Work package 1: The impact of colleague suicide and the current state of postvention guidance for affected colleagues: a critical integrative review

Parts of this chapter have been reproduced from Causer et al.33 This is an Open Access articles distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

The study and findings reported in this chapter respond to the following research 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.

Introduction

Suicide is one of the leading causes of death around the world, with more than 700,000 people dying by suicide every year.34 This means that 1% of all global deaths are due to suicide.35 Suicide affects the physical and psychological health of the bereaved16 and, 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 death.20,36 Every suicide impacts approximately 8017 to 13537 people, of which 1 in 30 may be deeply impacted and so can be considered bereaved.38 Suicide bereavement has also been identified as a risk factor for attempted suicide;19,21,39 approximately 7–9% of people bereaved by suicide subsequently attempt suicide.21,22 There is also an association with occupational dropout.23

Previous studies have measured and explored the impact of suicide on family members,40–43 friends,44 teachers,45 university staff33,46 therapists and other healthcare workers.47–49 A recent UK-wide survey on the impact of suicide36 found that 2% of participants reported being bereaved by a colleague’s death. However, the impact of colleague suicide has not been widely investigated, even though the suicide rate in the UK is higher for certain professions; approximately 12 deaths per 100,000 were suicides between 2011 and 2015, while the risk of suicide for female healthcare professionals was 24% higher than this national average.2

The support offered to those impacted by suicide is known as postvention.50–53 Effective postvention has been shown to improve mental health and grief-related outcomes,54 help bereaved people seek and share support and information and memorialise their loved ones.55 While there is some postvention guidance for workers impacted by colleague suicide,52,56,57 existing guidance is limited and is not always evidence-based.

Additionally, we argue that suicide research often focuses on the individual rather than the context in which suicide happens58,59 or on preventing more deaths rather than improving quality of life.60,61 Critical suicidology, an approach which considers the context and cultures in which suicides happen,59,60,62,63 such as the occupational factors or antecedents, provides a useful lens through which to explore the impact of suicide and the support needs of those bereaved. We used this to inform our analysis.

Our review has drawn together empirical research and current guidance on colleague suicide, highlighting what we already know and what the gaps in the research are, signposting the next steps for researchers and support.

Review aims

Three questions guided the review:

1. What is the impact on staff of a colleague death by suicide?
2. What is the current guidance for providing postvention support to staff following a colleague suicide and has this guidance been evaluated?
3. What kinds of postvention have been offered, or ought to be offered, to staff affected by a colleague suicide and what are staff experiences of that postvention?

Methods

An integrative review is a robust methodology64 which allows a comprehensive understanding of a topic via the synthesis of all available evidence.65 It is suited to reviewing a combination of diverse methodologies including experimental and non-experimental research66 and allows a broad sampling frame.67 We followed the five steps set out by Whittemore and Knafl66: problem identification, through which we developed our review questions; literature search; data evaluation; data analysis; and presentation of conclusions.

Eligibility criteria

We were interested in reports on the impact of colleague suicide, postvention guidance for workers and evaluations of that guidance. Eligibility criteria can be seen in Table 1.

Search strategy

The databases listed in Table 2 were searched for the below terms between October and November 2021. The selection process ended in May 2022.

The reference lists of chosen papers were hand-searched for further relevant articles. We did not apply any search limiters in terms of dates or country as we wished to scope the literature as widely as possible.

Article screening

Hilary Causer and JS independently screened all article titles, rejecting those which did not fit the criteria. We used the Rayyan.ai platform to support article screening. Duplicates were deleted. HC and JS accepted or rejected articles based on their abstracts. Disagreements were discussed until a consensus was reached; had we not reached a consensus, a third reviewer (NE) was available to make a final decision. The full articles were read and any which did not fit the inclusion criteria were rejected. Seventeen articles were included in the review. The screening process is summarised in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram in Figure 1.

FIGURE 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the selection process. Adapted from the Preferred Reporting Items for Systematic Review and Meta-Analyses flow diagram. Reproduced from Causer et al.33 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original text. (Figure not reproduced here; see the original article.)

Quality appraisal

Our purpose in appraising the quality of the included articles was not to exclude any articles which could usefully contribute to answering the review questions,68,69 but instead to be aware of the overall quality of the papers.

Hilary Causer and JS appraised the 17 included articles using a range of tools, including the AGREE-II tool,70 Joanna Briggs Institute (JBI) qualitative appraisal tools,71 the Mixed Methods Appraisal Tool72 and the Quality of Survey Studies in Psychology tool.73

Hilary Causer and JS conducted independent assessments of the quality of all papers, providing inter-rater reliability to check each other’s assessments. Any disagreements were discussed and resolved.

