Abstract
Aims:
A series of podcasts and videos was created to assist medical students with learning about suicide prevention. The aim of this research was to explore medical students experiences of using a suicide prevention learning resource.
Methods:
A multimedia repository of learning resources for suicide prevention was designed and created for use across all years of the medical programme at The University of Auckland. Emphasis was placed on ensuring that the resource was culturally safe. The impact of the learning resource was evaluated with a qualitative approach using focus group methodology. Two focus groups were audio-recorded, transcribed and a thematic analysis was conducted employing three cycles of coding.
Results:
Three themes were identified: perceiving that suicide is complex and sensitive; tailoring knowledge to match students’ developmental stage and context; and elements that facilitated interaction with the resource.
Conclusions:
Suicide is unsurprisingly a challenging topic for medical students. The students in this study actively engaged with this resource on suicide prevention, which supplemented their core learning of the topic. Early access to resources developed in a culturally safe way within a spiral curriculum empowers students to understand that they have an important contribution to make in preventing suicide. This may prepare them for encountering suicide with peers, family members and in clinical practice.
Introduction
Encounters with suicide take place in all fields of medical practice; with patients and peers. Medical schools, particularly clinical teachers in psychological health and primary care, have a responsibility for preparing graduates to work with people who contemplate suicide (Balon et al., 2014). We know that suicide is a topic that medical students grapple with through their training (Cheng et al., 2014). Within a packed medical curriculum it can be challenging to provide early training in mental health literacy, psychological first aid and clinical psychiatry (Nguyen, 2021). Such training can improve students’ confidence in helping others, deconstructing stigmatising attitudes and taking active measures to support their own psychological health at their stage of learning (Davies et al., 2018; Lyons, 2013).
An integrated curriculum design facilitates skill acquisition and knowledge retention (Brauer & Ferguson, 2015). Suicide prevention may be regarded as an example of a topic that requires a broad, thoughtful approach across disciplines that leads students to master skills and build knowledge in a logical and stepwise manner (Harden, 1999). Curriculum approaches can include lectures, small groups, e-learning, simulation based learning and authentic learning in the clinical setting (Hawgood et al., 2008). Curriculum considerations include prioritising course content, contextual learning and assessment of skills mastery (Burke & Brodkey, 2006; Hazell et al., 1999); promoting clinical reasoning in educational interventions (Chaudhary et al., 2019; Morriss et al., 1999), a graduated learning process over years of training and pastoral care issues including students’ own psychological health and concerns for their loved ones (Moir et al., 2018). In addition to learning ‘psychological first aid’ to respond to a person in mental distress, relevant content may include epidemiology, mental illness, stress reduction and avenues for support (Roman, 2015). Teaching about suicide prevention within a medical curriculum may have multiple aims alongside students gaining knowledge and skills. These might include improving access to reliable mental health information, de-stigmatising psychological difficulties, facilitating a supportive learning environment and promoting peer and faculty competence in responding to issues that accompany a topic that invokes anxiety among students and staff. Students at the early stage of training may encounter suicide in their personal lives and may have taken on a ‘trusted listener’ role well before they enter a clinical context. Therefore, it may be important to promote early interventions that upskill students in conversing about suicide (Teodorczuk et al., 2017). As well as supporting students in their personal lives, this provides training and support in advance of a student encountering a patient with suicidal thoughts during a clinical rotation (Henry et al., 2020).
Suicide is a societal concern that all doctors are required to respond to personally and/or professionally (Monrouxe, 2010). Medical training is a key time of emerging adulthood where students explore their identity (Arnett, 2007). Offering students opportunities to reflect on their role in encounters with people who are suicidal signals that a professional response is required. The topic is not a comfortable one as it deals with ambiguity, incomplete information and consideration of multiple perspectives (Cruess & Cruess, 1997). Students’ lived experience(s) or discomfort can lead them to be reluctant or even resistant to conversing about suicide. However, providing a foundation of learning in this topic builds confidence and attributes of reflection, self-awareness, respect for others, accountability for actions and social responsibility (Hilton & Slotnick, 2005). Curricula that develop these meta-skills foster attainment of professionalism. Conversations about suicide also require a self-aware, culturally safe approach, with respectful communication, development of trust and avoidance of assumptions and stereotyping (Curtis et al., 2019).
