The Impact Of Patient Suicide on Doctors and Nurses: A Critical Interpretive Meta-Synthesis

Figures & data

TABLE 1. Search terms utilized for systematic literature review.

Patient suicide	Profession	Qualitative research
patient suicide	doctor*	impact
client suicide	physician*	effect*
completed suicide	general practitioner*	experienc*
suicide postvention	gp*	attitude*
SUICIDE**	psychiatrist*	qualitative
	medic	interview*
	PHYSICIANS	focus group*
	GENERAL PRACTITIONERS	phenomenolog*
	INTERNSHIP AND RESIDENCY	ipa
	nurse*	hermeneutic*
	nursing	ethnograph*
	NURSES**	narrative*
	NURSING**	thematic analysis
		content analysis
		discourse analysis
		grounded theory
		ATTITUDE OF HEALTH PERSONNEL
		QUALITATIVE RESEARCH**
		QUALITATIVE ANALYSIS**
		INTERVIEW AS TOPIC
		FOCUS GROUPS
		GROUNDED THEORY
		DISCOURSE ANALYSIS
		CONTENT ANALYSIS
		PHENOMENOLOGY
		HERMENEUTICS
		ETHNOGRAPHY

Lower case terms indicate key words; Capitalized terms indicate subject headings, matched across databases.

*Terms were truncated to maximize relevant returns.

**Subject terms were exploded within databases wherever possible to optimize the search strategy.

FIGURE 1. PRISMA flow chart documenting the identification process for papers.

TABLE 2. Study profiles for the ten papers included in the meta-synthesis.

Study	Research aims	Theoretical framework	Sampling/ population	Methodology	Analysis	Ethical considerations	Reflexivity
Davidsen (2011), Denmark	Investigate effects of patient suicide on GPs and whether reaction linked to propensity to explore risk	Interpretative phenomenology	Purposive sampling GPs (n = 14)	Semi-structured interviews	Interpretative phenomenological analysis	Ethical approval and informed consent	First person reporting, clear decision rationale and prolonged analysis period for reflexivity
Foggin et al. (2016), England & Wales	Explore GP experiences of dealing with parents bereaved by suicide and personal impact of patient suicide	Thematic	Purposive sampling GPs (n = 13)	Semi-structured interviews	Thematic analysis with constant comparatives	Informed consent was obtained	Recruitment rationale was reported
Gibbons et al. (2019), England	Explore effects of patient suicide on psychiatrists’ emotional well-being, clinical practice and support needs	Thematic	Purposive sampling Psychiatrists (n = 174)	Email-based questionnaires (quantitative and free responses)	Thematic analysis	Not reported	Recruitment rationale considered
Hultsjö et al. (2019), Sweden	Explore nurses’ experience of suicide of patients during ongoing care	Reflective lifeworld	Purposive sampling Nurses (n = 12)	Unstructured interviews	Phenomenological analysis	Ethical approval and informed consent	Researcher pre-understandings considered
Joyce and Wallbridge (2003), USA	Gain insight into the effects on nurses of a series of patient suicides and identify factors that helped them to cope	Thematic	Purposive sampling Nurses (n = 9)	Structured interviews	Thematic analysis	Informed consent was obtained	None
Pavlič et al. (2018), Slovenia	Identify GPs’ problems and needs after patient suicide, and identify ways to support GPs during this period	Thematic	Purposive sampling GPs (n = 22)	Semi-structured interviews	Inductive content analysis	Informed consent was obtained	Prolonged analysis period for reflexivity
Robertson et al. (2010), Scotland	Explore how psychiatric nurses construct and orient to accountability when discussing patient suicide experiences	Discursive	Volunteer sampling Mental nurses (n = 2)	Unstructured interviews	Discourse analysis	Institutional approval and informed consent	Clear decision rationale and researcher position considered
Saini et al. (2016), England	Explore how GPs are affected by patient suicide and the formal support available to them	Thematic	Purposive sampling GPs (n = 198)	Questionnaires and semi-structured interviews	Framework analysis	Ethical and institutional approval, and informed consent	None
Talseth and Gilje (2007), Norway	Describe psychiatrist response to patient suicide in light of a published model of consolation	Interpretative phenomenology	Purposive sampling Psychiatrists (n = 5)	Semi-structured interviews	Thematic analysis	Ethical approval and informed consent	Clear decision rationale, verification strategies, researcher position considered and reflections offered
Wang et al. (2016), China	Explore impact of inpatient suicides on nurses, patterns of regulation and their support needs	Descriptive phenomenology	Purposive sampling Nurses (n = 15)	Semi-structured interviews	Phenomenological analysis	Ethical, institutional approval, and informed consent	None

TABLE 3. Example of first- and second-order constructs from a selected paper.