Data extraction

Data were extracted to meet two aims. Firstly, HC extracted data from all articles to inform an overview of article attributes. These data are reported in Tables 3 and 4.

Secondly, HC and JS extracted relevant primary data, author opinion or interpretation and any other major findings, such as links to existing theory, into a matrix for analysis. Data were organised under the headings: impact of colleague suicide on staff members; postvention guidance; and evaluation of postvention guidance. We then uploaded extracted data into NVivo (QSR International, Warrington, UK) for coding.

Data analysis

Data were analysed following the thematic network method.74 Thematic networks are ‘web-like illustrations’ that summarise themes and relationships between themes. We took the following steps as set out by Attride-Stirling.74

Coding the material

Hilary Causer and JS devised a coding framework based on the research questions and the critical suicidology literature.60,62 Using NVivo, meaningful sections of the data were coded into that framework,74 which was discussed and refined as the analysis continued.

Identifying the themes

Codes were refined and grouped into similar themes. This resulted in the final table of basic, organising and global themes (Table 5).

Constructing the networks

Hilary Causer and Johanna Spiers constructed two thematic networks (‘impact of colleague suicide’ and ‘postvention following a colleague suicide’), which can also be considered as a single network under the unifying global theme ‘after a colleague dies by suicide’. Networks were constructed by considering relationships between the three levels of theme.

Describe and explore the thematic networks

Hilary Causer and Johanna Spiers used the networks as a springboard to fully explore the concepts, connections and findings arising from the analysis. The upshot of this discussion can be seen in the results section of this chapter (see Thematic network analysis and Figure 2).

Summarise the thematic network

A summary of the thematic networks can be seen in the following section.

Interpret patterns

Patterns across the two networks were identified and developed during the writing of the results section.

Quality appraisal of included articles

We found that many of the papers had important methodological flaws. Regarding the guidance articles, which were assessed using the AGREE-II tool,70 authors57,76,87 did not always consult with the target population. Austin and McGuinness84 drew on case studies but did not report their sources. Only Kinman and Torry52 and Samaritans86 reported systematic methods of searching for evidence, while no authors reported criteria for selecting evidence or described the strengths and limitations of their evidence. It was not always clear how recommendations were reached,57,75,76,84 recommendations were sometimes not evidenced75,76 and work was not always peer-reviewed.57,75,76 Only Berkowitz57 and Kinman and Torry52 considered facilitators and barriers to carrying out recommendations. Only Samaritans86 provided any information about funders.

Regarding the empirical and other articles, six61,78–82 were appraised using the JBI checklist for qualitative research.71 All demonstrated congruity between the research methodology and question, although only three78,82,87 stated the authors’ philosophical perspective. Kleespies et al.77 were unclear in reporting their methodology and offered little interpretation of their results; Pak80 presented a ‘conceptual model’ but with no clarity on whether the model was constructed in response to review findings; and Sever and Ozdemir81 reported their findings in a descriptive rather than interpretative style. Only two papers78,82 addressed researcher influence on the research. Participants’ voices were well represented by all authors except Gulliver et al.,61 who did not include any verbatim quotes and Kleespies et al.,77 who reflected on rather than reported their findings. Kleespies et al.77 were the only authors not to make any ethical statement, while Gulliver et al.61 and Małecka79 offered no evidence of ethical approval for their research. Conclusions were clearly drawn from the analysis or interpretation of the data in all articles.

Two articles83,85 were appraised using the JBI checklist for text and opinion.71 They both met all criteria, although it was unclear whether the stated position of either article was the result of an analytical process. Carr75 was appraised using the JBI checklist for a case study.71 All criteria were met at least in part, although it is worth noting that this appraisal checklist assumes that the case study is a medical one; so criteria had to be interpreted broadly to accommodate the nature of the article. Overall, the literature appraised using JBI checklists was of mixed quality, but all met our requirement of making a useful contribution towards answering our review questions.

Thematic network analysis

Our analysis resulted in the development of seven organising themes that sit within two global themes, as illustrated in Table 5. We identified several connections between and across the two global themes which led to the development of a unifying global theme, ‘After a colleague suicide’. The relationships and connections between the organising, global and unifying global themes are illustrated in Figure 2 at the end of this section.

FIGURE 2 Thematic network. Reproduced from Causer et al.33 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original text. (Figure not reproduced here; see the original article.)

