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The GTISS is Actionable Knowledge

In 2010, the Centers for Disease Control and Prevention (CDC) funded an innovative project to help three sites (the Centerstone Research Institute, the University of Maine, and the Native American Rehabilitation Association in Oregon) create "actionable knowledge" (AK).  The CDC (YEAR) defines AKas “an innovation developed based on the knowledge gained from an integrated and comprehensive process, to transform synthesized information into something that benefits the end user to support (1) decision-making or (2) the application of that knowledge at the practice, research or policy level.”  The AK project was part of an ongoing inter-agency agreement between the CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA)—the federal agency that funds and oversees statewide suicide prevention grants through the Garrett Lee Smith Memorial Act.

Rather than prepare a manuscript for publication, the aim of the AK project was to use evaluation and practical experience to develop useful tools for the enhancement of suicide prevention activities.  The 5 stages and 10 tools of the GTISS are based on a combination of research and lessons learned from 5+ years of implementation and evaluation of three gatekeeper training programs (QPR, ASIST, and the Jason Foundation's Promise for Tomorrow).  Training was conducted with various populations, including thousands of teachers and school personnel, over 2,000 juvenile justice and juvenile court staff, hundreds of child welfare staff, nurses and health professionals, university faculty, graduate and undergraduate students in helping professions, foster parents, and youth in child welfare residential settings.

Steps in the Development of Actionable Knowledge Products

• Synthesize information: Summarize evidence of evaluation effectiveness; consider context and relevance for different audiences
• Consider all domains in which knowledge was gained; let the data drive your product; remember that data come in many forms
• Determine key audience(s) and applicability of evidence to audience(s) of interest (contextual knowledge) – elicit stakeholder feedback for key constructs to evaluate
• Translate evidence into every day terms specific to your audience
• Develop tools that support decision making and transformation of knowledge to action
• Evaluate use and effectiveness of tools and new implementation strategies

Research Findings and Lessons Learned from the Enhanced Evaluation

Prior research on gatekeeper training has shown that immediately after training, participants show increased knowledge (actual and perceived), improved attitudes about suicide, increased confidence (self-efficacy beliefs), and skills to help at-risk individuals. Little research exists, however, on the translation of knowledge, attitudes, beliefs, and skills to gatekeeper helping behaviors. Nor is there much research on the long-term effectiveness of gatekeeper training. In order to fill this gap, the Centerstone Research Institute has conducted several studies:

•      A longitudinal evaluation with a six-month follow-up to assess immediate and long-term outcomes of a 90-minute gatekeeper training;

•      A descriptive study of gatekeeper helping behaviors as they naturally occur in the child welfare system;

•      A study of child welfare case managers to determine whether trainees and non-trainees differ in self-efficacy and gatekeeper helping behaviors;

•      A longitudinal evaluation of a two-day gatekeeper training for juvenile justice staff, including a six-month follow-up;

•      A qualitative study involving focus groups with juvenile justice staff to examine how staff identify and help youth who are at risk for suicide and how these processes relate to more effective, comprehensive strategies for doing suicide prevention.

• A qualitative study involving focus groupswith juvenile justice staff to examine how staff identify and help youth who are at risk for suicide and how these processes relate to more effective, comprehensive strategies for doing suicide prevention.

Enhanced Evaluation Study Results

Several important evaluation findings and lessons learned from implementation of gatekeeper training have been documented. Some key results and conclusions include the following:

                Long-term gains are not guaranteed.

• Short-term gains in Self-Efficacy (beliefs that gatekeepers can effectively prevent suicide) and Procedural Knowledge (self-perceived knowledge of ways to help people who are suicidal) were not fully retained six months later. While these gains were not totally lost, there was a moderate decrease in both.

                Prior and ongoing training matters.

• Previously trained gatekeepersidentified 2.4 times the number of suicidal youth as those with no prior training.

                Procedural knowledge matters.

• For every point increase on a measure of Procedural Knowledge, trainees identified 1.9 times the number of suicidal youth.

                Organizational context matters.

• In comparison to school personnel, child welfare staff identified 5.8 times the number of suicidal youth, juvenile justice staff identified 4.8 times the number, and nurses identified 2.3 times the number.

                Connectedness matters.