The early curriculum (years 2 and 3) of our medical programme at The University of Auckland includes longitudinal learning in professional, personal and clinical skills contained in eight core modules per year. The curriculum is built around five broad domains: applied science for medicine; clinical and communication skills, personal and professional skills; Hauora Māori (covering facets of indigenous health); and population health. The professional and clinical skills (PCS) modules in Years 2 and 3 focus on preparing students for the skills and behaviours required for clinical practice in years 4 to 6. PCS lectures are reinforced by small group learning that incorporates self-care and mindfulness-based practices. In response to requests from students, we introduced teaching of specific psychological core health topics in 2018, including how to respond to someone with suicidal thoughts. However, students provided feedback that they would like more on the topic of suicide prevention. It is clear that medical students would like to be more prepared for encounters with suicide in their personal and professional lives, and that ideally this topic should not just be reserved for the psychiatry curriculum. Addressing this problem requires a culturally-safe sensitive educational approach, with learning materials being made readily available.
In this study, we aimed to ascertain the learning value of a resource that was developed around suicide prevention. In seeking to evaluate the resource, we posed the following research objectives:
To explore students’ response to the resource
To assess students’ use of the resource
To identify factors within the resource that support learning
To propose modifications to the resource to increase its acceptability to future students
To explore these objectives we chose a qualitative method using semi-structured focus groups to give students the opportunity to describe and express their experiences of interacting with and responding to the resource.
Methods
This focus group study has been conducted and reported in line with the standards for reporting qualitative research (O’Brien et al., 2014). Ethical approval was obtained from The University of Auckland Human Participants Ethics Committee.
Reflexivity
The authors are a group of academic and clinical staff who contribute to the medical programme, working in areas of psychiatry, psychology, general practice, palliative care and medical education. One of the authors works as a Māori cultural advisor and provided advice for the research in order to safeguard Māori interests, autonomy and promote Māori equity. Five of the authors were involved in the development of the repository of resources and therefore oversaw the content and overarching project. This brought an investment in the resources which is acknowledged and was addressed by having an independent focus group facilitator, an independent third coder and co-authors who were less invested and could offer challenge.
Setting
The MBChB at The University of Auckland is a 6-year programme, with Year 1 being a common health sciences year from which the majority of students are selected to start the medical programme in Year 2. Approximately a quarter of Year 2 entrants are graduates. Years 2 and 3 constitute early learning, most often, campus-based lectures, tutorials and labs, with some simulated and workplace learning, whilst Years 4 to 6 consist largely of workplace-based learning on clinical attachments.
Development of the multimedia resource
The suicide prevention repository was designed in 2019 and provided to all students from 2020. We conducted a scoping exercise with medical students associated with a student-led psychiatry interest network that included students from all years of the medical programme. This process yielded content and delivery ideas for the educational resource, including potential sub-topics suggested by students. This student input, alongside that from clinicians, researchers and service users, contributed to the development of an electronic repository of asynchronous suicide prevention resources for medical students (Appendix 1). Within the resource, we incorporated theoretical and evidence-based principles related to topics of suicide and teaching and learning methods combined didactic, small group work and self-directed learning. We were aware of making content accessible to cover all stages of the medical programme and layering online learning with practical clinical experience. We also designed a synchronous, structured, mandatory session focused on suicide prevention (Appendix 2). We held an established premise in developing the resource – to enable students to feel they can contribute to preventing suicide, and that they do not need to be experts to converse with others about suicide. Resources were developed to match a range of learning levels and experience (Taylor & Hamdy, 2013). Particular emphasis was placed on early learners as they are in transition from lay people to medical students and then from junior students to clinically-immersed trainees.
Participants and data collection
Focus groups were selected as the data collection method as the researchers considered that the group process might yield additional data. For focus groups, we selected a purposive sample of medical students to participate. We included students with a special interest in psychiatry or those who had completed a psychiatry rotation. The reason for doing this was to promote focus group discussion with students who may have chosen to access the multimedia resource or were potentially more inclined to discuss suicide. However, it transpired that some students viewed the resource for the first time in the focus groups. Invitations were sent to potential participants via administrators for clinical psychiatry rotations and to student leaders of a Special Interest Psychiatry Network. Students were recruited and invited to join a focus group at a set time. A semi-structured interview guide was designed, and both focus groups were facilitated by a research assistant to provide objectivity. The same interview guide was used for both groups. Focus groups were audio-recorded and professionally transcribed. Student names and any other identifying data were removed before analysis. Field notes made by the group facilitator indicated constructive group dynamics and active engagement in both groups.