Global theme 1: Impact of the loss of a colleague to suicide

Suicide loss in the workplace

The suicide of a colleague impacts individuals in a variety of ways and brings the usually private process of bereavement into a professional realm. Intense, complex emotions, such as sadness, anger, shame and guilt77 (p. 6), may be experienced and heightened by the manner of death: ‘Bereavement after suicide is often called “grief with the volume turned up”’.77

The most frequently reported emotions following colleague suicide are shock1,77,80,83–85 and anger.1,52,77,85 Anger may lead to further feelings such as ‘confusion, anxiety and shame’ that arise from perceptions of anger as an inappropriate response.52

Additionally, several authors52,75,76,86 reported behavioural responses including altered eating and sleeping habits and a need to talk about the event.52 Some behaviours may be visible and impactful within the workplace, such as absenteeism, presenteeism or problem drinking.52

This combination of responses may contribute to the challenging work of grief.1,84 Managers must understand that staff are not only experiencing the loss of a colleague by suicide but are also working through the multiple elements of that experience and will require space, support and empathy. Workers in a 1993 study cited by Lynn78 expressed the intensity of their experience: ‘as the same emotional burden experienced after the death of a family member’ (p. 462).

Colleagues may feel they must ‘carry on’ after the suicide. This may be a positive way of getting ‘back to normal’75 or may present tension between the need to keep working and the need to grieve. For instance, Kinman and Torry52 noted that the performative ‘effort’ of meeting workplace expectations and behaviours ‘can be exhausting and compound grief reactions’ (p. 6).52 A colleague’s suicide may give rise to suicidal thoughts or behaviours: ‘Sometimes the rationale for this increase in suicide or suicidal behaviour occurs out of guilt, a distorted sense of loyalty, or a perceived false “permission” to do so’ (p. 3).76

This is a particularly serious outcome. Leaders and managers ought to be aware of, and alert to, this potential risk. There is a danger that the ‘carry on’ narrative may detract from and indeed hide the real pain and suffering that some staff members may experience.

Professional identities and workplace roles

Dilemmas arise when staff come face to face with loss, trauma and grief while inhabiting their professional identities. Specific characteristics of job roles might bring colleagues into contact with dying or recently deceased colleagues, such as deployed military personnel1 or ambulance staff who may have been called to an incident involving their colleague: ‘the ambulance staff that attend the scene could have additional needs in relation to their efforts to help their colleague. There may have been a resuscitation attempt, for example. This places an increased burden on the clinicians present’ (p. 21).86

Professionals may feel they are attempting to navigate dual roles following a suicide. For example, doctors ‘may experience dissonance’ (p. 6)52 between the roles of ‘healer’ and colleague of the deceased. These dual roles may be especially challenging for team leaders or managers: ‘As the line manager, when a colleague dies suddenly you have a responsibility to all team members to assist them in coming to terms with the sudden death, whilst dealing with your own emotions’ (p. 50).1

A sense of impossibility is evident, as leaders reported that no matter which approach they take, it is impossible to meet all needs, especially given the challenges of information containment in the social media age:

It was already on social media, but the senior manager said it wasn’t our place to tell colleagues, as the family may not know yet, so then you’re chastised by staff for not letting people know. […] It all got very messy. And all that was on me. It was a lonely place that day.86

Further, leaders’ responsibility to safely contain teams was highlighted by Pak,80 who discussed the broad roles that army captains play in nurturing commitment, trust and good morale within military units.

Questions may be raised here around responsibility, not only for looking after staff following a colleague suicide but also for the colleague who took their life. The suggestion that a colleague suicide may be seen as a failure of leadership,81 potentially triggering mistrust, is a stark reminder that leadership is about creating and nurturing the cultures within which staff work.

Perceptions of professional uniqueness in bereavement

Many authors52,75,80,81,84,86 reported on the experiences of certain professional populations or participants with specific traits, beliefs or cultural values. Throughout, these reports were perceptions of being ‘unique’ among the wider population of those impacted by suicide, making the experience of colleague suicide somehow harder to bear. Pak80 described a combination of settings and relationships to explain perceptions of heightened impact:

[M]ilitary suicide may have an even greater impact than bereavement experienced in most collegial relationships due to the proximity and intimacy required for a unit to function in a combat environment … It is not uncommon for service members to refer to one another as ‘brother’, ‘sister’, ‘brother-in-arms’.

