Work package 2: Qualitative study: methods and grounded theory 1

Parts of this chapter have been reproduced from Causer et al.115 and Spiers et al.116 These are Open Access articles distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permitsothers 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:

• To explore the impact of colleague suicide on staff well-being and grief reactions to such an event.
• To explore staff views about risk factors which may have contributed to the suicide of their NHS colleague as well as any ‘warning signs’ the individual may have displayed.
• 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.
• To explore how managers and other staff tasked with delivering postvention respond to and support their employees and colleagues following a death by suicide, and to identify current postvention activity.

Methods

A qualitative approach was selected to gain an understanding of participants’ experiences, perceptions, and meaning-making processes. We generated data using semistructured interviews conducted via online video platforms or telephone calls, according to participants’ preferences. We applied a grounded theory analysis,117 which can be applied within any philosophical paradigm.117 In the case of this study, we adopted an inductive, exploratory inquiry. Grounded theory is particularly suited to exploring how people experience and resolve their problems, seeking to understand ‘what is going on’.118 We used the consolidated criteria for reporting qualitative research checklist to inform our reporting of this study.119

Ethics

Ethical approval was granted by the University of Birmingham (ERN_20-1566) and the Health Research Authority (IRAS 291050). Participants were given a list of signposted support resources, including those within and beyond the NHS. In addition, the researchers were actively aware of participant well-being throughout the interviews, offering options to pause, reschedule or curtail the interview at any point. A clinical team member was available ‘on-call’ during all interviews should a participant present with active suicidality. A follow-up phone call or e-mail was offered to all participants 2 or 3 days following the interview to check in regarding any subsequent effects of the interview. In addition, confidential therapeutic support was available to all participants and also to the researchers. We have de-identified all participant data.

Positionality statement

The researchers who undertook the interviews and led the analysis (HC, JS and RR) are all White British women, none of whom are currently, nor have previously been, employed by the NHS.

Participants

Participants were recruited via a range of approaches, including NHS Trusts in England, our stakeholder networks, for example NHS England and NHS Employers, social media posts on X (formally called Twitter) and Facebook groups for NHS staff, and practitioner journals such as the Nursing Standard.

We recruited two groups of participants: (1) employees of the NHS who had experienced and were affected by the suicide of a colleague between 6 months and 10 years prior to data collection; (2) NHS workers who self-identified as having supported their colleagues following the suicide of a coworker, either because this was part of their role (if they were chaplains or well-being leads) or because they were managers to whom the work fell.

Potential participants were sent an information leaflet; participants gave informed consent and completed a demographic questionnaire prior to interview. Despite our efforts to connect with NHS workers from diverse ethnic backgrounds, all participants in this study were White British. Given that minority ethnic people comprise almost a quarter of the NHS workforce,120 we accept that our findings are unlikely to represent the experiences of all staff members. We also made particular efforts to recruit participants from staff groups known to be at higher risk of suicide; this was successful with nurses, but, despite our efforts, not with paramedics. However, the number of paramedics in the study (n = 2) is representative of paramedics as a proportion of the NHS workforce.

Staff participants

We recruited a total of 51 NHS workers, 29 of whom had been impacted by the suicide of a colleague (N = 29). Participants held a variety of posts and had different levels of experience. Seventeen per cent of participants identified as male compared to 23% of the NHS workforce who are male;121 we therefore acknowledge this is not fully representative of the NHS workforce. Further demographic details for participants from both groups can be seen in Table 6.

Data generation

Semistructured interviews commenced in November 2021 and were completed in January 2023. Dates and times were set at the participants’ convenience. Interviews were undertaken by HC (n = 15), JS (n = 12) and RR (n = 2).

Two topic guides were used. The first, for NHS workers impacted by the suicide of a colleague, contained 16 questions about the participants’ relationship with the colleague who had died, participants’ accounts of their experiences in relation to their colleague’s suicide, experiences of support, and opportunities for learning (see Report Supplementary Material 2). The second, for supporters, included questions on participants’ relationship with the person who died by suicide, their reaction to the death, and their experience of supporting others and being supported (or not) (see Report Supplementary Material 3).

The topic guides were informed by and developed in response to a scoping review of the literature, input from our PPIE group, a consultation exercise conducted with NHS managers, and the lived experiences of study co-applicants. They were recorded via encrypted audio recorders and were transcribed and de-identified by professional transcribers.

