The impact on nurses when a patient dies by suicide

Keeping patients safe and preventing suicides is a priority for mental health nursing staff, and when a patient dies by suicide, family and friends will always be the most affected.

“My brain raced through all the things I had said to him, and it went from anger, to shock, to thinking about him and his family, to thinking, how did this happen?”

Adam Edwards

But research by the Royal College of Psychiatrists suggests that mental health professionals will witness between one and four patient suicides throughout their careers. Each of these deaths can have a significant impact on a nurse.

Mental health nurses and nursing students have told Nursing Times how a patient’s proximity to suicide has affected the wellbeing and practice of staff involved in that person’s care, and what changes they want to see to address this soften.

While working as a mental health nurse several years ago, Adam Edwards was the care coordinator for a young man with acute mental health problems, including delusions of persecution that led him to believe a family member was trying to kill him.

Mr. Edwards recalled dropping this patient off at his home one day after a disagreement with medics over whether he should remain in hospital. The next day he discovered that the man had committed suicide.

“This was a young man who I had worked with casually for several months, and I remember coming into work and everyone sitting there looking distraught,” recalls Mr. Edwards, who is now a child and adolescent mental health clinician ( CAMHS). ) Advanced Nurse Practitioner at Aneurin Bevan University Health Board.

“My manager told me that this young man, my patient, had committed suicide. I felt absolute shock, I felt numb, I was scared. I got the details of what happened. I had seen him the day before and dropped him off – it was the last thing we talked about, suicide – to make sure he was okay. He was very sick, agitated and upset.

“My brain raced through all the things I had said to him, and it went from anger, to shock, to thinking about him and his family, to then thinking, how did this happen? Was it my fault? Had I missed something? Was there something in his demeanor that I could have noticed?

Adam Edwards

Mr Edwards said these feelings did not subside quickly and led to him feeling hostile towards the medical team, with whom he disagreed over the man’s discharge from an inpatient facility.

He initially blamed them – something he described as a “traumatic reaction” to the suicide – but said mediation and intervention from his colleagues helped.

Simon Jones, a senior NHS leader in Wales, a mental health nurse and father of a teenager who committed suicide, compared suicide to a stone falling into a pond.

He said loved ones and family members were the hardest hit, but doctors and other professionals involved with the patient were also affected by the “ripples.”

He called for a “new balance” in the way suicides are handled in healthcare and said he believes the nurse’s welfare should be taken into account as part of post-death formalities.

“That’s the fear of it [Welsh NHS] councils around regulation, that the focus is now all on defending processes, policies and the organisation,” he said.

“While all that’s going on… there’s a good chance the nurse who found the person has another shift to finish [and] They are expected to be back the next day.

“It’s part of working in healthcare, but in mental health there’s a different kind of attachment and all the while you have an inner fear: ‘What if I have someone else?’ [suicide]? They will question my practice.”

Support structures for nurses in these situations need to be reformed, according to Mr Jones.

He described the feeling among nurses that clinical supervision – often offered after a patient’s suicide – was a punishment.

“I think the balance is wrong… retrospective clinical supervision sessions should be supportive, but in many cases they take place in the context of corrective action, not support and development,” he said.

Simon Jones

CAMHS nurse Edwards said it would be impossible to fully prepare a nurse for the possibility of someone committing suicide, and stressed that the focus in the aftermath of a suicide should always be on the person who has died and their/ her family.

But he added: “There is a growing awareness that staff need to be well looked after. We need a workforce that is robust.”

Mr Edwards referred to research suggesting that trauma, and suicide itself, could be “contagious”. Figures from the Office for National Statistics suggest nurses are at a higher risk of suicide than the general population.

In recent years, the issue of the well-being of healthcare workers, who are often exposed to traumatic experiences at work, has risen up the healthcare agenda.

Mr Edwards said that in Wales the level of support for nurses has improved in recent years, but dedicated staff to support healthcare workers affected by trauma and patient suicides would help.

“We have a trauma framework that recognizes that there needs to be compassion for the workforce,” he added.