Interestingly, Lynn78 also cited ‘proximity’ and shared experiences as ‘unique’ characteristics of healthcare workers’ roles. Kinman and Torry52 focused on the nature of small cohesive teams that nurture friendships for general practitioners (GPs). Finally, the shared professional identity and sense of ‘family’ was suggested as the reason for a ‘deeper’ impact on paramedics than others.86

Perhaps this sense of kinship and shared identities explain professional groups’ notion that their experience of colleague suicide is unique. Colleagues may struggle to articulate who it is they have lost; the deceased is more than a colleague, but not a family member. There are challenges here for organisations and leaders in understanding the nature of the loss they are supporting staff to come to terms with. Again, the complexity of loss and need sits uncomfortably within the ‘carrying on’ narrative.

Personal beliefs and cultural norms can also shape a colleague’s ideas about and responses to a death by suicide; diverse belief systems may be held by colleagues who work closely together.78 Dominant discourses within belief systems may present colleagues with additional challenges: ‘You feel the closeness of death, as in every funeral. However, as a Muslim, I do not find this right. According to our religion, it (suicide) is a rebellion against God’ (p. 3).81

As Sever and Ozdemir81 note, it is complex for individuals and leaders to understand and accommodate a range of belief systems. This poses the question of how diverse belief systems might be accommodated within teams who are impacted by a colleague’s suicide.

Professional unpreparedness, abandonment and silencing

Organisational unpreparedness for responding to a colleague’s suicide due to skill and knowledge gaps shapes staff members’ experiences, leading to perceptions of unmet needs:

It was very surreal – I had to deal with all of this, and I just acted on instinct. There was no help or guidance given to me. Suddenly I was in charge of everybody else’s feelings and just expected to carry on as normal.52

Unpreparedness may take the form of skill and knowledge gaps or lack of guidance: ‘In the absence of any guidance, our interviewees were obliged to “ring round” desperately hoping to receive help which was not forthcoming. This clearly intensified their distress and the difficulties that practices, especially small practices, experienced’ (p. 17).52

Placing the onus on individuals to seek support to meet their individual needs assumes that people experiencing shock, anger, guilt and grief can identify and articulate what those needs may be. Whether these staff members knew what they needed, they knew they needed something, and the lack of resources within their organisation led to a wider search.

Małecka79 reported that similar deficits were experienced in a higher education setting, where a colleague’s suicide went unacknowledged, leaving staff members feeling abandoned, confused and angry. Kinman and Torry52 also reported a ‘reluctance’ towards responding to need. It is unclear what drove this reluctance; perhaps not knowing how to respond or fear of doing it ‘wrong’.

Yentis et al.82 demonstrated the stark difference between the numbers of bereaved anaesthetists who felt supported (n = 22) and those who did not (n = 179): ‘[participants] described absent or poor support and, in some cases, deliberate attempts to prevent or stifle discussion and/or debriefing, although in some cases the issue of protecting the deceased’s confidentiality and/or sparing the family further anguish was mentioned’ (p. 1369).82

There is evidence here of a process of silencing, where no platform for acknowledging or discussing needs is provided. Bogle87 reported the perception of US law enforcement officers who described the administrative response to their colleague’s suicide as ‘avoidant’:

As long as you’re doing your job, doing what you need to do and say, administration would acknowledge if you lost your life in the line of duty. You’d be a hero. But the moment [an officer] loses their life because of suicide, it’s unspoken.87

A similar response was reported by Belgian military service members,76 whose perceptions of social stigma acted to silence them, thus further perpetuating the cycle of stigma. Silencing stigma was also noted by Małecka79 in a Polish Catholic university; note that in Catholicism, suicide is considered a mortal sin. The conspiracy of silence experienced by these police officers, service members and academics across organisational, social and cultural contexts denied them opportunities to honour their deceased colleagues and process the impact of the suicide and risked their psychological well-being.76 Ultimately, silencing and stigma leave impacted staff alone with their need to find meaning and answers following their colleague’s suicide.

Global theme 2: Postvention following a colleague suicide

Individualised responses

Currently, postvention guidance tends to focus on individuals and individual change rather than contexts and systemic change. Attempts to consider the context within which suicidal behaviours occur are often lacking. We see this as a flaw in existing guidance.

A common claim was that personal vulnerabilities and mental health challenges increased the risk of contagion, whereby one death by suicide increases the risk of subsequent deaths by suicide among those who are affected53,76,85,86 with no consideration of context. The following quote from a police officer87 demonstrates a deep-seated belief that suicidal feelings are solely located within the individual: ‘We’re all adults. You have entrusted us with the authority to take people’s freedom and the authority to take lives, if necessary. [...] So aside from offering programs, there’s nothing anybody can do to stop them’ (p. 106).

While this participant described the culture in which the suicidal behaviour was occurring, they still felt the only available option, on which they place little worth, was individual support.

