This work package responds to research objective 6a: To use the findings to develop evidence-based postvention guidance for NHS organisations and managers so that they can support and respond appropriately and effectively to bereaved or affected employees.
Methods
This section has been reproduced from Causer et al.149 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 text below includes minor additions and formatting changes to the original text.
For generating the guidance, we employed a three-step process of data synthesis: analysis – synthesis – interpretation
- Analysis
- This is the first stage in understanding the key messages that sit within the data sources.
- Extract theme headings and recommendations from data sources.
- Tabulate to enable comparison and organisation which will allow identification of common themes across the data sources.
- Synthesis
- Combine similar themes or messages that occur across the data sources to generate composite themes. This stage may involve working iteratively – repeatedly returning to the original source to check the meaning and details of theme headings.
- Generate a final group of themes and key messages and track where and how they have been informed by each of the data sources.
- Translate themes into the key headings under which your recommendations will sit.
- Interpretation.
- Moving away from broad ‘themes’ and common meanings, interpretation involves exploring organising principles that help to explain variation and differences across contexts and individuals.
- Taking account of these variations and differences, you will now develop the recommendations that sit within the themes developed by the synthesis.
Part 1: Synthesis of recommendations from review, grounded theory studies and guidance thematic analysis
Table 9 summarises the key messages that arose from the synthesis of evidence from our review study, grounded theory analyses and thematic analysis. Column one contains the key messages that were developed from the synthesis, column two reports the source and nature of the supporting data, and column three provides a narrative generated from these findings.
| Message | Supporting data | Overview of findings |
|---|---|---|
| A supportive culture which is open and accepting about mental ill health while challenging stigma will enable the delivery of effective postvention. | Review: Postvention guidance must be developed for specific professional groups, drawing on lived experience, so that cultures and traits of professions are accommodated. | NHS cultures are often hostile spaces where vulnerability is not permitted. We encourage the development of caring cultures which challenge stigma around both mental health and suicide. These caring cultures will facilitate the delivery of postvention and allow staff to step out of their healthcare professional (HCP) role so that they can more fully engage with the support they are being offered. Additionally, given that supporters are operating from postvention situations which are not always ideal, learning is a better outcome than blame following the delivery of unsupportive postvention. |
| Affected staff: Culture that challenges mental health (MH) stigma gives staff permission to talk about the suicide; staff might need support to step out of HCP role so that they can engage fully with support. | ||
| Supporting staff: As above, the culture must challenge stigma around MH and suicide; a blame-free culture which focuses on learning instead better facilitates effective postvention; caring relationships, comms, meetings and actions are useful. | ||
| Guidance TA: Cultures need to change; policies need to change; organisations need to change. | ||
| Information about the death must be shared quickly, compassionately and congruently. | Review: There is a need to communicate clearly to staff while balancing preferences of the family. | Information about the death needs to be broken quickly and in a way that works for the people hearing it. The person doing this needs to be able to match their emotions to the sadness of the news and to be able to support staff immediately. It might be that some questions cannot be answered right away – honesty and transparency around this are essential. Guidance might be needed to help supporters word the news in the best way, and they may need support with this emotionally challenging task. |
| Affected staff: Staff need to hear the news in a timely and sensitive manner; person breaking the news needs to be available for immediate support; person breaking the news needs to be skilled and knowledgeable about suicide. | ||
| Supporting staff: Data from ‘breaking the news’ and ‘controlling the news’ codes; news needs to be broken quickly and with care; maybe tailored to who is hearing it; emotional congruency is key; a social media policy needs to be in place. There may be an emotional impact on the supporter who is breaking the news. | ||
| Guidance TA: Guidance can include wording to help with comms. | ||
| Physical and emotional staff-only spaces are needed for workers to process a colleague’s suicide. | Review: Physical and emotional time and space for processing grief must be provided in the workspace. | The lack of resources currently facing the NHS includes a lack of time and space for bonding and relaxing with colleagues. This impacts postvention as it makes it harder for staff to be together to share and talk about the person who died and their feelings. If these spaces (both physical and emotional) can be provided, they appear to be beneficial in the healing process. These spaces must be for staff only; supporters also need spaces just for them, away from the colleagues they are supporting. |
| Affected staff: Staff need safe, private spaces where they can be together, share memories and plan for remembrance. | ||
| Supporting staff: A lack of physical space is a disabling element which makes it harder for supporters to deliver postvention; Schwartz Rounds may be a useful space for staff and supporters to be able to share and process feelings. | ||
| Guidance TA: Talking and being together are important; support must be tailored; supporters need space away from the staff they are supporting to process their feelings with other supporters. | ||