Grounded theory 1: Filling in the gaps: a grounded theory of the experiences and needs of healthcare staff following a colleague death by suicide in the United Kingdom

Data analysis

The methodological aim of the analysis was to uncover any patterns in reported participant behaviours that explained their main concern.117 Coding was done by HC alongside ongoing discussion with JS. Data saturation was informed by the quality of the data collected, and the depth and rigour of the analytic process.122 Therefore, the data analysis was considered complete when there was nothing further to add to the categories that had been developed. The analytic process included three stages of coding and category building, the development of a core category, and theoretical conceptualisation of the relationships between the core and other categories. At all stages of analysis, constant comparison,123 analytic memoing, memo sorting117 and diagramming124 were used. Engaging these tools promoted an ongoing iterative and reflective process of comparing and checking as codes, categories, and the relationships across and between them were developed.

We present the developed grounded theory below, followed by each of the categories with illustrative verbatim quotes. Findings about ‘the workplace’ and ‘professional identities’ are reported within other category sections to reflect the integration that was evident throughout our analysis.

A grounded theory

The analysis resulted in the development of a grounded theory, ‘filling in the gaps’ (Figure 3). The theory combines seven categories and one core category. Figure 3 illustrates the relationships between and across the categories. Participants’ experiences included the event of their colleague’s suicide, their experiences of needing support and being supported, and their encountering of gaps and barriers to the support that they required. In response to these gaps and barriers, participants acted and reacted in a range of ways, to ‘fill in the gaps’. The prevalence of participant reactions in their accounts, and the emotional vehemence with which participants spoke about them, illustrated the centrality of this aspect to their experience. As such, they are captured in the core category, ‘filling in the gaps’, which describes the many ways that participants sought to support themselves and their colleagues in the absence or failure of formal provision of acknowledgement, information, and support. For some participants, however, the experience was more akin to ‘falling through the gaps’, which resulted in a range of challenging outcomes. Participant accounts evidenced how their experiences and reactions throughout were shaped by their work environments, the physical and cultural environment of the workplace, and the multiple aspects of their professional identities. For all participants, there were repercussions to their experiences, that, for some, continued to impact on their professional or personal lives.

FIGURE 3 Filling in the gaps: a grounded theory of NHS staff experiences following a colleague death by suicide. Reproduced from Causer et al.115 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.)

Experiencing and reacting to a colleague suicide

Some participants’ experiences began with the discovery of a colleague’s body and active attempts to save a colleague’s life.

[M]y brain went just full paramedic mode [...] like didn’t think. Erm so yeah then we started CPR [cardiopulmonary resuscitation] and when [the ambulance arrived] I ran to warn them who it was cause I just didn’t want my colleagues to have the shock that I’ve had. Like I, it’s gonna be awful for them anyway, but I wanted [to warn them].

However, most participants heard the news of their colleague’s suicide either via an online or in-person meeting, telephone call, by word of mouth from other colleagues, or through less formal channels: ‘we all found out through social media’ (Nurse).

I got a text message from a colleague saying ‘is it true that one of your juniors has killed themselves?’ [...] and I was like oh crikey, you know I was really shocked because I hadn’t [been informed] [...] I kind of found out about it in a less than ideal way and then spent a bit of time erm trying to establish you know what had happened and what we needed to do.

The way in which participants received the news was affected by the physical and cultural contexts of the workplace, and the behavioural norms of their professional identities. Some heard the news via an online meeting and were advised to turn off their cameras and mute themselves so that their responses remained ‘private’. Participants reported mixed feelings about this privatising of their grief/shock responses: some believed it was sensitive, others found it disrupted the shared experience and was isolating and harmful: ‘I was left alone with my thoughts and feelings’ (Administrative Assistant). One participant was haunted by the memory of hearing a colleague crying (because they hadn’t muted their microphone) but not knowing who it was.

Initial reactions described included shock, emotional and grief responses. Some felt anger towards their deceased colleague and found it difficult to express this: ‘it would have been hard for me just to … say “actually I’m not sad, I’m ****ing pissed off”. Cause it’s not what a lot of the other people were saying’ (Therapist).