Strategies for communication about the reasons for suicide were also individualised: ‘the important information is that the person mistakenly felt that they could not get help for his or her problems, when in fact help was possible’ (p. 163).57

Since suicide happens within a context, changes to culture (in addition to individual support) may be beneficial for postvention.

Checklists of postvention tasks1,53,57,76,84–86 or the utilisation of psychological or organisational models of support53,57,76,80,84,85 similarly tended to focus on individual needs rather than culture.

Training was mentioned as a potential tool for effective postvention. Most proposed education focused on individual needs or signs of mental ill health.57,76,84,86,87 In contrast, Pak et al.80 suggested training as a way for leaders to positively influence work culture: ‘Military leaders can be encouraged and taught to recognize that to compartmentalize the unit suicide and to ignore it in the short-term, may also place their units at risk’ (p. 196).

We endorse positive cultural changes as part of postvention,60 while cautioning against putting unrealistic pressure on managers, who may also be grieving or operating within an under-resourced system.

Dual function of stigma

Stigma both leads to and arises from inadequate postvention. It causes inadequate postvention since, if an organisation cannot talk about suicide, it cannot properly support those impacted by it. It is an effect because if postvention is steeped in stigma, it perpetuates stigma at individual and organisational levels.

Authors reported that suicide was not properly acknowledged in the workplace.1,57,76,83,85 However, it was widely agreed that this increased risk.53,57,80,83,84,86 Discussion of suicide helps address stigma and so could aid postvention. However, one could question whether acknowledgement of suicide is enough without also acknowledging any difficulties with the context in which the suicide occurred.

Workers of various professions reported a culture of invulnerability75,76,79 where mental ill health was unacceptable. This could prevent education around suicide, impacting postvention: ‘To have training on officer suicide would mean that [suicide] would have to be talked about. And that’s not going to happen’ (p. 96).87

This culture may further challenge postvention by preventing workers from being open about emotions or asking for help.76,87

Organisations operating from a culture of invulnerability could also perpetuate stigma: ‘Personnel allowed to attend the service were limited [...]. Restricting access to the memorial service created a sense of shame about the death’ (p. 102).75

Additionally, it could be suggested that the term contagion, which was commonly used in reference to the statistic that one suicide may result in more,1,85,86 may perpetuate stigma and so hamper discussion and healthy postvention. Perhaps non-pejorative language such as ‘further suicides’ may be more useful. Given the prevalence of this narrative, it is perhaps unsurprising that contagion continues, and has: ‘…sometimes led to misguided efforts to maintain secrecy after a suicide death, including blaming or stigmatizing the deceased’ (p. 168).57

More helpfully, several authors made suggestions for how stigma could be combatted. These include the use of more sensitive terminology86 and group counselling.81 Several reported workplace cultures which were already supportive.76,81,86

Complex pressure on managers

Complex pressure is placed on managers of workplaces in which a colleague dies by suicide, as the delivery of postvention support becomes their responsibility. Specific tasks that managers might be expected to undertake include regularly checking in with staff, looking out for affected colleagues52 and being visible to workers.85 Additionally, leaders may be expected to undergo training to deliver postvention.57,85–87

Managers must also provide practical support such as accompanying employees during inquests,84 offering meals and transport57 or arranging alternative duties for staff.86 Some authors provided detailed explanations of ways for employers to emotionally support grieving workers1,53,76–78 such as engaging in empathic listening and sharing stories. Several agreed that leaders must guide employees through the grieving process.78,85,86 Further pressure on leaders is added by the suggestion that they should be ‘a role model for healthy grieving’.84,85

Various authors acknowledged that managers, who are also grieving, must also be supported.52 Suggestions included covering time off53,86 regular check-ins with HR86 and reassurance that it is OK to express emotion.86 We feel that these are worthy suggestions that may help combat that toxic culture of invulnerability. Working with teams within75,85 and outside of1,53,57,76,84,86 the organisation to deliver postvention may also relieve pressure. Such support for managers, who are uniquely pressured following the suicide of an employee, is sorely needed.

Unifying global theme

Thus far, we have described two thematic networks: impact of a colleague suicide, and postvention following a colleague suicide. Both networks are illustrated in Figure 2, in blue and green, respectively. In line with the thematic network methodology74 (p. 393), this figure is intended to explore and illustrate the deep meaning and relationships behind the reviewed texts, rather than to demonstrate causal relationships. We found that both networks describe events that occur simultaneously following a colleague suicide, and that these networks feed into and inform each other. Thus, they can be illustrated as being connected by a unifying global theme: after a colleague suicide, represented in Figure 2 in orange. The orange arrows indicate how individual experiences and needs following a colleague suicide are shaped by the availability and content of postvention support. Likewise, the design and delivery of postvention impact how workers respond to and heal from the suicide of a colleague as illustrated in Figure 2.