| Staff need time and space in which to talk about and remember their colleague. Remembrance and memorialisation should be acknowledged and encouraged as important processes for the staff who are impacted by a colleague suicide. | Affected staff: Staff need time away from work to attend their colleague’s funeral and should not be expected to return to work following a funeral. Memorialisation activities by colleagues should be encouraged and supported by senior leads and Trusts. Trusts should openly acknowledge the death of a colleague by suicide and pay respects/tribute to the colleague as they would if they had died by any other means. Anniversaries of the death, and of the deceased’s birthday (if that would usually be celebrated) need to be openly acknowledged within teams and staff given time to remember, talk and share memories to mark these occasions. | Remembrance and memorialisation have been evidenced in our data as being activities that staff find helpful and healing. Staff also require their department or organisation to visibly acknowledge their colleague’s death and appreciated the contribution that their colleague made within to the NHS. Visible activities such as a write-up in a newsletter, or an all-staff e-mail let co-workers know that their experiences of loss are seen, acknowledged and shared by their employers. |
| Leaders should be mindful of significant anniversaries following a colleague suicide and work with staff to discuss further acknowledgement or remembrance activities. | Supporting staff: Memorialisation is important to colleagues. | Memorialisation needs to be led by the deceased’s colleagues and supported by the organisation. Memorialisation is incredibly important to staff who have lost a colleague to suicide. |
| Psychological support for impacted staff members must be clearly signposted, timely and ongoing. | Affected staff: Psychological support needs to be available, clearly signposted, and offered repeatedly for the first few months. | Postvention must be timely and sustained to be effective. Help also needs to be clearly signposted, as staff might not be aware of its existence otherwise. |
| Supporting staff: Effective postvention needs to be delivered in a timely, sustained manner; well-being services need to be available out-of-hours. | ||
| Guidance TA: Support must be timely and sustained; resources must be signposted. | ||
| NHS staff who might be called upon to support their co-workers following the suicide of a colleague need training. | Review: Postvention teams need training before suicides happen. | Training and guidance were often entirely lacking for supporters. Training needs to happen before a suicide so that postvention teams know how to respond right away. |
| Supporting staff: Postvention leads need training before suicides happen. | ||
| Guidance TA: Those delivering postvention need training. | ||
| Thought must be given to who delivers postvention; it might be useful to include external supporters. | Review: Guidance could offer creative alternatives to the ‘postvention team’ model; complex pressure on managers means that someone other than a manager might be ideally placed to offer support, or at least contribute to support. | Postvention is not a job for one person – rather, a team needs to work together to ensure all aspects are covered and to support each other in the delivery. Additionally, many of our sources of data suggest that including someone impartial or external in the postvention team would be a good idea. Chaplains and well-being leads [many of whom did not know the person who died by suicide (pwdbs)] appear well placed to deliver postvention, adding further evidence to the suggestion that postvention should not be coming entirely from a manager who did know pwdbs. |
| Affected staff: Given that supporters may also be grieving, many staff suggested that something impartial/external might be the right person to offer support. | ||
| Supporting staff: Postvention should be delivered by teams rather than individuals; some roles (e.g. well-being lead or chaplain) are more enabling than others (e.g. manager). | ||
| Guidance TA: Postvention must be delivered by the right team of people. | ||
| Educational elements are essential in postvention delivery and guidance. | Review: Guidance needs to include education around stigma, misunderstandings of ‘contagion’ and the protective factors of openly talking about suicide. | Educational elements are essential for both supporters and receivers of postvention. |
| Guidance needs to include education around stigma, misunderstandings of ‘contagion’ and the protective factors of openly talking about suicide. | Affected staff: Postvention delivery should include educational information about the causes and impacts of suicide. | For supporters so that they understand the dangerousness of silence and how it generates stigma; so that they understand that talking about suicide will not increase the risk of other staff feeling suicidal, but rather, that it is a protective factor. |
| Postvention delivery needs to inform those who are affected by the causes and impact of suicide. | Supporting staff: ‘Educating’ is one of the behaviours that staff can choose to engage in to negotiate their postvention situation. This education might include awareness raising, teaching, pushing for change and fighting stigma. | For staff who are affected, it is helpful to gain insight into the kinds of reasons why people might feel and behave suicidally; and what the expected impact may be for them. This will help staff navigate the unanswered questions and make some sense or meaning of their colleague’s death. |
| Guidance TA: Support should be educational. | ||
| Risk management and assessment should be an integral part of staff care following a colleague death by suicide. | Affected staff: Each affected staff member should be consulted to assess their ability to return to full duty following a colleague suicide. | Our data show that this is particularly pertinent for staff who work with patients who experience suicidality or who engage in non-suicidal self-harm. Participants reported experiences of self-doubt in their ability to undertake this kind of work following their colleague’s suicide. Specifically, participants feared that they no longer had the skills to work in a preventative way with suicidal patients. Professional dangerousness can be avoided by the implementation of robust risk assessment and good supervision, thereby ensuring patient safety. |
| An assessment of risk should be undertaken with affected staff who work with suicidality – risks to the staff member, their colleagues, and their patients ought to be considered. | ||
| Staff who do not engage with support should be followed up with and a one-to-one conversation to check in and find out if specific support is required. | ||
| Guidance TA: Postvention is prevention; postvention is a circular system which also acts as prevention. | ||
