Creation and validation of a high-fidelity simulation scenario for suicide postvention

Abstract Objective to create and validate a high-fidelity simulation scenario about the initial support to suicide bereaved people. Method a methodological research study to create and validate a simulation scenario about postvention. Its creation was based on scientific recommendations, the validation process was carried out by experts, based on an instrument developed by the authors; the data were statistically analyzed using the Content Validity Index and Gwet concordance coefficient. Results the scenario was created to provide initial support to suicide bereaved people in the Primary Health Care context. As learning objectives, welcoming, health care and organization monitoring were proposed according to technical-scientific recommendations. The scenario was validated by 10 specialists in the themes of postvention (5 judges) and high-fidelity simulation (5 judges). The scenario items met the acceptance and reliability criteria (Content Validity Index = 0.80) and satisfactory concordance (Gwet coefficient = 0.640). Conclusion the study presented in full a scenario on postvention with innovative potential that can be used free of charge in clinical simulation development during training of different categories of health professionals, to act in support of suicide bereaved people.


Introduction
Suicide is a social, complex and multifactorial phenomenon with significant numbers and impact at the global level (1) . A little explored aspect of suicide prevention is postvention, which refers to a wide set of actions and strategies carried out after a death due to suicide with the survivors (2)(3) . Listed in the scientific literature as an essential factor for suicide prevention in different contexts, postvention is related to care, welcoming, social and individual support provided to a suicide bereaved individual (3)(4)(5) .
More than 130 people are directly or indirectly affected by a single death due to suicide (2) . Suicide bereaved people can experience different feelings, sensations, reactions and psychological and physical changes during grief, which can present different aspects of experiences from other types of bereavement (6)(7) .

Improving strategies and interventions focused on
training and qualification of health human resources for the prevention and postvention of suicide is fundamental to manage the problem (3,8) . Thus, clinical simulation is considered a promising educational strategy to qualify human resources in the health area (9) .
Structured and systematized planning of a highfidelity simulation scenario is fundamental for the simulated clinical practice to be successful (10)(11) . For this reason, creation of a scenario is the first stage of a carefully developed proposal and must consider aspects of planning, development, reflection and evaluation of the simulation (10-13) . Another extremely important aspect is validation of the scenario by expert judges, in order to verify validity of the objectives and results proposed for the simulation (14) .
The lack of Brazilian studies on postvention, as well as of creative and innovative methods for the training of human resources in health based on good care practices, highlights the need to expand discussions and knowledge, focusing on support for suicide bereaved people (8,15) .
In this context, development of a fully available highfidelity clinical simulation scenario for postvention enables scientific progress on the theme with potential subsidies and results for health care improvement. Thus, the current study aims to create and validate a high-fidelity simulation scenario about the initial support to suicide bereaved people.

Method Study design
This a research study of a methodological nature (16) that describes the creation and validation of a high-fidelity clinical simulation scenario about suicide postvention.

Creation of the simulated scenario
The scenario was created in a Higher Education Institution in the city of Ribeirão Preto, State of São Paulo, from a script previously prepared by the research authors and in accordance with national and international recommendations on high-fidelity clinical simulation for the training of human resources in health (10)(11)17) . A number of researchers and a Nursing professor specialized in the clinical simulation and mental health areas took part in creation of the scenario.
The script built for elaboration of the scenario was defined in two sections and structured in 12 items, which direct planning (seven items) and development of a highfidelity simulation (five items). This division proposal was defined in order to facilitate organization of the diverse information and contents necessary for preparing the simulation, such as the necessary prior knowledge, learning objective, preparation and development of the simulated activity, theoretical foundation and debriefing.
The scenario was internally evaluated and reviewed by members (undergraduate and graduate students) of the authors' research team.
Through internal evaluation, changes were suggested in relation to the scenario content and appearance, in addition to the final review of the material, considering spelling and grammatical aspects of the writing. The changes proposed were discussed among the research authors and, subsequently, they were accepted or refused according to the possibility of improving and adapting the scenario. Based on the adjustments made in the internal evaluation and validation stages, the final version of the scenario was defined, in order to address and emphasize real aspects related to the initial support that has to be provided by students and health professionals to suicide bereaved people.

Face and content validation of the simulated scenario
The validation process for the scenario was conducted between March and September 2020 by means of online virtual tools. At this stage, it was decided to select 10 expert judges (16,24) , five with expertise in postvention and another five with expertise in high-fidelity simulation.