Study	Aims	Themes (1st order)	Authors comments (1st order)	Conclusions (2nd order)
Saini et al. (2016)	To explore how GPs are affected by patient suicide and the formal support available to them	Part and parcel. Suicide accepted as “a fact of life.” “It would affect me if I knew the patient well and I hadn’t picked up they were suicidal.” Some would not seek support, “it’s obviously distressing but not such that it warrants professional counseling.” Failing patients. GPs reported significant self-scrutiny “The first thing you think is was it my fault,” “It certainly did affect me because I felt I put myself out and say that I wanted to help.” Informal support systems. GPs uncertain of support available. Level of support depended on each case.	Despite some being pragmatic about suicide, other GPs reported frustration at inability to help. Grief, guilt and self-scrutiny emphasized. Suggested older GPs needed more support, possibly due to deeper GP-patient relationship over time with high professional attachment. However, younger GPs might be more emotionally vulnerable. Individual differences in support required depended on preference and impact of suicide. Peer discussions gave GPs opportunity for reflection and learning.	Inevitability of suicide and impact on GPs accepted as core to role. Relationship with the patient affected level of self-scrutiny, particularly where patients were on the “road to recovery.” GPs uncertain what constituted formal support. Ambivalence toward seeking support possibly due to: seeing distress as intrinsic to role; feeling unworthy due to perceived failure; or lack of formal guidance. Reflection and debriefing important for growth.

TABLE 4. Third-order constructs—taxonomy of findings.

Intrinsic but taboo

Patient suicide thought to be unavoidable in healthcare

Perceived helplessness potentiated clinicians’ distress

Despite perceived inevitability, stigma made it difficult to talk about suicide

Significant emotional impact

Clinicians deeply affected by patient suicide—shock, panic and grief

Level of distress dependent on quality of professional attachments

Resilience important for mitigating personal and professional impact

Failure and accountability

Intense self-scrutiny exercised—clinicians wondered if they had overlooked something

Rumination of failure to prevent suicide resulted in guilt and shame

Attributions of blame differed across professional cultures:

Nurses identified external locus of control through increased reliance on protocols

Medics suspected failure in doctor-patient relationships

Legacy of patient suicide

Self-reflection engendered opportunities for personal and professional growth

Uncertainty evident when attending to patients’ families

Organizational responses required to enable supportive cultures post-incident

Lack of formal guidance for postvention procedures and self-care highlighted

*Foggin, E., McDonnell, S., Cordingley, L., Kapur, N., Shaw, J., & Chew-Graham, C. A. (2016). GPs' experiences of dealing with parents bereaved by suicide: A qualitative study. British Journal of General Practice, 66(651), e737–e746. doi:10.3399/bjgp16X686605

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*Gibbons, R., Brand, F., Carbonnier, A., Croft, A., Lascelles, K., Wolfart, G., & Hawton, K. (2019). Effects of patient suicide on psychiatrists: Survey of experiences and support required. BJPsych Bulletin, 43(5), 236–241. doi:10.1192/bjb.2019.26

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*Hultsjö, S., Wärdig, R., & Rytterström, P. (2019). The borderline between life and death: Mental healthcare professionals’ experience of why patients commit suicide during ongoing care. Journal of Clinical Nursing, 28(9-10), 1623–1632. doi:10.1111/jocn.14754

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*Joyce, B., & Wallbridge, H. (2003). Effects of suicidal behaviour on a psychiatric unit nursing team. Journal of Psychosocial Nursing and Mental Health Services, 41(3), 14–23.

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*Pavlič, D. R., Treven, M., Maksuti, A., Švab, I., & Grad, O. (2018). General practitioners’ needs for support after the suicide of patient: A qualitative study. European Journal of General Practice, 24(1), 177–182. doi:10.1080/13814788.2018.1485648

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*Robertson, M., Paterson, B., Lauder, B., Fenton, R., & Gavin, J. (2010). Accounting for accountability: A discourse analysis of psychiatric nurses’ experience of a patient suicide. The Open Nursing Journal, 4(1), 1–8. doi:10.2174/1874434601004010001

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*Saini, P., Chantler, K., While, D., & Kapur, N. (2016). Do GPs want or need formal support following a patient suicide?: A mixed methods study. Family Practice, 33(4), 414–420. doi:10.1093/fampra/cmw040

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*Talseth, A. G., & Gilje, F. (2007). Unburdening suffering: Responses of psychiatrists to patients’ suicide deaths. Nursing Ethics, 14(5), 620–636. doi:10.1177/0969733007080207

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*Wang, S., Ding, X., Hu, D., Zhang, K., & Huang, D. (2016). A qualitative study on nurses’ reactions to inpatient suicide in a general hospital. International Journal of Nursing Sciences, 3(4), 354–361. doi:10.1016/j.ijnss.2016.07.007

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