| Staff members who are delivering postvention support will require additional support to enable them to complete this task in a safe, timely and compassionate manner. | Review: Guidance needs to include support for the supporters; postvention guidance needs to acknowledge the workloads of managers and the complex pressures that they experience following a colleague suicide. | Support may include emotional and psychological support, practical support in managing key tasks and personal workloads, support in meeting the needs of their department/ward/patient group while staff members are taking the time they need to process the news and attend support group activities, or one-on-one therapeutic support, and skills support. |
| Supporting staff: Guidance should include information about how to care for supporters. | ||
| Guidance TA: Supporters need guidance; supporters need emotional support. | The kinds of support required will vary according to who is delivering postvention, what their usual job role is, and whether they knew (and what their professional/personal relationship was with) the person who died. | |
| Evaluation of postvention delivery and associated outcomes is essential to inform further learning and improvement in support and processes. | Affected staff: A 3-monthly and 6-monthly check-in is advised to monitor how staff are coping and adapting. These check-ins can also be used as opportunities to evaluate staff perceptions of the delivery of support and postvention. | Evaluation could take the form of ‘what happened’, ‘what went well’, ‘what could have been done differently’, ‘what, if anything, failed’. |
| Evaluation processes also generate an opportunity for further check-ins with staff who were affected by the death. | Supporting staff: Evaluation of postvention following delivery is essential to harness and integrate learning opportunities. | Evaluation should include perspectives of the person/s who delivered the postvention and those who were supported, as well as other staff members who are connected to the affected team. |
| Guidance TA: Some support is already happening; some excellent support is already happening. |
Summary of key messages by theme
Context/culture
- Contexts and cultures shape the experiences of staff after a colleague suicide; they also inform how postvention is delivered and accessed.
- A supportive and non-stigmatising culture which is open and accepting about mental ill health will give staff permission and space in which to process their responses to a colleague suicide and will enable the delivery of effective postvention.
- The context from which support is offered needs to be well-resourced and well-staffed to enable effective support.
Organisational response
- Organisations need to be prepared to respond immediately and with a skilled workforce to support staff.
- Organisations must acknowledge and respond to a colleague suicide to create a suicide-aware culture where conversations are welcome and supported.
Support needs
- Staff need support to be timely, sustained and proactively offered by skilled, empathic leaders.
- Support should include safe spaces in which staff can be together to talk and share.
- Physical and emotional staff-only spaces are needed for workers to process a colleague suicide.
- Staff need time and space in which to talk about and remember their colleague.
- Remembrance and memorialisation should be acknowledged and encouraged as important processes for the staff who are impacted by a colleague suicide.
Delivery of support
- Thought must be given to who delivers postvention; it might be useful to include external supporters.
- News of the death must be shared quickly, compassionately and congruently.
- Psychological support for impacted staff members must be clearly signposted, timely and ongoing.
- Leaders should be mindful of significant anniversaries following a colleague suicide and work with staff to discuss further acknowledgement or remembrance activities.
- Failings in the delivery of support leave staff to draw on their personal resources to ‘fill the gaps’ themselves; some staff will ‘fall through’ these gaps and remain unsupported, unheard and potentially harmed or disengaged.
Educational elements in postvention support
- Educational elements are essential in postvention delivery and guidance.
- Support should include education about suicide, its causes and effects.
- Guidance needs to include education around stigma, misunderstandings of ‘contagion’ and the protective factors of openly talking about suicide.
- Postvention delivery needs to inform those who are affected about the causes and impact of suicide.
Risk management
- Risk management and assessment should be an integral part of staff care following a colleague death by suicide.
Supporters’ practical needs
- NHS staff who might be called upon to support their coworkers following the suicide of a colleague need training.
- Postvention must be delivered by a team to ensure support is offered in a safe, timely and compassionate manner.
- Supporters require an enabling environment and sufficient protected time to be able to offer effective postvention.
Supporters’ emotional needs
- Staff in supporting roles may also be affected by a suicide, thus requiring postvention support themselves.
- Supporters will be impacted by the quality of the support they are offered. Therefore, support for supporters must adhere to these guidelines also.
Evaluation and learning
- Supporters can learn from the postvention that both they and others have delivered.
- Some current postvention is supportive and can be used to inform learning.
- Evaluation of postvention delivery and associated outcomes is essential to inform further learning and improvement in support and processes.
Evaluation processes also generate an opportunity for further check-ins with staff who were affected by the death.
Part 2: Synthesis of workshop data into evidence synthesis
We organised data from the stakeholder workshop alongside the themes and key messages that were developed in part one of the synthesis. This organisation can be seen in Appendix 1 (Table 10). The key finding that arose from part two of the synthesis process, as illustrated in Table 9, was that data collected from the stakeholder workshop corroborated and strengthened the findings from part one of the synthesis. Data supported all of the existing themes and key messages. While there were some new examples of specific needs and new ideas for solutions, the data did not support the development of any new themes or key messages.