Selection of the participants or specialists
For selection and characterization of the specialists, a number of adapted criteria about expertise in the themes were used (25) . The criteria were having a curriculum on Pedrollo LFS, Silva AC, Zanetti ACG, Vedana KGC.
the Lattes Platform (a channel created by the National

Council for Scientific and Technological Development
-CNPq-that integrates the curricula and centralizes the scientific information of Brazilian researchers) that proves that the specialist meets, at least, one of the following items: a) Master's or PhD degree with a paper on the topic (postvention and high-fidelity simulation); b) guidance of academic papers on the topic; c) teaching experience in the area; d) authorship of scientific articles on the theme in high-impact journals; e) guest speaker at a national or international scientific event on the theme.
The search for specialists was carried out via Lattes Curriculum, using the "search curriculum" tool with active

Data treatment and analysis
The data obtained from the 10 evaluations by the expert judges were organized and transcribed into a Microsoft Excel 10 spreadsheet, with double typing and crossing of the typings. The study analyses were performed with the statistical support, by means of the R software.
The data obtained in the questionnaire for the sociodemographic characterization of the judges were analyzed by means of descriptive statistics. The statistical analysis of the data regarding validation of the scenario was carried out using the Content Validity Index (CVI) and the Gwet agreement coefficient, the First-order Agreement Coefficient (AC1) (26)(27) . For the study, CVI values equal to or greater than 0.80 or 80% were considered (obtained from the following calculation: "total number of 'adequate and fair' answers/total number of answers") and AC1 values close to 1 representing greater agreement (< 0.40 poor; from 0.41 to 0.75 satisfactory to good and from 0.75 to 1.00 excellent) (28) .
The compilation of suggestions and comments received in the judges' evaluations was transcribed into an editable document, ordered according to each item in the template created specifically for this study and reviewed by the research authors, as a basis for necessary changes in the scenario.

Ethical aspects
The study was approved by the Research Ethics

Validation of the simulated scenario
The postvention scenario was validated by 10 experts, mostly women (90%), with a mean age of 44.6 years old (minimum 31, maximum 58, median 43.5, and standard deviation = 8.02). In relation to the geographical location of the judges, three were from the Southeast region (30%), another three were from the South region (30%), two were from the Northeast region (20%) and another two were from the Midwest region (20%).
The study participants attended the following In relation to acceptance and agreement (CVI), all the scenario items obtained values equal to or greater than 0.90, thus reaching the minimum approval criterion (CVI = 0.80) ( Table 1). The Yes (adequate and fair) and No (inadequate) options were used for both analyses.   Title of the scenario Initial support for suicide bereaved people (postvention)

General objective
To develop initial support actions to suicide bereaved people during a home visit.

Target audience of the scenario (scenario participants)
Undergraduate students from the health area (having attended some academic discipline related to Mental Health/Psychiatry) and health professionals.
Number of people required to develop the scenario • Two simulation facilitators (in charge of planning, coordinating and developing the simulated activity); • Two participants (target audience), who took part in the simulated activity; • One simulated patient (who will simulate the person treated in the scenario); • Observers (other participants from the target audience who will externally monitor development of the scenario proposed, as observers of the simulation).
Physical and material resources • Physical: Teaching or educational practice laboratory, that simulates a living room from a house (depending on the regional context) to conduct a home visit. • Materials: Common objects that make up a domestic environment (living room) depending on the regional context, such as chairs, cushions, rocking hammock, radio or television, glasses, books, pens and decorative objects, among others.

Pre-briefing (diverse information about contracts and conduction of the simulation)
1. Introduce the environment to the scenario participants; 2. Discuss contracts about emotional safety: secrecy, anonymity, respect and importance of participating in the discussion after the simulation. 3. The following is not foreseen for this simulated case: handoff, reading the user's medical chart and presentation and/or use of drug prescription.