Specifically, the impact of suicide loss in the workplace can be heightened or ameliorated by the response of the organisation. Our findings evidence that staff experiences occur within the contexts and cultures of workplace settings, identities and roles. Guidance, however, promotes individualised approaches to responses that fail to acknowledge these factors. A holistic approach, looking at the context and systems within which the suicide occurred as well as support for teams and whole organisations, in addition to any necessary individual responses, may reduce overall distress. Further, stigma is linked to organisational unpreparedness, abandonment and silencing. Teams delivering postvention which is marred by stigma will, as our findings demonstrate, find it harder to acknowledge and respond to suicide, leading to a silencing which, in turn, perpetuates stigma. Solving organisational unpreparedness may fall to managers, adding to their complex pressure; equally, if managers cannot fulfil the unrealistic battery of tasks assigned to them following an employee suicide, the organisation may continue to be unprepared and silence grieving workers. Finally, the organising themes of complex pressure on managers and professional identities and workplace roles are intertwined, as the dual roles that managers must inhabit while simultaneously grieving and caring for bereaved employees further add to their complex pressure.

Discussion

We reviewed and synthesised 17 articles, including empirical studies (n = 7), case studies (n = 1), opinion pieces (n = 2) and guidance (n = 7). We explored the impact of a colleague death by suicide across a range of workplace settings, reviewed the current guidance for workplace postvention support following a colleague suicide, and developed an understanding of what kinds of postvention support have been offered, or what authors thought should be offered to staff affected by a colleague suicide. We found that the workplace impact of colleague suicide and associated postvention has been sparsely explored, and published articles are of an overall moderate quality. Published guidance is rarely underpinned by empirical evidence, while the guidance included in this review cite each other (with and without full acknowledgement and referencing). Some guidance appears comprehensive, but it is not always clear where the underpinning knowledge has come from. Experiences of loss and bereavement by suicide were shaped by workplace contexts, cultures and job-role identities. Further, organisational responses, or lack thereof, created additional struggles for staff.

In this discussion, we explore three (dis)connections between staff experiences of impact following a colleague suicide and the postvention guidance currently available to managers and organisations, as illustrated in our thematic network (see Figure 2).

Workplace cultures, professional contexts and individualised responses

Suicide loss is shaped by perceptions of professional identity and workplace settings. However, this is unacknowledged in postvention guidance, which takes an individualised view of cause and impact. While the emotional impact reported by staff following a colleague suicide reflects the wider literature88–91 experiencing this impact within professional identities and workplace settings complicates individual responses.

For instance, perceptions of professional identity and uniqueness shape staff experiences of grief. We reviewed the experiences of police officers, firefighters, military personnel and primary care health professionals. Such professionals may work within a culture of invulnerability,92 whereby perceptions of being impervious to work-related stresses become part of a professional identity. Staff who perceive themselves as invulnerable are less likely to find psychological safety following a colleague suicide. Researchers have concluded that talking about vulnerability and illness reduces perceptions of isolation and promotes coping mechanisms for GPs.93 It is likely that such openness may also promote healthy coping in other professions. Furthermore, we found that staff across a range of professions believed that their experience of suicide loss was more impactful due to their perceptions of the unique traits of their job role or professional identity. While several professions perceived themselves as unique for similar reasons, this indicates that these ‘unique’ attributes and their impact on professionals’ experience of a colleague suicide ought to be understood, acknowledged and incorporated into support to meet staff needs for all groups.

Currently, workplaces do not provide the time and support required by employees to undertake the emotional work that arises following a colleague suicide. We found that a ‘carry on’ narrative dominates, prioritising work tasks and productivity over emotional needs. Similarly, when exploring the experiences of bereaved staff on their return to work, Bento94 used the phrase ‘the show must go on’ to describe employees’ perceptions of silence or pressure to catch up with work tasks. It may be that leaders working in ‘24/7’ professions such as medicine or the military are expected to keep working to prevent the fallout from a depleted workforce, meaning they must put work ahead of their wellbeing.