Team cultures informed how people responded or shaped expectations around how staff ‘ought’ to respond in the workplace. Fears of upsetting others or speaking out of line were expressed. Some struggled with picturing their colleague’s suicide and, for those who were present, there were trauma responses such as flashbacks or intrusive images.

The professional mask was used as a means of conforming to the dominant narrative of invulnerability and expectations about carrying on. However, professional identities, where healing was central, led some to doubt their professionalism.

I’ve had a real wobble myself [...] not feeling suicidal, but really, a crisis of confidence in terms of am I doing a good job? You know? Am I ok as a nurse? What’s it all about? All those sorts of questions, you know, if you can’t protect your own what [are] we doing? Are we doing this the right way?

The conceptualisation of and sense of belonging to the ‘professional family’ magnified some participants’ sense of loss, grief, guilt or anger.

[I]t’s what a family would go through [...] we spend more time in our workplaces with the people we work with, than sometimes our own family and it does feel like family, so that loss was as deep, as hurtful as a family member.

Such emotional responses were still present, for some, years after the event.

Needing support and being supported

Participants reported needing support to manage and validate their emotional responses, processing, and ability to continue working. Additionally, they needed permission and protected spaces to talk, a confirmed point of contact who would regularly check in with them, and clear signposting to other resources.

Experiences of being supported included structured, informal, and self-generated support, which was delivered within the workplace as well as through peer and personal networks. Support, if provided, came from team leaders or managers, staff well-being/liaison services, or an NHS chaplain. When staff could share memories of their colleague, they felt supported and able to process events and feelings.

... and [my manager] said ‘I want you all to go into the office […] I need you as a team to be together and supporting one another’ so, we did […] we all got together and just sat and laughed and cried and laughed and cried. And, you know it was nice to be together, support one another.

Many participants described being together with colleagues, sharing space and talking as vital. Disconnection from colleagues, however, due to different job roles or ways of working, generated feelings of being ‘othered’ or overlooked for some.

Finance departments are sort of notoriously erm … I think we get the reputation of being the grey robot people so the – one would expect that that you know signposting probably wouldn’t have been that great, erm we probably couldn’t get any further away from clinical services. Had I worked in the clinical team I guess that I would have had erm probably better support and signposting probably would have been there straight away but, but that’s not something we had.

So, while the ‘professional family’ can feel safe, supportive and inclusive to some, it can feel remote, exclusive and discriminatory to others.

Overall, support did not meet most participants’ needs. Some reported offers of support that never materialised, while others chose not to engage with the available support. Some felt that managers needed training to be able to offer empathic, compassionate support. Several felt that an impartial/external person to provide support would be beneficial and would avoid placing the burden of support on a manager who was also affected by the suicide. Participants felt they were expected to ‘reach out’ and ask for support rather than supporters ‘reaching in’ to ask what they needed:

The managers are there, we know they’re there, but they never initiated anything like ‘are you all okay’ um, ‘are you all alright, do you need five minutes to chat with me about anything?’. That never occurred.

Encountering gaps and barriers

Most participants reported gaps in support provision or barriers to accessing support. They described miscommunications or insensitivities, pre-conceptions of professional identities such as invulnerability, and cultures of silence and secrecy around the suicide, where everything was felt by staff to be ‘brushed under the carpet’ (Nurse manager).

Participants who were informed of the death while working faced the challenge of having to continue to perform. A stoic ‘carry on’ narrative appeared to be woven through the culture of teams and organisations which, when combined with a ‘patient first’ value-base, created a barrier to staff feeling ‘allowed’ to attend to their own needs.

In many instances, participants reported a complete absence of support, where both the death of their colleague and the impact on staff went unacknowledged.

[T]here’s, there’s been nothing to remember [our colleague] from the NHS. Nothing at all. Erm, you see where other people died of cancer or something, then they have a lot of recognition. Erm, but there’s been nothing for [our colleague] [...] and [they] must have worked in the NHS for about 20-odd years.

The lack of staff-only spaces or meeting rooms posed challenges to participants who needed private or shared spaces in which to express their feelings.

Some participants reported that their professional identity prevented the release of difficult feelings, slowed down processing, and acted as a barrier to accessing support:

[W]e’re terrible at going to the doctors or seeking any – any sort of support. So, we don’t practise what we preach.

There was a sense of challenge around crossing the line from perceptions of being the ‘healer’ to the ‘patient’.

