initiates the appropriate level of response based on the risk of the patient
Safety Planning	Trainee and patient collaborate to generate plan during the session. May include: invites patient’s parent to collaborate on this plan/ facilitates communication instills hope increased monitoring restrict access to lethal means addresses confidentiality coping skills for triggers		Correctly identified that hospital evaluation was not indicated 0 = recommended hospitalization, no intervention replaced the safety plan with any other intervention, or delegated decision to another provider 1 = identified hospitalization not indicated Note the recommendation/s offered: Hospitalization Delegate to other provider Other:____________
			Instills hope that through collaboration/treatment suicidality will pass in the near future 0= does not instill hope 1 = communicates hope through language of positive change and tone: “we’re going to work together so you’re not feeling this way” , “step by step we’re going to get you through this”, “I know this feels hard now, but we’ll work together for change”
			Details from this patient's assessment interview are incorporated in a specific /tailored plan including take away access to means of intended or actual plan i.e., medications and gun 0 = previously ID’d means not addressed or no means addressed/revealed in interview or no mention of gun and/or pills 1= whatever means ID’d in interview is addressed in terms of restricting access (i.e., Abby/mom locks up pills/ask brother to take gun / ammo
			Includes proximal coping skills when identified triggers and/or suicidal thoughts occur (e.g., loneliness, arguments with partner, etc.). They have to make the connection to receive points, (e.g., “When you have that thought/feeling...?” [clearly referring to suicidal feelings/thoughts] or “When you’re feeling suicidal…?”) 0 = no coping skills identified/included; or coping skills are not connected to triggers/ suicidal thoughts .5 = one coping skill 1 = two or more coping skills Examples of coping skills: calling a friend or family member (code calling any friends or family members as one skill), watching movies, drawing, journaling, mindfulness, exercising, texting, paintball, call an emergency contact number/ provider (e.g., 911, lifeline, etc.), taking self to the emergency room if it gets bad enough (code any kind of “crisis support” including phone numbers or taking self to the emergency room as one skill)
			Identify factors to improve overall mood and functioning 0 = did not elicit any factor 1 = one or more factors discussed Increase Social Supports Decrease Alcohol Consumption Behavioral Activation Sleep Hygiene EAP/Academic Counseling Other Counseling Medication
			Identified events that would make suicidal intent worse 0 = did not ask what would make patient more sure/serious about ending life 1 = know factors that could increase suicidality (argument with my fiancée/boyfriend, discovers XX has a new girlfriend, got a bill or poor work performance, got a bad grade or lost scholarship)
			Provider provides emergency contact /phone numbers 0 = doesn’t provide/ identify 1 = identifies – lifeline, pager, 911, mobile crisis, personal number, 24-hour office number, other plausible 24-hour contact, going to the emergency department if it gets worse
			Clear plan for appropriate follow up with clinician and other providers as discussed in session 0 = no follow up with clinician stated/set up OR follow-up appointment in more than one week .5 = scheduled a phone follow OR follow-up appointment within at most one week with clinician scheduled 1 =scheduled a phone follow AND follow-up appointment up with clinician within at most one week scheduled)
Follow-up	Trainee initiates a follow up plan		0= does not create a follow-up plan 1= schedules an additional appointment or phone appointment to follow up on plan within a short period of time. Reviews emergency contact information with patient.
Interviewer Quality Overall		1-9	1-3 = Needs work from at least one major ‘miss/anti therapeutic’ behavior to low level of skill throughout 4-6= Acceptable work; mixed; some good examples but also some “needs work” 7-9= Good work = quality that you would teach from/use as an illustration. Good balance of open and closed ended questions (e.g., collaborative, socratic questioning) Works collaboratively with patient Maintains appropriate boundaries (e.g., does not overshare, patronize or act overly familiar with patient) Uses appropriate language that is not clinical or jargon, not too repetitive or with too many fillers or other inappropriate language use Keeps an even tone (i.e., not overly directive, lecturing, dismissive, minimizing, forceful, or harsh) Appears appropriately concerned (not indifferent) Notes: If clinician shares about own mental illness or too much about self, cannot be in the “good work” range If clinician mentions a safety contract or wants to contract for safety, cannot be in the “good work” range