Data analysis
The transcripts were returned to participants for member checking. Transcripts were initially read for familiarisation and then re-read, and interview segments were assigned codes by two of the authors (LN, FM), using an inductive approach (Braun & Clarke, 2006; Thomas, 2006). We approached thematic analysis in an iterative manner, with three successive rounds of coding and the creation of a codebook. The first and second rounds of coding were conducted individually by the two coders. An audit trail was documented in NVivo containing memoranda containing reflections and questions on the analysis. The two coders discussed the coding framework (codebook) and conceptualised broader overarching themes and sub-themes. In the third round, the transcripts were reviewed by an independent researcher (LL) and the coding framework was discussed with all coders and further refined. The final themes, codes and coding were agreed between the three coders.
Results
Nine medical students participated in two focus groups (Year 2 (n = 1), Year 4 (n = 4) and Year 6 (n = 4)) Four were female and five were male; and they were of Chinese, European, Indian and Māori ethnicity. We identified three main themes: perceiving suicide as a complex and sensitive topic; the need for knowledge to be tailored to match students’ developmental stage and context; and elements that facilitated interaction with the resource. We report each theme with sub-themes, including illustrative quotes.
Perceiving suicide as a complex, sensitive topic
Students perceived suicide as daunting: the idea of talking about it as well as the content contained within the suicide prevention resource. They perceived that provision of the electronic resource highlighted the importance of the topic. Participants (including senior students) described their limited pre-knowledge of suicide prevention, that being exposed to the topic provided some reassurance if they were to converse with someone who spoke about suicide, and that they learnt practical skills that they could apply.
i) A daunting topic: Students, acknowledged suicide to be ‘very intimidating’, uncomfortable, confronting, stigmatising and fear evoking: ‘it’s difficult because it’s a very sensitive topic, you don’t want to say the wrong thing’. They described the material as ‘incredibly useful’ with therapeutic benefits in terms of self-care and countering feelings of anxiety in asking questions about suicide: ‘it definitely makes you more comfortable. . .the presenters are very reassuring in their approach’.
ii) Limited pre-knowledge: Students described variable, ad-hoc knowledge about suicide in the early stages of training: ‘we are not well equipped with skills’. Some attributed feelings of inadequacy to inexperience and their juniority.
iii) Students felt reassured and empowered: Students described positive benefits of the resources: ‘from what I’ve seen of it, it’s all incredibly useful’. Students described feeling more comfortable to converse about suicide: ‘calming yourself. . .making us realise it’s not something to be afraid of’. Some reported the resources bolstered confidence: ‘the feeling of inadequacy of being a person to go to, who is qualified to give support to a person in mental distress. . .the podcasts are really good and reassuring. . .teaching you how to do that’. Some felt empowered, ‘much more so after seeing the available resources. . .[which were] pretty much non-existent before that’.
iv) Cultural safety: Students reported ‘definite value’ in the emphasis on supporting holistic aspects of Māori and Pacific wellbeing: ‘It’s fantastic that you’ve got Māori and Pasifika [perspectives] in there, it’s important in terms of making people learn that mental health presents differently in different cultures. . .every person presents different, everyone has their own journey and their own experience’.
Tailoring knowledge to fit developmental stage and context
Participants described they were more likely to use the electronic resource when they interacted with someone who had suicidal thoughts or if the resource was introduced in a specific context, such as while doing clinical psychiatry. Some participants described the timing of accessing content and their stage of training as important; more senior students described the material as ‘the deep end for preclinical students if it is the first major resource on suicide they have been exposed to’. They identified the importance of training to be present with someone who had suicidal thoughts and the need to acquire practical knowledge with increasing seniority. Students articulated their experience of exponential learning in clinical years as they progressed through various clinical attachments, including psychiatry when suicide was highlighted in risk assessment, and general practice, where it was common to address psychological issues with patients during consultations.
i) Essential training: Students identified related learning in psychological first aid skills as ‘completely crucial’ in preparing them to apply the skills to an actual clinical situation: ‘being able to deal with acute mental health crises should be bread and butter as CPR [cardiopulmonary resuscitation]’.
ii) Salience: Students were more likely to seek out material on suicide prevention at specific times, such as after a critical incident or at a time they perceived it to be important: ‘if something goes wrong in a clinical environment, a suicide attempt on the wards. . .if it happened with one of the patients I knew well, I can definitely see myself going to that [resource]’. They proposed that a critical event would enable student to engage more deeply with learning when they were already aware that specific resources were accessible and relevant.
iii) Developmental stage: Clinical students found the material practically helpful in their transition to the clinical environment, ‘really good resources to incorporate, augment or supplement knowledge for the psychiatry run’. Some emphasised specific clinical skills, ‘for example the risk assessment portion, you can go into it and make notes . . .you might refer back it as a refresher or recommend it to someone else’.
