The goal of this randomized clinical trial is to determine whether a virtual reality (VR) training program can help healthcare providers improve their skills in discussing suicide prevention and safe storage of firearms and medications with Veterans. The study will test whether VR training increases providers' self-efficacy, confidence, and comfort in conducting lethal means safety counseling, and whether it improves their intention to use these counseling practices in their clinical work. Researchers will compare healthcare providers who complete the VR training to those who complete a 2D video training to determine whether the VR approach is more effective. Participants will complete online surveys before and after the training and again three months later. They will be randomly assigned to one of two groups: VR training group: Participants use a VR headset to interact with a virtual Veteran patient in a simulated rural clinic and practice suicide prevention counseling skills; Video training group: Participants use the same headset to watch a ~10-minute 2D video depicting the lethal means safety counseling session. After the training, participants will also provide feedback about their experience, including how realistic and useful they found the training.

This study will test whether a virtual reality (VR) training program can improve healthcare providers' ability to talk with Veterans about suicide prevention and safe storage of firearms and medications. Rural Veterans have suicide rates much higher than the national average, and providers in rural areas often do not receive enough training in suicide risk identification or lethal means safety counseling.

This project builds on our prior Veteran Suicide Assessment in Virtual Reality (VET-SAVR) study, which showed that VR can be a feasible and acceptable way to deliver suicide prevention training. In the current study, called the Virtual Reality Lethal Means Safety Training (VR-LMST) project, we will compare an immersive VR training simulation to a 2D video training.

Study Aims

Aim 1: Develop a VR training simulation focused on suicide prevention counseling with rural Veterans.

Aim 2: Test whether VR-LMST improves provider confidence (primary), and comfortability and intention (secondary) to engage in lethal means safety counseling.

Aim 3: Assess user experience of the VR simulation, including presence, realism, acceptability, feasibility, and tolerability.

Study Design

This is a randomized controlled trial. Participants will be assigned to one of two groups:

VR-LMST group: Participants will use a VR headset (Meta Quest 3) to enter a simulated rural clinic visit with a Veteran avatar who presents with thoughts of suicide. They will practice counseling skills related to safe firearm and medication storage.

2D Video group: Participants will use a VR headset to view a 10-minute video showing a provider having a lethal means safety conversation with a Veteran.

Assessments

Pre-test, post-test, and 3-month follow-up surveys will be completed online.

The Counseling on Access to Lethal Means (CALM) Core Scale (13 items) will measure provider confidence (1-5), comfortability (6-8), and intentions (9-13). An additional two items measure counseling behavior at 3 months (14-15).

The ITC-Sense of Presence Inventory (ITC-SOPI) will measure presence, naturalness, engagement, and negative effects.

Open-ended questions will gather feedback about realism, acceptability, and feasibility.

Demographic and professional background information will also be collected.

Sample Size and Timeline We will recruit 36 participants (18 per group). Power analysis indicates this sample size is sufficient to detect moderate effects with 80% power for the primary outcome.

Phase 1 (completed): Recruited 11 healthcare providers for qualitative interviews; conducted coding and analysis; developed and refined VR and 2D scripts.

Phase 2 (completed): Prototype VR clinic environment developed through iterative meetings with VR developers.

Phase 3 (completed): Pilot playtesting in October 2025 with 5 participants.

Phase 4 (planned): Randomized trial enrollment to begin mid-November 2025.

Phase 5 (planned): 3-month follow-ups to begin January 2026.

Oversight IRB approval was received September 27, 2024, from the University of Texas at Arlington. This study is funded by the American Foundation for Suicide Prevention (AFSP).

Significance This project will test a novel, scalable training method to give allied healthcare providers repeated opportunities to practice suicide prevention counseling in a safe environment. By equipping rural providers with the skills and confidence to have culturally sensitive, Veteran-centered conversations about firearm and medication safety, VR-LMST has the potential to improve clinical practice and reduce suicide risk among rural Veterans.

Inclusion Criteria:

• Age 18 or older
• healthcare providers serving rural Veterans in Texas (e.g., physicians, physician assistants, nurse practitioners, nurses, pharmacists, social workers, healthcare case managers)
• English-speaking
• Able to provide informed consent

Exclusion Criteria:

• Self-reported pregnancy
• History of motor or balance disorders
• Color blindness
• Neurological or cognitive disorders
• Cardiovascular issues that may be worsened by VR use
• Use of cardiac pacemakers, defibrillators, or hearing aids incompatible with VR equipment
• Significant discomfort in virtual reality environments (e.g., severe motion sickness, vertigo)

This study collects survey and qualitative data from a small sample of healthcare providers. Because of the limited sample size and potential identifiability of responses, individual participant data (IPD) will not be shared. Aggregate data will be shared in publications and presentations.

Participants and study personnel are aware of assignment because the intervention content differs (interactive VR simulation vs. 2D video). Both groups use headsets to reduce expectancy differences, but this does not blind allocation. To mitigate bias, we use centralized randomization, standardized instructions, and prespecified analyses; where feasible, data analysts will be masked to group labels.