“When my worse fear happened”: Mental health nurses’ responses to the death of a client through suicide

Introduction: Experiencing a client's death through suicide is complex and challeng ing, yet limited research exists on how MHNs might deal with its aftermath. Aim: This study aimed to explore the impact and responses of MHNs to a client suicide. Method: The study design is a secondary analysis of an existing data set involving semi- structured interview with 33 MHNs that were analysed using the principles of grounded theory. To answer the secondary question on the impact and responses of MHNs to the death of a client by suicide a subset of the data from 10 participants who


| INTRODUC TION AND BACKG ROUND
In the wider nursing populations, the death of a client from physical illness has been researched extensively and is a known stressor (Anderson et al., 2015;Kent et al., 2012;Muliria & MuliriaJ, 2016;Puente-Fernandez et al., 2020;Yu & Chan, 2010;Zheng et al., 2016); however, less is known about the death of a client within the mental health services. In mental health the death of a client through suicide is a tragedy that all nurses strive hard to prevent; however, many professionals, including mental health nurses (MHNs) have experienced the death of a client by suicide (Gulfi et al., 2010;Murphy et al., 2019;Rothes et al., 2013;Taakahashi et al., 2011).
In the UK, it is estimated that in 2017 1,517 people who were in recent (within 12 months) contact with mental health services died by suicide (National Confidential Inquiry Suicide Safety (NCISH) 2019). In Ireland, the Mental Health Commission (2019) annual report estimated that approximately 168 "suspected suicide deaths" were among inpatients or "recent" inpatients (recent being ill-defined). A recent brief report by the NCISH (2020) identified 281 nurses who died by suicide over the 6-year period 2011-2016; of these 204 (73%) were females.
More than half (60%) of females who died by suicide were not in contact with mental health services. Therefore, MHNs may encounter suicide not only with clients but also with nursing colleagues. Despite this, there is limited research both nationally and internationally, on MHNs' experiences of caring for clients who die by suicide, the strategies they use to cope with such an event and/or their support needs (Spencer, 2007). The lack of studies in this area no doubt reflects the sensitivity surrounding a client's suicide and the professional and personal discomfort and distress that it may evoke for both potential participants and researchers.
The studies available suggest that the death of a client by suicide evokes a range of emotions such as distress, anger (Valente, 2002), guilt (Midence et al., 1996), panic, sadness, grief (Bohan & Doyle, 2008), self-doubting and rumination Robertson et al., 2010) with 13.7% of MHNs (n = 531) in Japan scored high for posttraumatic stress disorder (PTSD) following the death of a client by suicide (Taakahashi et al., 2011). Bowers et al. (2006) UK study of multidisciplinary staff (n = 56), including MHNs (n = 33) found that a client's suicide prompted a number of fears, including fear of blame, fear of threat to professional registration and fear of a suicide by another client. Studies involving multidisciplinary staff, including MHNs working within the Irish mental health services reported distress in the form of feelings of sadness, shock and responsibility, coupled with concerns around supporting the family (Gaffney et al., 2009;Murphy et al., 2019). Spencer (2007) suggests that unlike other health professionals the expectation that mental health staff including MHNs develop a sustained relationship with clients in a direct attempt to reduce the risk of them taking their own life increases their sense of responsibility or failure if the relationship ends because of suicide. The importance of support in the aftermath of a client's death through suicide is highlighted by practitioners (Bohan & Doyle, 2008;Gaffney et al., 2009;Spencer, 2007) with MHNs expressing a preference for informal individual support as opposed to formal group debriefing (Spencer, 2007).
While these studies provide valuable insights into the emotional impact and fears, the majority focus on multidisciplinary practitioners or nurses working in inpatient services, with little information provided on the experiences of nurses working in the community or the personal or professional strategies used by nurses to cope with the death of a client by suicide. This paper, a secondary analysis of data gathered from a larger grounded theory study , aims to fill this information gap. Although the mental health nurses' responses to the death of a client by suicide were part of the extant paper, both authors believed that it was not covered in the detail as presented in this paper.

| Aim
To explore the impact and responses of MHNs to the death of a client by suicide. experienced the death of a client by suicide were re-analysed using thematic analysis.
Ethical approval was granted by the university ethics committee.