Elements that facilitated interaction with the resource
Students highlighted the benefits of a learning environment that supported concepts of vertical integration of knowledge and the development of competence. Foundation concepts can be introduced and reinforced in clinical practice after students had gained some experience in the field. They considered that resources were more useful when different learning preferences were incorporated, for example visual aids. The students had mixed views of assessment, with some advocating for compulsory testing of knowledge as this was an important topic. Some participants deemed podcasts to be excessively lengthy, rendering material less accessible and difficult to retain.
i) Integrating learning: Students reported that the resources reinforced learning derived from a combination of lectures, workshops and clinical experience. They supported introducing the resources: ‘in second year listen to the podcast and writing a reflection then submitting it to tutors, that’s a good introduction’ and subsequently embedding in-depth learning at clinical stages of training: ‘go through these particular modules, you’d engage with them. . .then go back to them [later] as a form of debrief, that would be the time I’d wish to go back to them’. Students rebuffed the idea that teaching them about suicide prevention should be delayed until psychiatry in their more senior years of medical school: ‘the first time I encountered help in dealing with the topic of suicide was in fifth year psychiatry, up until then I would say I hadn’t come across it, hadn’t had much exposure to it and hadn’t grown in skills’. They expressed that retaining core skills for future use was viewed as important, as was maintaining their own psychological health: ‘exercise, socializing, eating well, sleeping well, mindful activity. . .put emphasis on these five and that is a structure for looking after mental health’. Competing demands on time were identified by students as a barrier to accessing the resource, as was feeling pressured by a task-driven imperative at medical school, ‘the main restraint is time when it’s available as a resource but not a compulsory part of education’.
ii) Taking into account learning preferences: Students reported that the electronic resource were thoughtfully designed and demonstrated awareness of their learning styles: ‘I liked having transcripts as well. . .it depends on how people take in their information, some prefer to have visual and some want to be listening while they’re doing something else, having the choice and the combination of the two is really good’. Some cited preferences for tandem visual aids such as diagrams, bookmarks highlighting key material and take-home messages presented on power point. The inclusion of multiple perspectives – personal lived experience, clinical and cultural – made some students consider future scenarios where they might apply their skills, ‘to go further in-depth from one’s own interest, only through that do you get the investment, retainment of information and knowledge for the long-term’.
iii) Assessment: Perspectives on assessment varied. Some stated that incorporating some assessment would highlight the importance of suicide prevention ‘awareness of the topic should be compulsory in the medical curriculum’ and would ensure that students engaged with the topic: ‘it’s definitely of sufficient importance to warrant some sort of assessment’. Others put forward the view that compulsory assessment of a clinical scenario based on suicide triggered difficult emotions in students, thereby disadvantaging them as they were being marked on performance: ‘we’ve got to be careful, it’s a triggering sensitive issue and thinking about the way we assess it’. Some proposed module-based online testing of knowledge: ‘a component you want everyone to pass so people have to do multichoice tests at the end, like a computer module’. Many discussed mandating psychological first aid or small group activities based on talking to patients about suicide: ‘must attend versus must pass’. They endorsed some form of thoughtful examination that tested core skills in psychological first aid such as listening to people in distress, validation of their concerns and observing safety and appropriate boundaries.
Discussion
In this research, we aimed to explore medical students experiences of using a suicide prevention learning resource. Direct feedback was gained from students using focus group methodology. The complex and sensitive nature of suicide as a topic was discussed by students, with all finding the resource stimulated personal engagement that demystified the topic. Students found it helpful to consider a person’s cultural background as the resource specifically covered Māori and Pacific perspectives. The medical students in our study perceived suicide prevention as essential learning, which should start in the early years of a medical curriculum. They also liked the concept of having the resource available whenever it was needed throughout the programme. Students connected with ideas of safety and boundaries and the ability to practise responses to a person who has thoughts of suicide, after engaging with the material. Students provided useful feedback on how a resource such is this should be integrated, signalled, staged and assessed. Overall the students found that electronic resources were useful in introducing the topic at an early stage of training and also for supplementing learning as they progressed to clinical rotations in psychiatry and general practice.
