A national suicide prevention toolkit for England

Version 1, September 2023, publication ref: B1563

Foreword

Dame Ruth May, Chief Nursing Officer for England, and Dr Navina Evans, Chief Workforce Officer – NHS England as co-commissioners of this work.

NHS staff have always gone above and beyond to support the millions of patients they care for every day but looking after ourselves and our people is of paramount importance too. The pandemic created an environment with unprecedented challenges for staff, who were also dealing with the impact of lockdowns and grief in their personal lives. The challenges facing the NHS now can also feel relentless at times. Our support for our colleagues is needed more than ever. We are committed to building on our existing resources to support the mental health and wellbeing of NHS staff, and to creating environments where staff feel able to be honest about how they are feeling and comfortable in asking for help. We know that some groups of staff are more at risk of suicide than the general population.  

This toolkit has been designed to help NHS organisations reduce the risk of suicide in their workforce. It will assist organisations to embed suicide prevention strategies in the organisation’s health and wellbeing policies and guide the approach to supporting those at risk of suicide within the workforce. It is just one of a number of resources available to the NHS to support their staff, which also includes a Postvention toolkit on how to support healthcare staff after the death of a colleague by suicide. 

We hope this toolkit will help organisations to support the health and well-being of their staff and to understand and act on suicide risk factors. 

We would like to thank all the individuals and organisations involved in the development of this resource. This toolkit could not have been created without the expertise and collaboration with the many individuals from NHS trusts, professional bodies, charities, and those with a lived experience of suicide. 

This document should be read in conjunction with the NHS employee suicide: a postvention toolkit to help manage the impact and provide support which sets out guidance on supporting NHS staff following the suicide of a healthcare colleague.

Aims

• To provide an organisation level toolkit to raise awareness of poor mental health and suicidality among healthcare staff across all healthcare settings.  
• Provide information enabling all staff to be able to signpost healthcare colleagues to mental health and wellbeing.
• Provide examples of good organisational practice in preventing suicide in staff working in healthcare.  
• Provide recommendations to support organisations’ suicide prevention strategies.  

1. Introduction

Raising awareness of the mental health and suicide risk within staff in healthcare settings

This document provides guidance to NHS organisations, including secondary care, community care, ambulance sectors and primary care, to prevent suicide and support the mental health and wellbeing of employees. It has been developed in partnership with key stakeholders from NHS organisations and external interested parties. There has also been significant engagement and input from people working in NHS organisations with a lived experience of suicidality.

This toolkit builds on our commitment to valuing our people and promoting their wellbeing as set out in the NHS Health and Wellbeing Framework and NHS People Plan. The NHS Health and Wellbeing Framework recognises that many factors influence the health and wellbeing of our workforce and offers a range of tools and resources to assist organisations in putting proactive interventions and services in place. 

In England alone in 2021, there were 5,583 deaths by suicide in the general population registered, leaving behind many more thousands who are impacted by their loss (ONS 2022)[1]. Given that one in five adults experience suicidal thoughts and feelings during their life, it is likely that there will be many healthcare staff struggling to cope in the workplace. Men remain the most at-risk group within the general population and are three times more likely to die by suicide than women. However, the rate of suicide by women aged under 24 has increased in 2021 to the highest level since 1981 and female nurses have a 23% higher rate of suicide than other women.

A staff survey on work-related stress identified the reported underlying trends of sickness absence, key factors included ‘anxiety/stress/depression/other psychiatric illnesses’ which has steadily increased in the last few years. In 2021, the level of absence due to stress and anxiety was 50% higher than 2020.  In England in 2022, this has accounted for 25% of all sickness absence. (NHS Digital, 2023)[2]

This toolkit on preventing suicide is part of a wider commitment to supporting the NHS workforce and forms a critical element of a broader programme of work to promote positive mental health and wellbeing. Suicide is not inevitable and suicide prevention is everyone’s business. This toolkit sets out simple steps that can be taken to embed an approach to mental health, wellbeing and suicide prevention in the workplace and builds upon and complements wider national, regional, and local health and workforce strategies and suicide prevention initiatives.