Findings:
The findings identified five themes: "Hearing the news," "Experiencing the impact of grief," "Grieving privately" "Searching for meaning" and "Questioning practice." Discussion: Findings highlighted that although participants perceived the need for support, they were offered minimal support beyond the debriefing meetings, with their grief experience being largely unacknowledged and disenfranchised. Implications for practice: MHN services need to promote a culture of openness wherein all MHNs are supported and encouraged to discuss their concerns and fears during the aftermath of a client suicide.

K E Y W O R D S
community care, loss and grief, Suicide

| Design
The design for the study is a secondary analysis of a qualitative data set that already existed. Johnston (2014) asserts that secondary data analysis is an empirical exercise that applies the same basic research principles as studies utilizing primary data.
It is considered an effective means of analysing data when dealing with particularly sensitive issues, small populations and rare phenomena, as it is eliminating the need to spend time recruiting, gaining access to participants who may not wish to speak about sensitive issues (Andrews et al., 2012;Heaton, 1998). It is also acknowledged that the re-use of qualitative data is maximized when extensive context is known about the primary study and context of the fieldwork practices (Andrews et al., 2012;Johnston, 2014). Both authors were involved in the design of the primary study. Thus, both authors were familiar with the background to the research, original research design, data collection and biography of participants. The aim of the primary study was to develop a grounded theory to explain the responses of nurses to clients with suicidal behaviour .
The study was informed by the writings of Glaser (1998Glaser ( , 2001Glaser ( , 2007

| Data collection
Descriptive qualitative research aims to describe and enhance understanding of human experiences, which in this study focused on exploring the impact and responses of MHNs to the death of a client by suicide. The first author recruited and conducted in-depth interviews guided by an interview protocol, and together with the second author analysed the primary data set. All interviews were audiorecorded and conducted at a time and venue of the participants' choice. Each interview lasted approximately 60 min. Participants were not known to the first author.

| Sample
In total, a sample of 33 registered mental health nurses 16 men and 17 women, were interviewed. Participants were working in inpatient and community services.

| Data analysis for this study
For the secondary data analysis, which is the focus of this paper, a subset of the data from the primary study, which included the data on ten nurses' accounts of their experience of a suicide, was analysed (see Table 1 for demographics). Braun and Clarke's (2006) thematic analysis framework was utilized for the analysis of the data. This method produced a straightforward descriptive summary of the informational contents of the data that is presented in the most relevant manner, as there is no mandate to re-present the data in any other terms other than to remain true to the participants' accounts (Bradshaw et al., 2017). The use of an established framework is vital to demonstrate the rigour of the study; therefore, the six-phase thematic analysis framework developed by Braun and Clarke (2006) was utilized to guide the process of data analysis. Data analysis was conducted by the first author who then discussed the coding process and interpretation of the data with the second author. The second author acted as a critical colleague and through a dialogic process, alternative explanations perspectives and biases were constantly explored, assisting both authors to remain open to and vigilant about how their biography and assumptions might influence and impact the data analysis. Although

Gender
Nursing grade Level of education reached TA B L E 1 Participants' demographics the participants had the option of receiving a copy, they did not request a copy. The theory and the findings of this paper were presented nationally and internationally.

| Ethical considerations
Ethical approval for the original study was granted by the Ethics Committee at the University and ethics committees within the health services. Written and verbal consent was obtained for the interview, audio recording as well permission for the data to be analysed and used for original and any subsequent analysis. Being mindful that conducting qualitative research can pose risks to both participants and researchers (Dickson-Swift et al., 2008), all participants and researchers had access to professional counselling services. In writing up the quotes, care was taken to remove any information that may inadvertently identify the person who died or their family member.

| Findings
We re-analysed data into five themes that followed the participants' journey postnotification of the death of a client by suicide: "Hearing the news," "Experiencing the impact of grief," "Grieving privately" "Searching for meaning" and "Questioning practice" as outlined in Table 2, "Thematic Map." 2.7.1 | Theme 1: "Hearing the news" Although the participants spoke of making every effort to prevent clients from ending their life, they were unable to do so and consequently they were confronted with their worst professional fear-the death of a client by suicide. The participants encountered the death of a client through suicide at different stages in the person's recovery and treatment; some clients died in hospital or while on leave from the hospital, others died following their discharge from inpatient care, or when in contact with community services and nurses.
I've known of lots of clients over the years, but I was client's GP and, in a few instances, family members. At the time, a few participants were not only shocked by the news but were taken back by the lack of sensitivity in the way the news was delivered by their colleague. I had two days off and came into work and was met by a colleague who said-ah you'd never guess. You know that lad has just died. That for one was extremely upsetting and two the way I heard it I would have thought that they would have said you know the chap that you're working with…, well I've got bad news and their might have been a lead into it. I was really surprised; the person would have known the client and they would have known the work I would have done with him (P6).
For some participants who worked in the community, they learned of the client's suicide when they arrived at the client's home and discovering that they had taken his/her own life, as described: It was a Saturday morning, I was working, and we went down to the [client's] house but got no answer. I then rang the ward and they [staff] said he wasn't admitted so obviously I went back to the house on a few occasions, no answer. I rang his [names relative] and that evening she [relative] came up to the house, she had a key, and we went in and he'd taken an overdose.