“I think it took a while for people to realize that staff really need to be taken care of.”

‘Chances are the nurse found it [patient who died by suicide] has a shift to complete [and] They are expected to be back the next day”

Simon Jones

In 2023, NHS England published a national toolkit aimed at preventing suicides among healthcare workers and the NHS Confederation have approxPrevention toolkit for when a death occurs in the workforce.

Meanwhile, Dr Emma Wadey, deputy director of mental health at NHS England, recently commissioned a survey of mental health nursing students to look at the impact of exposure to suicide during their training.

A suicide can have consequences for the practice, but also for the well-being of those in trouble.

At a 2023 Royal Society of Medicine conference, Dr. Steven Voy, a child and adolescent psychiatrist in Scotland who researches suicide risk among young people, quoted a nurse who responded to a patient’s suicide.

This nurse said they experienced an “overwhelming” sense of guilt and personal responsibility, as well as difficulty concentrating at work.

Mental health doctors, Dr. Voy said, often became more risk-averse after a patient’s suicide, keeping future patients in hospitals longer. He said this put pressure on services and meant the right care decision was not always made.

He called for individualized and tailored support for nurses and other doctors, in addition to strengthening ‘generalizable’ supports such as signage, occupational health care and dedicated pastoral support staff.

Euan greets

Dr. Euan Hails, a CAMHS consultant nurse at Aneurin Bevan University Health Board, surveyed nurses in the area about the impact of patient suicides, along with Mr Edwards.

Dr. Hails said the research found some postvention measures were ineffective.

A nurse who witnessed a suicide on her ward told the inquiry that she was “too upset to talk” in front of others and that the group therapy she was offered was “not helping”. This nurse, Dr. Hails said, had to find other forms of support on her own. Dr. Hails argued for more flexibility in support.

Research from the Royal College of Psychiatrists has found that “many” of the suicide deaths experienced by mental health professionals during their careers occurred while doctors were in training.

Third-year mental health nursing student Frank Colville, while working part-time as a health care assistant during his studies, was involved in the care of two patients who died by suicide. He said the syllabus for nurses – especially those in mental health – should mention suicide earlier and more often.

He recalled feeling guilty about being upset after a teenage patient took his own life shortly after moving from the area in which he worked. Although he was not directly responsible for the patient, he had spoken to them shortly before their death and was involved in their treatment.

“That feeling emerged among some employees: that they were failing, even though they thought they had done the right thing”

Frank Colville

‘I remember hearing someone [the Royal Society of Medicine conference] saying it feels wrong in the tragedy of the family and friends, and [that of] anyone left behind, to focus on the feelings of the mental health team. In a way I felt that too, but even more so in terms of that ripple effect,” he said.

“I was completely off-center and it felt wrong to think I was actually sad.”

Frank Colville

After the suicide, Mr Colville saw the morale damage among staff, who felt they could have done more to help the patient.

“That feeling emerged among some staff – that they were failing even though they thought they had done the right thing,” he added.

“[Mental health nurses] are very up close and personal, in a way that some nurses are not.”

Self-reflection after a death is inevitable, Mr Colville added, but can easily become destructive if the nurse is not supported.

He said: “I think self-blame is normal, self-criticism, thoughts of ‘what if?’; that’s a natural tendency – especially for people who care deeply. It’s harder to pass the buck and say, “Well, I did my job.” If you care deeply about a patient.

‘I don’t think it’s easy to avoid that self-blame and questioning. But it is possible [become] unhealthy.”

As he nears the end of his nursing training, Mr Colville said he believed that preparation for the prospect of a patient’s suicide could be improved in education, particularly in relation to “how to deal with emotions ”.

He described his experience of patient suicide as ‘harrowing’ and said he was aware of some student nurses who had been involved in the care of a patient who had committed suicide during their very first placement.

That’s why Mr Colville said he would like suicide to be openly discussed in the training ‘from the start’, warning: ‘I don’t know if it’s still a taboo or something, but it shouldn’t be must be.’