2. Current data

Prevention of healthcare staff suicides

There is already evidence that some healthcare professions are at a higher risk of suicide than other professional groups. Office for National Statistics (ONS) data on occupational mortality in England and Wales between 1991 and 2000 indicated that doctors, dentists, nurses, vets and agricultural workers such as farmers were at increased risk of suicide. Similar patterns of risk have been found in other analyses of England and Wales data as well as those of other high-income countries (see Agerbo et al, 2007; Kelly and Bunting, 1998; Kõlves and De Leo, 2013; McIntosh et al, 2016 and Meltzer et al, 2008). Common explanations for the high risk of suicide in occupations like these include having easy access to lethal drugs (for example, health professionals; see Hawton et al, 2000; Milner et al, 2016 and Skegg, 2010) and firearms (for example, farmers: see Malmberg et al, 1999 and Skegg, 2010). High risk of suicide among health professionals could also be explained by these occupations possessing relevant knowledge on methods of suicide (for example, different kinds of drugs, lethal doses and their effects).

A report by the ONS in 2017 on suicide by occupation data[3] identified female healthcare workers as having a risk of suicide 24% higher than the female national  average and is largely explained by the high suicide risk among female nurses.

Following this a brief study was commissioned by NHS England, based on basic quantitative analysis of the existing National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) database.  The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) report ‘Suicide by female nurses: a brief report’ was published in June 2020 by the University of Manchester. Key messages from the report included a requirement to improve access to mental health care for nurses.

It has been suggested that nurses remain at particular risk of suicide due to a unique combination of attributing factors including mounting pressures to work extended / extra shifts, self-imposed psychological pressures due to patient dependance and lack of engagement of mental health support due to fears of job insecurity or percieved collegial failure.

Staff working for ambulance services are also at a higher risk of suicide. A MIND survey (n = 1,600) found that 1 in 4 emergency services workers and volunteers had experienced thoughts of suicide due to work related stress or poor mental health (MIND, 2016)[4].

Female doctors are considered to be at a higher risk of suicide than the general population (Lindeman et al, 1996)[5]. Being part of the healthcare workforce means exposure to factors that may increase the risk of suicide. This includes frequent and close proximity to traumatic experiences, and work environments and cultures associated with high levels of stress.

Examples of workplace stress are captured in the NHS staff survey (National Health Survey, 2022)[6], the most recent of which reported high levels of physical violence, harassment, bullying and abuse experiences in the last twelve months. Association between burnout, moral injury and suicide also means it is likely that healthcare staff are at an increased risk of suicidal ideation; NHS staff survey data found an increase in staff unhappy with the care they were able to provide in the last twelve months (National Health Survey, 2022)^[6].

Moreover, providing healthcare during the Covid-19 pandemic has impacted on the mental health of the healthcare workforce (Greene et al, 2021)[7] and the subsequent cost of living crisis has further added to the potential stressors that may increase the risk of suicide within the NHS workforce.

Intersectional inequalities are also likely to impact on the exposure to factors that increase the risk of suicide. Healthcare staff experience stereotyping and discrimination relating to a wide range of protected characteristics that impact on mental wellbeing; an example is staff from ethnic minority backgrounds are more likely to experience disciplinary processes (Ross et al, 2020)[8], an experience known to cause high levels of workplace stress.

The reasons for suicide are complex and there are likely to be a range of risk factors which need to be considered such as gender, age, current social circumstances and work based factors.

3. Key strategies for suicide prevention

An effective suicide prevention plan should be embedded within a broader framework of health and wellbeing as set out in the NHS Health and Wellbeing Framework and NHS People Plan.  The NHS Health and Wellbeing Framework recognises that many factors influence the health and wellbeing of our workforce and offers a range of tools and resources to assist organisations in putting proactive interventions and services in place. Supporting healthcare staff to stay mentally well supports them to realise their full potential, work effectively and deliver excellent patient care.

Key to developing a mentally healthy healthcare workforce is the fostering of a positive culture by encouraging healthy and supportive behaviours such as thanking people for what they do, recognising and valuing the work colleagues deliver, supporting  healthy eating, hydration and access to fresh air, being kind to each other, noticing when a colleague is out of sorts and asking them about it and providing a healthy work environment which promotes team away days and team development to strengthen team relationships.