| Theme 2: Experiencing the impact of grief
Hearing about the client's suicide evoked a range of initial responses, including feelings of numbness, shock and sadness.
Although the participants were in their professional role when they heard the news, they found it difficult to conceal their personal shock and distress at the time. Participants' distress related to the nature of the therapeutic relationship with the deceased client, which for some was over a sustained period, as reflected by this comment: I cried when I was told about her suicide; I couldn't believe it. …I had worked with this woman for 3-4 years, seen her for a long time and been there after she had her 3 children (P8).
We had a client who committed suicide at [names location in the hospital], which affected everybody really in a big way (P3).
The client's suicide also reminded some participants of their own personal loss and grief as a result of the death of a family member/ friend by suicide.
I would have had experience of a man who killed himself and I was working quite closely with him and his wife. They were a lovely couple; she tried so hard to help him. I was very fond of the family and the last thing you want to see is that happening to anyone in Working with clients in the community meant that several participants had established a good rapport and alliance with the client's family. After hearing of the client's suicide, the participants immediately thought of the sadness and loss experienced by the family, while at the same time they were concerned that the family might blame them.
My whole weekend was taken over worrying. It was terrible, I would have known his brothers and his mother I was afraid they would blame me, or I would have to go to court, they would say-did you not see this happening? (P9).

| Theme 3: Grieving privately
Although the participants perceived the need for support, several participants were not offered formal support beyond the initial debriefing meeting. In the absent of formal support, such as clinical supervision or peer support/reflective groups, some participants were left without an opportunity to process their feelings and thoughts concerning the client suicide: I was working in a team and everyone was very supportive to each other and that was a great help. It was great to be able to feel you were getting support from your colleagues (P4).
In contrast, others felt isolated and not in a position to discuss with colleagues for fear that their colleagues would misconstrue their need to talk, as an indication that they were in some way Only those who were attending clinical supervision (n = 2) discussed their attendance at the funeral with their supervisor. Others chose to attend the client's funeral as they considered it an important part of their ending with the client but did not inform their managers or colleagues for fear of criticism. In terms of contact with the family post the funeral, a few participants maintained some contact, albeit distant and unknown to their work colleagues and clinical manager, while others believed that contact should end since they no longer had a professional relationship/contract with the client. Interestingly, the participants who maintained contact with the family also restricted and censored their communication with their colleagues as a means of protecting themselves from potential judgement.

| Theme 4: Sense making
All the participants struggled to make sense and articulate some plausible explanation for the clients' suicides. Sense making appeared to be a strategy that enabled the participants to process and act when their world was shifting and not matching their expectations and perceptions at that time, as some participants recalled: When you go into somebody's house and you see the woman's husband and child, it doesn't make sense.
You are trying to make sense of it, because it's very sad, seeing the child. [Names the means that the person died by], it's final, with this client it's the finality in there's no more we can do. We're finished here (P6).
It was an unbelievable shock, someone I had been seen at 4 pm the previous day, I got into work the next day morning and she was gone. She killed herself at 6 pm that night. Not a word, not a word (P8).
Drawing on their clinical knowledge and professional experience of suicidality, they explained the clients' actions using the biomedical and socio-cultural perspectives, as well as the perspective that positioned the person as an autonomous individual. Using the biomedical lens, participants' conceptualized suicide as a problem located within the person and associated with mental health problems, particularly by proposing a cause and effect relationship between depression or psychosis and suicidal behaviour. While many reported gradually regaining their confidence over time, some participants reported that the death of a client by suicide heightened their awareness of the risk of uncertainty when working with suicidal clients. In addition, it also prompted them to question the effectiveness of the community care model-"Home Care" whereby they provided "intensive" care to clients at risk with suicidal behaviour.
It was definitely a learning experience… it's definitely made me more aware when I go into somebody's home and while I think Home Care is great for some people-it's not for everyone, visiting a person sometimes twice a day every day in their home can be too much …it is their home after all… I never thought about that before (P6).