Hochschild95,96 utilised the concept of ‘feeling rules’ to describe the processes of emotion management that occur in workplace settings. Similarly, Doka97 talked about ‘grieving rules’ that describe societal norms around loss and grief behaviours. Together, these concepts may provide a framework for better understanding how staff are expected to manage grief in the workplace and how organisations operate to direct grieving processes away from the workplace. Within the social model of individualisation, we are expected to do our emotional work in the privacy of our homes.98 However, when grief occurs at work, this expectation generates further stress and an understandable disconnect for staff. We found that staff must work to navigate these complex expectations surrounding grief after a colleague’s suicide. Similarly, Grandey99 identified that employees suppress or regulate emotions following a stressful event to deliver an appropriate emotional presentation for the workplace. Such emotional management has been conceptualised as emotional labour.96 When expressed emotions differ from those that are felt, emotional dissonance and internal tension may result.100 As such, emotional labour is stressful and may lead to burnout.101

As Pitimson102 pointed out, UK legislation regarding compassionate leave does not recognise the death of a colleague, meaning any leave is at the discretion of the employer. In response to this point and the findings of our review, we argue that time must be offered in workplaces to accommodate the emotional work that may follow a colleague suicide and to avoid the risk of emotional burnout.

It would be beneficial for authors of postvention guidance to offer strategies for addressing these specific staff experiences and needs following a colleague suicide. Overall, the guidance we reviewed did not take an organisational perspective, nor did it address professional identity and working spaces as the contexts within which loss and grief must be navigated and postvention support delivered. As previously noted, current guidance has drawn only sparsely on empirical evidence, which may explain this disconnect between need and delivery. We argue that postvention guidance must draw on the lived experiences of the people it aims to support. The reviewed guidance largely missed an opportunity to support organisations and staff by meeting them at the point of their experience.

Unpreparedness, abandonment, silencing and the perpetuation of stigma

We found that organisational unpreparedness for suicide loss generates feelings of abandonment and perceptions of silencing that further complicate experiences of grief and perpetuate perceptions of stigma. Managerial or organisational failure to acknowledge colleague suicide and its impact leaves staff feeling abandoned in navigating their path to recovery. Pitimson102 reported that lack of workplace acknowledgement leaves bereaved staff with fears of being judged and a need to find safe places at work for privately expressing grief. As Lattanzi-Licht103 stated, the workplace requires the bereaved to be silent, hiding their feelings. Disenfranchised grief104 refers to instances of dismissal when either the relationship with the deceased, the nature of the loss, or the griever themselves is not recognised. Doka104 proposed that acknowledgement of grief is necessary for bereavement to be completed. The silence and silencing found in our review leave staff unable to talk about or process their experiences. Thus, the idea of suicide as a taboo105 topic is perpetuated, staff are unsupported in their grief, and their trauma remains unacknowledged and unaddressed. Our findings illustrate that, alongside the absence of organisational response, the event of a colleague suicide and attempts by staff to mourn and remember their colleague were actively silenced. Staff grief in the workplace is not just disenfranchised; it is actively stifled.106

This active silencing has an impact. As our findings demonstrate, stigma both leads to and arises from inadequate postvention. When organisations do not deliver postvention, they perpetuate stigma around suicide by failing to provide forums for conversation, acknowledgement, understanding and healing. Paradoxically, it is the stigma surrounding suicide, and associated fears, that may cause organisations to fail in this way. There is a fear of acknowledging suicide due to misunderstandings around the risk of ‘contagion’ and the likelihood of further deaths by suicide.21 We argue that it is the role of guidance to address these naïvetés. However, if guidance is not underpinned by evidence, it may be difficult to convey these messages robustly.

Managers: identities, roles and complex pressures

Colleague suicide generates complex challenges for managers. This is exacerbated by perceptions of professional identity, whereby managers are perceived as strong and knowledgeable, and further, by postvention guidance which situates managers as supporters of other staff. Balancing the needs of their team alongside managers’ own needs, expectations that the workplace should continue to function as usual alongside staff grief and the need to communicate clearly to staff, while balancing the preferences of the deceased’s family and the need to protect the deceased’s privacy, are all factors that generated this complexity. The wider literature also identifies the manager as a key provider of support and comfort when a staff member is bereaved.107–109

Several authors highlighted that, with proactive support and compassion, the workplace can facilitate healing following bereavement106 and bereaved staff may feel safe in the familiarity of the workplace.102 Compassion is defined as ‘an active orientation towards the well-being of others who are in pain’ (p. 168).110 Kanov111 suggested that managers are well placed to offer compassion by noticing the suffering of others, feeling empathic concern and acting to alleviate suffering. The manager must be alert, empathically in tune with others and knowledgeable about appropriate proactive responses. It is often assumed that managers will provide this support and compassion, while managers’ struggles are not acknowledged.102,107,111

The agency of bereaved staff within the supportive relationship was recognised by Dutton et al.,112 who posited that compassion requires both parties to interpret and understand each other’s circumstances to make sense of the situation. Even here, however, there is no acknowledgement that the manager may be experiencing their own grief. We propose that, importantly, postvention guidelines provide guidance for the support of managers while they, in turn, support their teams. Additionally, guidance can identify external sources of postvention support (availability of which, we acknowledge, varies), so that the weight of being the expert and supporting staff can be lifted from the potentially grieving manager.