Coming up against these gaps and barriers led to secondary impacts such as perceptions of being dismissed or ignored or feeling invisible. There were additional hurdles to overcome and feelings to process, such as the task of self-care to make up for lack of support or the risk of continuing to work without support or safeguards in place. These experiences gave rise to intense frustration, anger, or bitterness, emotions which disrupted participants’ ability to process thoughts and feelings:

The anger about how the lack of support from the organisation was getting in the way of us grieving and thinking about [our colleague].

Participants, including those who worked with suicidal patients, reported a lack of process to check if they were safe to practice following the suicide of their colleague:

... in [my] role, you’re by yourself. A lot of that time I was on my own and then, nobody said, nobody thought that could be really horrible, knowing what’s just happened [...] [It was] just unsafe for everybody really.

Filling in the gaps

Participants’ main concern was the gaps in their support. This core category describes the diverse ways participants responded to those failings and absences. The work of responding became a prominent focus, disrupting the work of loss and grief. This dominated accounts and greatly influenced participants’ experiences:

[W]e supported ourselves as a team. I think that’s how we got through it really, rather than the managers being at the forefront of it, if I’m being honest.

Filling in the gaps was a necessity for several reasons: so that staff could process their feelings and thoughts about what had happened; so that they could remember and honour their colleague in ways that felt appropriate and compassionate; and to enable them to continue to work safely. The work entailed in filling in the gaps happened both within and beyond the workplace and alongside participants’ need to process their grief. One recalled the efforts required to ask for time off to attend their colleague’s funeral.

I remember having to build myself up for [...] the conversation, why I want [the day of the funeral] off, and it being a case of, I’ll see what I can do as opposed to yeah, we’ll get it sorted, and so I just remember thinking, I’m not gonna get this. And it was very, [last minute] only that day that I got confirmation.

The strategies that participants engaged in response to these gaps included sharing grief and remembrance with peers, self-supporting, change-making, organising, and rationalising, wrangling processes such as meaning-making, going into professional mode, not speaking and self-protection, and doing things differently.

Sharing grief and remembrance

The loss of a colleague is a shared experience; having the time to talk about that loss collectively appeared crucial for some participants through the earliest days following the death. The importance of talking, remembering and crying together came through in several accounts, but more important was being physically present with each other.

Participants felt that sharing helped them to process, release difficult feelings and reconcile with what had happened. Those who were able to be together found this helpful:

And so people just shared stories, expressed their sadness, um, might have been a little bit of ventilation, it helped.

Due to coronavirus disease discovered in 2019 (COVID-19) restrictions, some participants were unable to meet. They spoke of the difficulty of being apart:

[I]t feels hard to see someone upset and not be able to put an arm around them or comfort them in a physical way.

There was a felt need by participants to remember their colleague. If facilitation of remembrance was absent, participants created ways to do so informally, like a chat in the workplace, formally through activities such as visiting their colleague’s grave, or through actions like creating a space in honour of their colleague:

[T]here was a tree right in the corner of the car park, and we, we made it [our colleague’s] tree, and we went and planted things and put flowers in the tree. You know, just made it really beautiful.

Some reported a culture where their colleague was often spoken of in their workspaces.

[E]very new member of the team, that comes into the team, you know I’ll say ‘You know we used to have a colleague called [name] and we talk about her so you know so if we are laughing about her and talking about her that’s who she is, and this is what happened’.

Self-supporting, change-making, organising, rationalising

Staff employed a range of proactive behaviours to support themselves and their colleagues. They made requests for counselling, accessed their GPs, found information online, drew on personal support networks, and found support via other organisations. Sometimes, these actions were underpinned by uncertainty and a lack of guidance alongside the realisation that action was needed in the absence of formal provision. For instance, one nurse recalled arranging a get-together with colleagues.

There wasn’t any, you know, manualised OK, let’s just go to the ‘colleague who’s just died by suicide’ book, you know, and, and structure it in this way. There’s nothing like that, it was […] just an acknowledgement that we, that we’ve lost [our colleague] and my sense of speaking to people is that there’s a lot of pain and heartache out there. And um, people might benefit from having an opportunity to get together [...] I wasn’t sure whether I had permission to do this.