• The relationship between youth and adult gatekeepers matters. An example survey item addressing Connectedness was, "Youth talk with me about their thoughts and feelings." For every point increase in Connectedness, trainees identified 1.6 times the number of suicidal youth.

                The targeted populations chosen by TLC do interface with youth at risk of suicide.

• 63% of juvenile justice staff, 55% of child welfare staff, 37% of nurses, and 36% of educators identified at least one suicidal youth in the six months after training.

                Suicide prevention occurs in a system context—therefore, gatekeeper training is most   effective when it addresses communities, organizations, and individuals at all levels.

• A comprehensive staged-approach to training produces behavior change. An effective intervention involves supplemental activities that occur before, during, and after training.

Making Results Real: Creating the Tennessee Actionable Knowledge Product

In conducting evaluations of gatekeeper training, it became increasingly clear from quantitative and qualitative results that training should be tailored to audiences to be most effective. When analyzing feedback from participants, trainers, and organizations affiliated with TSPN and TLC, we identified several system-level and individual-level barriers impeding effective use of skills learned from gatekeeper training. However, existing gatekeeper training curricula were inadequately equipped to address those barriers. We also realized valuable information could be gleaned from existing practices such as how child welfare and juvenile justice staff identify suicidal youth and work with others in their systems to help youth. From this information, we identified system- and individual-level factors (barriers and facilitators) that play critical roles in the success of organizational and individual responses to suicide. These key areas and corresponding recommendations are summarized in

Acting on Knowledge to Create Change

To help organizations and communities increase the effectiveness of gatekeeper training, we developed a Gatekeeper Training Implementation Support System (GTISS). Its stated purpose is to provide practical knowledge and tools used for creating an infrastructure and culture that helps systems, organizations, and communities implement effective suicide prevention strategies. The GTISS has five stages: (1) Preparation, (2) Training, (3) Translation, (4) Application, and (5) Reflection—each stage has one corresponding tool for organizations (the "system level") and gatekeepers (the "individual level"). The five stages and ten tools are based on research evidence, lessons learned from the TLC projects, and direct input from TLC participants concerning effective strategies for translating knowledge into practice. Tool formats include worksheets, templates, charts, toolkits, discussion guides, and surveys–each of which can be tailored to the context of the end user. Figure 2 outlines the stages and associated tools. Local leaders are encouraged to consider the critical participant, organizational, and system factors we have identified in our research, determine how they apply in their local contexts, and use the stages and tools to guide future implementation.

Figure 2.

An example of such guidance is the leadership/management version of the Suicide Prevention Training Needs Survey shown in Figure 3. This survey is designed as a Preparation Stage discussion tool for key figures within a suicide prevention system (community- or organizational-level), including training coordinators, executive-level staff, management teams, supervisors, etc. Used in tandem with the quantitative staff survey, this tool assists in decision-making about approaches to and goals of training. More importantly, perhaps, is how the surveys help decision makers develop and communicate the message that key leaders in the organization will partner with and encourage gatekeepers as they work together to translate and apply knowledge and skills learned in training.

Suicide Prevention in Tennessee

This project benefited from over 10 years of work that the Tennessee Department of Mental Health (TDMH) has done to oversee statewide suicide prevention activities. TDMH coordinates the Tennessee Suicide Prevention Network, a public/private partnership of eight regional groups of survivors, advocates, professionals, community agencies, universities, businesses, and faith-based communities. TDMH received federal grant funding in 2005 to create the Tennessee Lives Count initiative (TLC). The Tennessee Suicide Prevention Network and TLC have worked collaboratively to address suicide prevention in the state—from 2005 to 2008, TLC provided brief gatekeeper training to 18,000+ adults, focusing on those who have contact with at-risk youth ages 10-24. In 2008, TDMH received additional funding to support the suicide prevention initiative in the juvenile justice system (TLC-JJ). To date, TLC-JJ has trained more than 500 adults using comprehensive two-day training. Since 2005, the Centerstone Research Institute has conducted program evaluations of the two TLC projects. After the initial award, the institute received Enhanced Evaluation funds from the Centers for Disease Control and Prevention to address some important questions about the effectiveness of gatekeeper training.

Funding

The GTISS was created as part of an inter-agency agreement between the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) to create "Actionable Knowledge."  We are indebted to our national supporters for six years of funding and collaboration that allowed our work to flourish.