Pre-briefing (basic guidelines for the simulated case -They can be read
and no information should be omitted) This simulation will be developed with the participation of a simulated patient.
You are health students/professionals and are in a Basic Health Unit. For today's activity, you were requested by the health team to carry out a home visit to Mrs. Marta, 44, who lost her son Bruno, 22, due to suicide 3 days ago. You have approximately 20 minutes to perform the initial welcoming of Mrs. Marta, as you need to return to the health service for a team meeting that will discuss users' cases. Consequently, it is necessary to evaluate the user's initial needs and implement the required immediate actions.
You have to concentrate on the initial welcoming and support actions towards the user in this case (which are important for the individualized therapeutic plan). Immediate postvention support has already been carried out with the user immediately after the death due to suicide and there will be a subsequent follow-up of the user by the Health Unit, which does not need to be fully planned during the scenario. The simulation laboratory will not be subjected to the intervention of people outside the activity, and will be completed by the simulation facilitators when at least one person from the health team leaves the user's home or at the end of the maximum execution time.
Question for the participants and observers: Do you have any doubt about the guidelines and preparation presented?
Instructions for the simulated patient (preparation must be done in the days before the simulation) You will be Mrs. Martha, 44, who lost her 22-year-old son due to suicide 3 days ago. During the simulation, you should address some feelings, sensations and difficulties experienced in the period of mourning, presented in the form of clues, such as: Clues that you will necessarily address in the case • Unbearable pain and sorrow; • Guilt: "I feel guilty for his death"/"I am to blame for his death, I should've done something"; • Anger: "He didn't think about me, he didn't think that I'd be left alone"; • Shame: "I don't want to go out of the house any more, people keep saying things about me"; • Denial and questions related to the death; • "I want to disappear, but not to kill myself"; • Difficulty performing daily activities (self-care); • "People close to me don't mention my son's name and don't want to talk about what happened".
Clues that you will address if you have the possibility/opportunity to do so • Loneliness and isolation; • Lack of listening and attention from other people; • "The wish to sell my house and move"; • Reporting that the son's birthday would be next month (birthday-related reactions): "I don't think I can live that day without him!"; • Reporting that she saw some posts by her son some years ago on the Internet about wanting to die, but she thought he was only kidding with friends. Note: It is necessary for the simulated patient to know the "Structured Objective Clinical Examination" (item below) before the staging, in order to program her clues according to what is expected in the scenario.

Discussion
The use of clinical simulation in the training and qualification processes of human resources in health has been the focus of several studies over the last few years (29)(30)(31)(32) . The initiative to create and validate a highfidelity simulation scenario related to initial support for suicide bereaved people originated from the interest in grounding knowledge and care processes on postvention, from a realistic approach and with training potential (29,31) .
In mental health education, especially in approaches to suicide prevention and postvention, the use of highfidelity simulation, as well as other innovative methods, is still poorly portrayed at national and international

Analytical Phase (Evidence perspectives about non-technical skills involved in the simulation that were important for the participants)
• How did you feel while offering the initial support to Mrs. Martha? Comment. (Question directed to the scenario participants and observers). • How did you offer the initial support to Mrs. Martha? (Question directed to the observers). • How do you assess your performance in the group work while offering the initial support to Mrs. Martha? (Question directed to the scenario participants). • What positive actions were performed while offering the initial support to Mrs. Martha? (Question directed to the scenario participants and observers).

Application Phase (Evidence perspectives about how the participants may apply this knowledge in their clinical practice)
• What would you do differently when facing a new experience of initial support to a suicide bereaved person? (Question directed to the scenario participants). • What can you learn from this experience in the simulation about postvention, and apply it to you professional practice? (Question directed to the scenario participants and observers). levels (8,30) . These findings corroborate the analyses of recent studies showing the difficulties encountered by health professionals in the construction of knowledge and attitudes towards mental health care (33)(34) .