By employing this range of proactive behaviours, participants created the space and time they needed to attend to tasks such as checking in on each other, organising memorials, and working through their ideas and understanding about the death:

We helped each other. We’d meet, we’d meet for a coffee somewhere and chat and say how we was feeling. I think we got more comfort from that.

Wrangling, seeking answers and meaning-making

All participants shared experiences of cognitive ‘wrangling’ with the death as they struggled to find resolution or answers and to fill in the gaps in their understanding. Some described going around in circles with unanswerable questions, which felt excruciating. This wrangling impacted all participants, often remaining unresolved.

Sometimes you wonder, I wonder if she, you know, that’s a stupid question ’cause she’s done it – but if she’d regret it [laughs]. It’s a stupid question. But actually, it’s like – yeah, so it, it’s those bits of just trying to make sense of something that – that – it’s difficult.

It seemed that being a healthcare professional led participants to self-scrutiny, questioning why they did not notice, and why they could not save their colleague, ‘did [we] really know them?’ (Nurse); ‘were we complicit?’ (Therapist).

[W]e’re a mental health team – we work a lot with suicidal patients, and then you start questioning yourself, like, well why didn’t we notice it? Like, what could we have done, like why couldn’t we help her? Like, this is our job, and she’s one of us, and and we’ve lost her.

These processes seemed to be shaped by shared professional identity. Participants often spoke collectively, saying ‘we’ when they spoke about seeking answers or understanding around their colleague’s death. In framing these thought processes as being collective, there emerged a shared sense of responsibility.

Additionally, some participants asked if systemic structures, cultural expectations and behaviours, institutional narratives, and discourses had contributed to their colleague’s death. Participants experienced cognitive wrangling, their thoughts jumping from one line of questioning to another, as they tried to find answers.

And this ongoing bad management I think is what upsets me. Because it was, I feel like all these failings affected [my colleague] to the extent that [pause] I don’t think that’s why she did it. I don’t think so. And I don’t think that even with the greatest management in the world it would have [pause] changed what she did that day? Because I fully accept that it was her mental health. It was so much more complex than just [mental health].

Falling through the gaps

Some participants were left with unresolved, complex feelings and thoughts about their experience due to insufficient or absent support. This could result in stress and burnout.

I just completely burnt out and had to have some time off, yeah, everything just kind of piled up. Erm, and yeah, I definitely became depressed and I just, well my tank was empty, that’s how it felt [...] Like I’d be sat at my laptop but physically couldn’t do anything. So yeah I had to take [some time] off.

The lack of acknowledgement, support and safeguarding of staff working with suicidal patients led to increased anxieties around this aspect of their work.

[Y]ou have your patients that are suicidal and so you you’re listening to them, and so it does put you on edge. You’re frightened of you know [when] you can’t be there, you you’re going in for 45 minutes to talk to somebody. You know and then you’re closing the door and leaving them and it’s, yeah it’s frightening.

Repercussions

Most participants described some form of impact or legacy following the event. These ‘repercussions’ were not only about recovery, healing, or ‘getting over it’, but also about ongoing effects. As they continued to work, they did so alongside the impact of their experiences, which shaped their approach to work and sense of self:

[T]here’s a little part of me that worries maybe I’ve just kind of shut down or just become that’s my way of protecting myself or yeah distancing it a bit.

This impact meant that others’ experience of work was compromised or harmed.

Which makes it hard [...] going back to work, you want to do your best, [describes new job-role] like it’s an amazing [opportunity] and I can’t make the most of it. And that gets on your mental health too. Yeah, it’s all [a] spiral.

Participants described career impact, with some leaving their jobs:

[W]e’re working with high levels of risk on a daily basis [...] I’ve found it really difficult, I’m, I’m actually, I’m leaving the team in the near future. So I’m I’m, moving out of mental health services.

There were more positive changes for other participants:

I think what [their] death did, did do, as [my colleague] said is that it changed our personal culture of you know how we are with each, how we look after each other on the unit. How we, we check in with each other a lot more.

Others found more personal ways of reconciling their loss:

[W]hat I found comforting was to imagine err [my colleague] as like a little fairy godmother, a cartoon. Erm and she swore a lot. So I was imagining her as this little fairy godmother, waving her wand and swearing as she goes. And err yeah so I wrote that to one of my colleagues and they said ‘yes yes, that’s exactly it!’ [...] And so that’s comforting and happy and makes me smile.