This study is an example of evaluating how cognitive and psychosocial meta-skills are acquired in a stage-appropriate way (Hilton & Slotnick, 2005). Medical students learn at a time of developmental challenge as they accept increasing social roles and obligations, as well as some experiencing their own mental health problems (Arnett, 2007). Some find themselves emotionally taxed in responding to people in psychological distress (Gallan et al., 2020). The multimedia resource promotes active learning experiences as clinical teachers and peers role-model expectations that students transitioning into medical professionals have a definite role in interacting with and relating to people with mental distress who are thinking about suicide (Monrouxe, 2010). Early introduction and ongoing access to the resource enables students to move from a naïve stance to evolving their skillbase (Hilton & Slotnick, 2005) as they will eventually hold specialised knowledge that they will use to serve their patients and society (Cruess et al., 2000).
Suicide can be considered one of the hardest of human problems, including recognition, prevention and management of someone with suicidal thoughts (Balon et al., 2014). We already knew that this was a topic that was likely to be confronting (Cheng et al., 2014), and this was reinforced in our data. However, these students found the resources reduced their perceived anxiety and helped them to prepare for having difficult discussions. We aimed to prepare students for encounters with suicide and normalise such interactions, and this data is reassuring, if not confirmatory. In training, medical students may be sought out by friends and family members to provide support in conversations about suicide. Some will eventually become part of a clinical team affected by a patient suicide; this resource may provide specific support as proposed by Henry et al. (2020) Our motivation to create this repository of podcasts and videos was inspired by students’ concerns about their own wellbeing and that of their peers, which may be linked to psychological needs of competence, autonomy and relatedness (Averill & Major, 2020). Students involved with designing and constructing the resources described feeling more confident to relate to the content and to be able to respond to someone with suicidal thoughts. This is in keeping with strategies for young people to have meaningful input in the early stages of any initiative (New Zealand Ministry of Youth Affairs, 2002). The resources emphasise knowledge and tools that would enable medical students to respond to an encounter with a person who is thinking about suicide. Skills in psychological first aid were incorporated within the resources, which students identified as personally useful in terms of safety, boundaries and taking responsibility for seeking out support for themselves and peers.
In our context, developing this resource in New Zealand, a bicultural society, we met with with a cultural consultant, in keeping with obligations to Māori under Te Tiriti o Waitangi (the Treaty of Waitangi). In simple terms the underlying principles can be described as requiring partnership, participation and protection to ensure equitable health outcomes for Māori. We would recommend a similar grounded and culturally safe approach to a sensitive project such as this in other settings (Curtis et al., 2019).
Our students reported that they benefitted from learning that provided a foundation to build on as they gained clinical experience. In this way, new learning is related to previous learning, increasing competence (Harden, 1999). They articulated that they felt more confident to discuss suicide amongst themselves and with patients. The research revealed that a gradual introduction to key areas of a daunting topic was more likely to reinforce learning at salient times, particularly as students encountered critical incidents and moved from being a student to having a health professional identity. Tailoring knowledge to the developmental stage of their educational journey suggests that knowledge about suicide prevention is needed at all levels rather than waiting until they start clinical psychiatry. The material may be more salient for some but is relevant at all stages. Some participants acknowledged personal and family mental health issues and the desire to learn strategies to support themselves and others. The shift to ownership of self-directed learning may reflect cognitive maturity and improved reflective functioning (Arnett, 2007).
It has been suggested that medical programmes have an important role in providing mental health literacy (Nguyen, 2021). We suggest that tailoring suicide prevention material to medical students may help them feel more confident to respond to those with mental distress. Attendance at small group activities in Year 2 (how to talk about suicide) and Year 3 (psychological health with a clinical scenario including asking a patient about suicidal thoughts) were mandatory and we believe this clearly set an expectation for students that all medical professionals require core skills to respond to someone in mental distress. Students may invest more time in the resources if they understand the relevance of the topic, hence the importance of small group work in early training to provide some context at a stage where learners have limited clinical exposure (Brauer & Ferguson, 2015). Students identified the importance of developing self-care and constructive coping strategies for their own wellbeing, something identified in other work (Butler et al., 2019; Kramen-Kahn & Hansen, 1998), and this was the subject of one of the podcasts and emphasised in small group work. The requirement for assessment was not viewed unanimously and was nuanced. However, students were clear in stating that some core learning in this area should be compulsory.