Development of a clinical simulation is initiated in
the structured and systematized creation of a simulated scenario, with a clear definition of the objectives and expected results (35) . The scientific literature about the elaboration of scenarios highlights the importance of resorting to a simulation script that structures the activity to be performed (10-11) .
Among some aspects that comprise elaboration of a scenario, the establishment of theoretical frameworks on the themes of study is evidenced, as well as a careful assessment of needs to be addressed, selection and preparation of the simulated patient, and definition of target audience and necessary resources (10)(11)14) .
In addition to that, other issues are important in this process, among them the participation of a prepared and experienced facilitator to conduct the simulated scenario, as well as offering moments of reflection and learning of the practice experienced (10-11,17,36) .
The scenario entitled "Initial support for suicide bereaved people (postvention)" was developed based on national and international recommendations on clinical simulation and structured in two sections, based on a template mentioned before (10)(11)17) . The objectives and expected results in a high-fidelity simulation, preparation (pre-briefing), development (simulation) and reflection for learning (debriefing), were included in this construction in order to favor the participants' teaching-learning process.
In the pre-briefing, guidelines and basic information necessary for the development of the simulated case are presented to the participants, including all preparation prior to the activity (12,37) . During simulation development, The initial support to a suicide bereaved person proposed in this scenario was described as high-fidelity, in order to value the proximity degree of the activity developed with the care reality, including the complexity to be worked on in the scenario (39) . It is worth mentioning that fidelity is related to simulation planning, as realism is based on definitions related to the expected objectives, environment and preparation, choice of participants and physical and material resources to be used (40) .
Characteristics commonly described in the scientific literature on bereavement due to suicide experiences, such as guilt, stigmatization, rejection, shame, anger, less self-care and higher suicide risk, were some of the aspects addressed in the scenario (6)(7) . The role of health professionals in the support provided is highlighted in this proposal, as postvention approaches are rarely portrayed in the scientific literature, which reinforces the stigma towards the theme and the difficulties approaching suicide (38) .
Studies on interventions carried out with people who have experienced suicide bereavement emphasize the importance of seeking qualified professional help to cope with the loss; however, they highlight the difficulty receiving support (18) . When performed early in time, quickly, actively and through professional actions, postvention presents positive results, with emphasis on welcoming, improvement in well-being and reduction of symptoms related to this process (3,41) . In this scenario, the importance of networking is highlighted, with Primary Health Care (PHC) as a gateway to approach the population, especially in carrying out home visits, which is a favorable moment to propose care, especially with regard to postvention (19) .
It is for this reason that working with high-  (30,43) .
By presenting characteristics that corroborate with teaching-learning processes, high-fidelity simulation has been characterized as an important link in theoreticalpractical approaches to various themes in the health area (29,(31)(32) . Among the gains perceived through the simulation, positive and strengthening aspects related to the participants learning stand out, with emphasis on communication, satisfaction, safety between patientprofessional, innovation, teamwork and appreciation of Rev. Latino-Am. Enfermagem 2022;30:e3699.
The lack of Brazilian studies on postvention and creative and innovative methods for teaching this theme also highlights the need to deepen the discussions and knowledge with a focus on support for suicide bereaved people (8) . Even with emphasis on the advantages present in professional training involving clinical simulation, the scientific gaps are extensive, something that can be evidenced by the few studies that address suicide prevention and simulation, as well as the nonexistence of studies in the scientific literature describing development of the high-fidelity simulation with a focus on postvention (44) .
The validation stage of the simulated scenario, carried out with specialists in the areas of high-fidelity simulation and postvention, allows analyzing the scenario agreement in relation to its items, considering objectives and results proposed for the simulation (45) . Validation confirms that the scenario created meets reality, needs and diverse scientific evidence on the themes worked on, in order to favor the training processes of human resources in health through scientifically based, validated materials, linked to professional practice and capable of promoting education through participatory and interactive methods (46) .
The cutoff point defined for the study CVI was 0.80 (80%), a value considered in the scientific literature as a parameter for the agreement analysis of the scenario in relation to its items (16,47) . It is worth noting that recent studies which validated clinical scenarios in health also considered this analysis parameter (14,47) .
In the analysis performed, all the scenario items were positively evaluated by the expert judges, obtaining values above the cutoff point defined for the study. Even obtaining the CVI, some items received suggestions from the judges, which were analyzed by the researchers and mostly accepted, providing a final version of the scenario in order to favor the initial support provided by professionals and students in the health area for suicide bereaved people.
Regarding the Gwet agreement coefficient, the AC1 (First-order Agreement Coefficient) statistic was used, which analyzes the agreement between the answers given by the evaluating judges (42) . The data from the analysis of the scenario indicate values inside the interval defined as satisfactory to good (AC1 = 0.640; CI: 0.515-0.764), a factor that shows agreement in the answers listed, reinforcing reliability of the analysis (28) . The option to use the agreement coefficient was determined by researchers as a measure recognized in the scientific literature for its robustness, especially in studies with participation of two or more judges, considering analyses on classification scales presenting two or more categories (27) .
The creation and validation of a simulated postvention scenario proposed in this study aims at contributing to improving the training of human resources in health on the initial support to suicide bereaved people. Deepening of studies involving the postvention approach through theoretical-scientific basis has the potential to improve teaching-learning processes in the mental health area involving and recognizing questions about bereavement due to a suicide experience, in order to support future initiatives in the fields of research and clinical practice that may promote and disseminate the theme of postvention at the national and international level (3)(4)8) .
The positive meanings present in the high-fidelity Among the limitations, the scenario script was prepared by the authors and was not previously validated by expert judges. The scenario created is an unprecedented production that will need periodic updates in its content, according to scientific advances on the themes that are focus of the study; as the effects of evaluating use of the scenario in professional training is an important aspect for future scientific approaches.

Conclusion
The current study resulted in the creation and validation of a high-fidelity simulation scenario related to the initial support provided to suicide bereaved people,