A collegial support group at Stavanger University Hospital
The eight in-patient locked wards in the mental health clinic for adults at Stavanger University Hospital see around five suicides per year in total. The clinic has procedures in place for systematic training in suicide risk assessment, conducting such assessments and implementing protective measures. These measures include the frequency of patient observations, assessment of medication for the alleviation of symptoms, and assessment of whether patients may go outside on their own or need to be accompanied. There are also alert procedures and documentation requirements as well as procedures for the safeguarding of relatives and the bereaved.
There has previously been no systematic follow-up of the practitioners involved. In joint meetings with doctors and psychologists at the clinic it emerged that they felt the lack of a type of follow-up that would focus on emotional responses and difficulties over time. Several practitioners who had experienced suicide among their patients, expressed the view that they were left to grapple with many difficult feelings largely on their own.
Possible differences were pointed out between the ways that practitioners and welfare workers experience suicide among patients. Among practitioners, the thought of being responsible for a treatment that may have been deficient or incorrect weighed more heavily on their shoulders, while the welfare workers were closer to the patients over time. They would often be the ones who found the deceased.
Consequently, the clinic's senior consultant and head of department took the initiative in 2014 to set up a collegial support group to assist practitioners in cases of serious incidents and in the aftermath of patient suicides. The group will also step in when patients commit serious acts of violence against members of staff or others.
The members of the group work in different psychiatric inpatient wards and sections. The group currently consists of two specialists in psychiatry and two specialist psychologists, all females of different ages. Participation in the support group is accommodated within the constraints of a normal job, and participants do not receive supplementary pay.
When a suicide happens, the group is alerted by the Head of Department or his/her deputy, with details of the staff member or members involved. These may be doctors on duty or on call, the doctor or psychologist treating the patient, or indeed the senior consultant who is clinical lead on the patient's ward.
The members of the group agree among themselves who should contact which practitioner, and the follow-up is provided one a one-to-one basis. It is endeavoured to establish contact with the practitioner within one or two days during normal working hours. This contact may be made in person, via email or telephone. During the first meeting the practitioner will receive summary information about the group and an offer of further conversations.
Since its formation, the group has been involved with the follow-up of 16 practitioners in the aftermath of seven suicides. A few have declined the group's offer of follow-up, on the grounds that they were receiving sufficient support within their own private networks. They did however express a positive attitude to the group's existence and appreciated the offer of support. Among those who have accepted the invitation, a range of diverse needs have been addressed.
The duration of the follow-up period has varied from a couple of weeks to several months. Practitioners may suffer a reaction some time after the suicide, which is why a point of contact at least a month after the incident is endeavoured. The group has focused on presenting a listening attitude and has sought to support their colleagues and fellow human beings at a difficult time. Providing emotional support for the practitioner is important, and it is made clear that that this support has no association with the formal debriefing. Also, the support group's work is not a substitute for the occupational health service or any other type of follow-up.
The group has received feedback that suggests it is perceived as an in-house resource, and the group participants consider their contributions to be meaningful. Whenever a potential for improvement is recognised, the group feeds this back to the management of the clinic.
In Stavanger the group has helped to bring about a change to the on-call roster system for doctors, so that any doctor who is directly involved with a suicide while on duty, is now excused from working the remainder of the shift. The Head of Department finds a replacement, and doctors who are directly involved with a suicide are given space to recover and time to debrief, and they are relieved of undertaking any further acute suicide risk assessments or making other similarly difficult judgements. The duration of this duty exemption is agreed between the doctor and the Head of Department, but it has most commonly lasted for a week.
The group has no knowledge of practitioners who have quoted a patient's suicide as their reason for leaving their job, whether before or after the formation of the support group. The group has no basis for expressing an opinion on sick leaves as a consequence of suicide among patients.
Other professional groups have asked why the group has consisted of doctors and psychologists only. The capacity and resources of group members have been contributing factors, but it is also the case that clinical practitioners are in a special position when it comes to suicide, as they are responsible for the treatment in a different way than welfare workers. The group's strength, we feel, lies in the fact that we recognise ourselves in the situation and the responsibility it entails.