In this study, students indicated that they were interested in learning about suicide encounters well before they see patients in clinical practice. Future research might examine how and when students access resources on suicide prevention and seek to measure impact in practice. Exploring the delivery format and innovative technology would further identify preferences for learning.
Strengths and limitations
Strengths: A strength of the study was the facilitation of both focus groups by an independent research assistant, a recently graduated doctor. The analytic rigour enhanced trustworthiness as coding was conducted by three researchers, one of whom was independent of the study.
Limitations: The study was undertaken in one institution. We did not interview tutors involved with small group teaching which may have provided more detailed data on the intricacies of teaching this topic at Years 2 and 3 level. Therefore, we only analysed the learner perspective. Some results relate to specific material we developed for the New Zealand cultural context and may not be transferable to other countries. The participants in this sample comprised students with a special interest in psychiatry or had completed a psychiatry rotation and therefore may not be representative of medical students more generally. The uncertainty of COVID pandemic restrictions led to the postponement of one focus group. The resource repository was optional and asynchronous, and some students may choose not to access them, given their heavy workload. Some students viewed the resource for the first time in the focus groups which may have affected the nature of reflections that were offered.
Conclusion
Suicide is a challenging topic for medical students, even in later stages of the programme. Students valued a culturally safe approach and engaged actively with the suicide prevention resource, which provided nuanced knowledge to supplement core learning in the medical curriculum. Students supported early access within a spiral curriculum. They felt empowered to contribute to preventing suicide. Students indicated that engaging with the resources increased their confidence and destigmatised the topic and offered practical advice regarding content and staging of resources to maximise engagement. Exposure to suicide as a topic may prepare medical students for encountering suicide with peers and family members as well as in clinical practice.
Footnotes
Appendix
Small group activity on how to talk about suicide.
| 1. Reflection: listen to a podcast and write a short reflection |
| 2. Students’ safety in discussing a sensitive topic: introducing concepts of confidentiality, professional boundaries and that talking about suicide can evoke distress but is an essential skill as a health professional. |
| 3. Discussion of how to be present with someone who is thinking about suicide (small groups) |
| What might someone say when they are thinking about suicide? |
| What might they be feeling? |
| How do you ask the question? |
| What non-verbal cues might you observe? |
| How might you feel when someone tells you they are thinking about death and suicide? |
| How might you respond? |
| 4. Discussion of contributing factors: Discussion of stress and the range of contributory factors to someone feeling vulnerable and suicidal |
| 5. Support: Discussion of podcast resources highlighting an individual’s decision to seek support. Students discuss what support they would seek and barriers to seeking help. |
| 6. Closing discussion. Questions about the small group activity and refer to podcast and video series. Emphasis that talking about suicide does not cause someone to die by suicide. Finish with karakia (prayer). |
| 7. Mindfulness exercise. |
Acknowledgements
The authors gratefully acknowledge the contributions of the research participants. Thank you to the many people who assisted with creating the podcasts and videos, especially Hamish Cowan, Teremoana Latimer, Uchit Gangoli and Tim Page. Thanks to Sobitha Manoharan for facilitating the focus groups and to Lyn Lavery for her assistance with the analysis. Since this research was conducted, the suicide-prevention resource has now been incorporated into a small group exercise that all students attend in Year 2.
Author contributions
Lillian Ng and Ashwini Datt are responsible for the concept of the work, development of the resource, study design and data collection. Lillian Ng and Fiona Moir are responsible for the primary analysis and interpretation of the data. All authors contributed to critically revising the content of the article and approving the final version. The authors are jointly responsible for the accuracy and integrity of the work.
Data availability
The authors report direct access to the study data. Access to surveys and transcripts of interviews with participants are stored in accordance with New Zealand ethics committee (UAHPEC) guidelines (Reference 023528).
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors would like to acknowledge the funding award received from the Daniel and Olga Archibald Medical Education Research Fund. The development of the Suicide prevention multimedia repository was supported by a Learning Enhancement Grant at The University of Auckland.