| DISCUSS ION
Death is a universal human experience, and it is a deeply emotionally and painful event. When a loved one dies, one is left grieving the loss of both the person and the relationship. Notwithstanding the unique circumstances surrounding the death of a client by suicide, and the fact that the findings in relation to the emotional pain echo, the findings from other studies (Gaffney et al., 2009;Gutin et al., 2010;Linke et al., 2002) including MHNs (Valente, 2002), the findings from this study do reveal the complex issues in meaning making than surround the death of a client by suicide in comparison with the death of a client from physical ill health. While there are differences, there are also similarities in nurses' responses postdeath of a client through physical health. Research on nurses providing critical care considers themselves underprepared and unable to provide endof-life care to relatives (Arbour & Wiegand, 2014). Similarly, nurses working in Emergency Departments who are vulnerable to the sudden death of patients and have a first-line role in dealing with grieving families, also report experiencing difficulty communicating with family members at this time (Raymond et al., 2017).
Findings from our study highlight the lack of support and guidance offered. The lack of acknowledgement and sensitivity to staffs' emotional pain sends a message that emotionality has no place in nursing, or in the nurse-client relationships, or that grief and grieving is a necessary part of the process following a client suicide. By minimizing staff distress, managers also negated and devalued the nature of the therapeutic relationship and the time and energy staff invested in working with the suicidal client. This gives nurses contradictory messages wherein the therapeutic use of self and the embodied engagement of practitioners with clients is held up as a core value underpinning practice (Barker, 2009;Peplau, 1997) and an integral part of the process of healing and recovery (Higgins & McGowan, 2014;Repper & Perkins, 2003). However, as reflected in this study the cost of this burden can be high, particularly in the absence of best practice guidelines and supervision to guide and support practitioners in the aftermath of client suicide.
Establishing a helping relationship should not be taken as a given; instead, it's built over time with care, compassion and respect (Higgins et al., 2015;Morrissey & Callaghan, 2011) and its loss is something that gives rise to grief and pain that needs to be mourned and acknowledged or not perceived by others as appropriate. However, the findings suggest that in many cases the loss and grief experienced was disenfranchised in several ways and on many levels. In line with Doka's (1989) work on disenfranchised grief, findings from our study indicate that not only was the nature of the relationship unacknowledged or socially sanctioned, but that in many situations the loss went unacknowledged or mourned publicly, with some participants being advised not to attend the person's funeral. Kauffman (2002) addresses the intrapsychic dimension of disenfranchised grief and the way grieving people may disenfranchise themselves. In this study, those experiencing the loss also censored their feelings of grief out of fear and/or shame because of societal or organizational norms of appropriateness following a client suicide.
While all grief is emotionally costly, the cost of disenfranchised grief is probably even higher, because disenfranchisement extends and worsens the consequences of the grieving process, postponing or even impeding its health resolution or integration. Dyregrov et al. (2012) point out that support plays a crucial part to the healing of those close to the deceased and who have been strongly affected by death by suicide, which includes those in the helping professions.
Within this study, the absence of a supportive place to think about and process their grief and grief responses meant many participants were left to carry the burden of grief and care for themselves with the support of their family and colleagues. Paradoxically, it could be theorized that in so doing participants were denied or denied themselves the opportunities and conditions for grief work and were being exposed to a different form of professional and personal danger that is the emotional cost of caring, also referred to as compassion fatigue (Figley, 1995).
Unlike other types of sudden deaths, suicide is self-inflicted, which leads to many people including the participants to ask the question-why it happened? (Dyregrov et al., 2012;Gaffney et al., 2009). The participants like many people including family members bereaved by suicide (Fielden, 2003), struggled to make sense of the clients' decision and like others, they also searched for answers and explanations for the suicide. As Roen et al. (2008) points out, "failing to explain suicide can give rise to a sense that suicide might be about chaos and uncertainty of human psychic life" (p.2095).
Through their attempts to rationalize suicide the participants were able to create meaning, which played an important role in maintaining some sense of order in relation to their day-to-day work experiences. Historically, suicidology is believed to result from the interaction of several different discourses that have influenced, shaped and reshaped how suicide and suicidal behaviour are understood. For Foucault, such discourses can be understood as language in action, which provide openings to help us to see and make sense of things (Danaher et al., 2007). However, while having an explanation that was individualized helped the participants to make the client's death understandable (Mellor & Schilling, 1993) and provided them with some comfort, Leenaars (2004) points out it is a multidisciplinary enterprise, since most suicidologists believe that no single discourse on its own will ever be able to explain sufficiently the phenomena as varied and as complex as acts of human self-destruction.
Although participants framed the suicide within various discourses, this sense making did not minimize their professional fears or concerns about a reoccurrence or having "missed something." While it is reasonable for participants to be cautious in the future, there is the possibility that in an attempt to protect themselves, they may consciously or unconsciously distance themselves from the therapeutic relationship. Indeed, in the absence of supports, practitioners are likely to have difficulty offering emotional and psychological support and/or feeling contained themselves. This, in turn, is likely to reduce the quality and efficacy of their clinical practice and as such have a negative effect on other clients, co-workers and the team as a whole. Failure to provide ongoing support and learning may also result in practitioners and organizations continuing to overuse restrictive risk aversive strategies, at the expense of relational based models of care, that strikes a balance between risk and recovery and between control and care (Michel et al., 2002;.

