Introduction and context

Rationale

There were 18,998 deaths due to suicide in England between 2011 and 2015 in the general population, constituting 12 deaths for every 100,000 people per year. The suicide rate among health professionals is 24% higher than the national average with 430 professionals killing themselves within a 4-year period.1 These figures are largely explained by the elevated risk of suicide among female nurses (four times the national average), male paramedics and female doctors.1

Elevated suicide risk among doctors and nurses has been attributed to high occupational work stress, vicarious trauma,2 burnout,3 mental ill-health, financial and relationship problems,2,4 specialist knowledge about potential methods of suicide, greater access to the means of suicide4,5 and barriers to help-seeking (e.g. stigma, lack of specialised services).6 Doctors and nurses undergoing fitness to practice investigations are at particularly high risk of depression and suicide, although this is currently underinvestigated in nurses.7 A critical literature review of suicide in nurses found that work settings associated with high stress and distress, or caring for patients with psychiatric problems, were risk factors for elevated suicide risk, as was vicarious/secondary trauma linked to work.8 An integrative review of suicide in nurses9 found that risk factors for depression, an established risk factor for suicide, included workload, working night shifts, conflict in the workplace, and the erosion of professional autonomy. Research conducted on risk factors for mental illness among paramedics found that high exposure to trauma, distress and suicides (of patients) increased the risk of suicide in emergency care staff, who were also more likely to develop mental ill health and experience secondary trauma (linked to exposure to trauma, suffering and distress at work) and post-traumatic stress disorder (PTSD).10–12

The devastating and detrimental impact of any suicide on family and friends, and patients on their attending clinicians, is well documented.13–15 It is estimated that for every one suicide, 60 people are intimately and directly affected.16 Suicide affects the physical and psychological health and well-being of the bereaved,15 with a range of feelings and symptomology, including shock, confusion, horror, anger, personal failure, shame, self-blame, complex grief (when painful emotions are so enduring and severe that people have difficulty recovering from loss and resuming their own life) and PTSD; affected individuals are also at greater risk of future mental and physical ill health and suicide.15,17–19 Compared to other causes of sudden death, those bereaved by suicide report higher levels of rejection, shame, stigma and a need to conceal the method of suicide.19,20 Suicide bereavement has been identified as a risk factor for attempted suicide,18,20 it is estimated that 7–9% of people bereaved by suicide subsequently attempt suicide themselves.20,21 There is also an association with occupational dropout.22

Despite the elevated risk of suicide among NHS staff and consequent risk of suicide bereavement among colleagues, no studies to date have explored the physical, emotional and psychosocial impact of completed suicides on colleagues and teams. Additionally, no research has investigated how NHS organisations respond to such deaths and support affected staff, teams and their communities, including the use of postvention policies across NHS settings. Postvention in this context refers to ‘the actions taken by an organisation to provide support after someone dies by suicide; effective support can help people to grieve and is a critical element in preventing further suicides from happening’.23

The provision of appropriate, timely and effective postvention support for staff bereaved or otherwise affected by suicide may help individuals adjust, process, (re)negotiate, cope with loss and complex grief, and play a vital role in rebuilding staff well-being, reducing the potential for prolonged distress and risk of suicide.23–25 There is also substantive evidence demonstrating the value of bereavement support in enabling individuals to process and manage their grief.26 The needs of those affected are determined, in part, by how an individual died (e.g. sudden death compared to death by known medical causes), which in turn affects the nature of the bereavement; understanding a person’s grief reaction is therefore important in identifying suitable support within this context.27

This support is particularly important for a population of professionals who are known to be at elevated risk of stress, distress and suicide28,29 and reflects current policy initiatives aiming to improve access to support for NHS staff and reduce mental ill health and distress among healthcare professionals.28–30 Despite this, early evidence derived through patient and public involvement and engagement (PPIE) and Freedom of Information requests to three acute hospitals across the country has found no evidence of trust-wide postvention guidance or policies for staff/managers to follow in the event of the suicide of a staff member.

This study also explored participants’ perspectives on causality and potential triggers for the suicides they have been affected by. This provided useful contextual data regarding the work environment, enabling lessons to be learnt and shared within and between organisations and the wider community. There is increasing evidence demonstrating that reduced well-being in staff has a negative impact on patient safety and the quality of care provided for patients.31,32 Hence, supporting staff bereaved by suicide and alleviating mental ill health by mitigating any adverse consequences is also likely to confer benefits to patients.

The findings from this study set out to identify the impact of suicide and the support needs of bereaved colleagues. The guidance was co-designed, based on our findings and with input from a stakeholder workshop [work package (WP) 3]. The study team, study stakeholder group, PPIE and Samaritans co-produced the postvention guidance (WP4). The guidance provides key information on timely, appropriate and effective approaches to responding to the suicide of a colleague in the NHS and will be disseminated widely to NHS managers and organisations across the NHS. Implementation is being facilitated by well-placed co-applicants and NHS stakeholders.

The study team will subsequently use the findings from the study and workshop outputs to apply for further funding to develop and evaluate the appropriateness and effectiveness of an empirically informed postvention support package for use across the NHS. The results from that work will be important to demonstrate the potential effectiveness of such an intervention.

Research question

Aim

To understand the impact of a colleague’s suicide on NHS staff and their support needs, in order to inform postvention guidance.

Objectives

1. To undertake an integrative review of suicide impact and postvention interventions in other settings.
2. To explore the impact of colleague suicide on staff well-being and grief reactions to such an event.
3. To explore staff views about risk factors, which may have contributed to the suicide of their NHS colleague and ‘warning signs’ the individual may have displayed.
4. To identify what helps and/or hinders bereaved colleagues to seek support, to characterise supportive work cultures, and to identify staff preferences for future support.
5. To explore how managers respond to and support their employees and colleagues following a death by suicide, and to identify current postvention activity.
6. To use the findings to:
   1. develop evidence-based postvention guidance for NHS organisations and managers to support and respond appropriately and effectively to bereaved or affected employees
   2. apply for further funding to develop and evaluate the appropriateness and effectiveness of an empirically informed postvention support package for use across the NHS.

Changes to the study protocol

There were several differences between our protocol and the completed research.

The participant recruitment process for WP2 required a change in the protocol. Initially, we had intended to recruit all/most of the participants using a case study approach from up to eight sites. However, this proved difficult as not many sites/participants came forward using these means. Instead, the bulk of our recruitment was completed using posts on X (officially known as X since 2023, Twitter, Inc., San Francisco, CA, USA) and Facebook (Facebook, Inc., Menlo Park, CA, USA), snowballing and reaching out directly to NHS chaplains. We believe this change did not alter WP2 results, as we were still able to gather data from a range of professionals who had diverse relationships with the people who had died. Participants were colleagues and managers of those who had died, had varying levels of closeness to them and had known them for different amounts of time. Thus, we collected a similar diversity of experiences to those we would have gathered if we had been able to follow our original plan.

While the Samaritans were initially a co-applicant on this project, they left the study in early 2023 due to an undeclared conflict of interest.

While the study started life at the University of Birmingham, Ruth Riley was appointed to a senior lecturer post at the University of Surrey in summer 2022. Therefore, she moved institutions with the grant funding and the two project researchers (Hilary Causer and Johanna Spiers).