Considering the broader contexts that underpin the complexity faced by managers allows for insights into the competing pressures of meeting staff’s emotional needs alongside the demand for the business to function. Pitimson102 noted that individualism and capitalism can shape the experiences of grief in the workplace. Peticca-Harris108 highlighted this in her first-person account of restaurant managers’ responses to the sudden death of a staff member. She described how the need to keep the restaurant open blinded managers’ ability to see, or relate to, the distress staff were experiencing.108 Granek113 suggested that control of grief in workplaces is political in terms of the expectation that staff will continue to contribute within capitalist societies. Peticca-Harris108 concluded that ‘managers did not know what to do and how to do it, and that brought about shame and embarrassment because it was at odds with the archetypes of leadership that dictate that leaders should just know’ (p. 608).114

These multiple juggling acts are addressed in part in postvention guidance, which often suggests the formation of a postvention committee or group, meaning postvention tasks are planned for and shared (see, e.g. Office for National Statistics1 and Samaritans86). This may be feasible in a larger organisation. However, it is likely that one team manager would still need to provide information, identify staff who need support and facilitate the implementation of support resources. In smaller organisations or those that have not implemented a postvention team, individual managers are likely to have to implement postvention support to team members while also having to deal with their own responses to the loss. Effective, evidence-based training may help lessen managers’ load. Attendees of postvention training for clinicians who support parents following the suicide of a child reported increased knowledge, skills and confidence following the session.39 We propose that similar outcomes might be achieved if training were provided to managers and leaders following colleague suicide. However, it must be considered whether such training is available before recommending it as a solution. As Tehan and Thompson109 have acknowledged, managers need to feel knowledgeable, skilled and equipped.

This is the first review to specifically explore the impact of colleague suicide and related postvention guidance. The robust methodology utilised in this review allowed us to bring together a wide range of source literature and first-person experiences alongside associated guidance. This has enabled us to identify areas of disconnect between experience and response, and make recommendations for improving the guidance and, therefore, the care of staff bereaved or affected by a colleague suicide. A limitation of this review is that we were unable to include papers written in languages other than English, due to time and budget constraints. Additionally, although a comprehensive search strategy was used, we may have missed literature not storied in the searched databases.

Recommended steps for practice and policy

Our review suggests that:

• Physical and emotional time and space for processing and grieving ought to be provided in workplaces to accommodate the emotional work that may follow a colleague suicide.
• Postvention guidance must be developed for specific professional groups, drawing on the lived experiences of that group, so that the specific needs of professional cultures and traits are understood.
• Guidance ought to include education around the dangers of stigma, the misunderstanding or misuse of ‘contagion’ and the protective factors of acknowledging and talking openly about suicide.
• Postvention guidance should acknowledge the competing pressures that managers experience following a colleague suicide and provide guidance for the support of managers while they, in turn, support their teams.
• Guidance could offer alternative models to the ‘postvention team’ to accommodate the limited resources of smaller or less resource-rich organisations. This may include accessing external expertise and support, if such a service is available.
• Postvention team members, managers and team leaders should be offered training around topics such as suicide stigma, risk and ‘contagion’. This should include strategies for supporting teams and individuals.

Recommended steps for research

Our review suggests that:

• Future researchers may wish to explore the impact of colleague suicide on those with pre-existing mental health conditions (such as military personnel with PTSD).
• Development and evaluation of postvention guidance that is informed by empirical evidence for specific professional groups is needed.

Conclusions

We suggest that colleague suicide can impact workers in health care and other settings and that perceptions of grief are complicated by professional identities and workplace cultures. A burden is placed on managers to be knowledgeable, skilled and available to support staff. Current postvention guidance, as well as the postvention offered to colleagues, while well-meaning, is not evidence-based, takes an overly individualistic view, may perpetuate stigma, and has not often been evaluated. As such, our next steps are to undertake qualitative empirical research to investigate the experiences and needs of NHS staff who have been exposed to or affected by a colleague death by suicide. We will use the evidence from this research to inform the development of a set of postvention guidance for NHS staff affected by a colleague death by suicide.