| Limitations of study
While rigour in the secondary analysis was enhanced by the fact that the authors were familiar with the context and fieldwork practices of the primary study, the findings need to be considered in the context of the following limitations. This original study was conducted at one location within one mental health service in the Republic of Ireland and depended on respondents' retrospective view of their experiences, it is therefore possible that recall bias impacted the findings, and some experiences may not apply or fit with populations in other mental health services at different geographical locations. In addition, given the sensitive nature of the topic area participants' may have censored consciously or unconsciously their accounts of the client's death through suicide as a means of self-protection, which may have influenced the accuracy and completeness of the data. Finally, one of the major drawbacks of secondary data analysis is that one cannot go back to the participants and probe for further responses to assist with filling in gaps in the emerging analysis.

| CON CLUS ION
The death of a client by suicide and the impact it had on the participants both professionally and personally evoked a range of grief responses for the participants, which varied in intensity according to the nature of the therapeutic relationship with the deceased client.
Although the participants perceived the need for support, they were offered minimal support beyond the debriefing meetings, with their grief experience being largely unacknowledged and disenfranchised.
The lack of guidance on how to interact with family members of the deceased client also left participants unsure about their professional practice. Given the limited research in this area, a larger study that explores issues such as impact of years of practice, suicide within the family or close network, personal experience and education on practice into this area is required.

| Implications for nursing practice and management
• MHNs and services need to establish and promote a culture of openness in which suicide is anticipated as a possible outcome, even with excellent standards of care and wherein all staff are supported and encouraged to discuss and reflect on their concerns and fears during the aftermath of a client suicide.
• As MHNs are often left to carry the burden of grief alone, services need to recognize the emotional cost of embodied engagement with clients and families and provide the necessary supports.
• There is the need for guidance on contact with the families of the deceased client given the lack of this in evidence and the risk of organizationally defensive practices.

| RELE VAN CE S TATEMENT
Health care professionals including MHNs are likely to be exposed to the deaths of clients throughout the course of their work.
Experiencing a client suicide is complex and challenging, yet limited research exists on how mental health nurses might deal with the aftermath of such a significant event. Establishing and promoting a culture of openness in which suicide is anticipated as a possible outcome, even with excellent standards of care, and wherein staffs are supported and encouraged to discuss and reflect on their anxieties while "taking therapeutic risk" when working with suicidal clients is therefore essential.

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest.

AUTH O R CO NTR I B UTI O N S
JM and AH analysed data and wrote paper.

E TH I C A L A PPROVA L
All procedures were performed in accordance with the ethical standards of Trinity College Dublin, the 1964 Declaration of Helsinki, and its later amendments. This material has not been published in whole or in part elsewhere. The manuscript is not currently being considered for publication in another journal. Both authors have been personally and actively involved in substantive work leading to the manuscript, and hold themselves jointly and individually responsible for its content.

DATA AVA I L A B I L I T Y S TAT E M E N T
Not able to share complete interview data as not part of the original ethics approval or participant consent.