Other areas to consider include: access to clinical supervision; extending access to psychological support; management of work-related stress; provision of additional support to those absent from work due to sickness; taking action to prevent bullying; and ensuring additional support is available during times of high additional stress, such as workplace changes, investigating allegations or following serious incidents. More information on health and wellbeing for teams can be found here:

A holistic workforce suicide prevention programme should include:

• A workplace that values its employees and their families and promotes respect, open communication and a sense of belonging, emotional and physical well-being and encourages people to seek help when they need it and to support each other.
• Education and training on mental health, including suicide awareness for all, such as the suicide training on suicide prevention delivered by Zero Suicide Alliance.
• Internal communications and induction programmes that ensure all healthcare staff are aware of available resources and support available.
• Clear policies, procedures and practical guidance to help healthcare staff on issues including mental health, long term physical health issues, domestic violence and financial advice.
• Having a clear plan to respond to a suicide attempt or death as set out in the postvention toolkit.

4. How to identify healthcare staff at risk of suicide

It is important there is an understanding of the factors which may increase the risk that someone may die from suicide. These include:

• Gender: men remain the most at-risk group within the general population and are three times more likely to die by suicide than women. However, the rate of suicide by women aged under 24 has increased in 2021 to the highest level since 1981 and female nurses have a 23% higher rate of suicide than other women.
• Age: highest rate of suicide in men is between 50-54 years and women between 45-49 years.
• Bereavement: there is a higher risk of suicide following the death of a loved one especially if by suicide.
• Sexual orientation and gender identity: the risk of suicide is significantly higher among the lesbian, gay, bisexual and transgender community.
• Mental Illness, which could be work-related but increasingly people could be employed with a pre-existing mental health condition which in the past might have been perceived as a reason not to employ them.
• Social deprivation: including debt, financial insecurity, and domestic violence.

Within healthcare settings, risk factors may also include workplace pressures – including burnout and moral injury, referral to a professional body and following a serious incident resulting in harm to a patient.

5. How to respond to warning signs and support healthcare staff

Talking about mental health and suicide can be difficult and not everyone will have the skills and or the confidence to do so. However, it is important that we are all able to talk about the issue and to signpost colleagues to specialist support as needed. To gain more skills and confidence, we recommend accessing the Zero Suicide Alliance (ZSA) training to help provide the information needed to start these conversations. If you have concerns about someone you can take the following steps.

1. Talk with your line manager, HR advisor
2. Reach out to the person: Ask how they are doing, listen without judging, mention changes you have noticed and say you are concerned about them. Suggest they seek support and signpost to the resources listed below. Follow up with others to ensure action has been taken.

In a crisis – Take the following actions immediately:

1. If self-harm is imminent make sure the person is not alone and call for help. This could be 999 or if in a hospital setting call a professional.
2. Stay with the person until professional help arrives.
3. Encourage the person to talk but do not promise confidentiality.
4. Ask the person if there is anyone they would like to speak to. This could include Samaritans who are highly skilled in this area.
5. Follow your employer’s policy (if you have one) to let someone know what is happening and who will follow up.
6. Seek support for yourself such as accessing restorative clinical supervision and /or by contacting your local and wellbeing advisor.

All of our NHS colleagues have access to the same mental health and suicide prevention services as patients across the country, which include:

• a local NHS mental health helpline for 24-hour advice and support if experiencing a mental health crisis.
• a number of charities and organisations that offer support to patients experiencing a mental health crisis, including the Samaritans, CALM, Mind and more.
• support from their GP – colleagues concerned about their mental health should seek an appointment with the GP they are registered with
• local talking therapy services – staff can be referred by their GP, or they can refer themselves directly to an NHS Talking Therapies service without a referral from a GP.

Our NHS colleagues also have access to a range of dedicated health and wellbeing support offers

(Including programmes specifically offered to support with mental health and wellbeing.)

• Many colleagues working across the NHS will have access to local Occupational Health and Wellbeing services and Employee Assistance Programmes (EAPs) delivered through their employing organisation. Self-referral to these services, where this is possible, is recommended. However, it is likely that for some a referral will need to be via a line manager.
• For colleagues who wish to seek support via text, there is a national NHS staff text support line delivered by trained volunteers at SHOUT. This support line is confidential, available 24/7 and can be contacted by texting FRONTLINE to 85258.
• All NHS colleagues have free access to the Unmind and Headspace apps, to help them proactively look after their mental health and wellbeing. Read more about these apps, including how to sign up.
• NHS staff can also seek support for themselves, and others, through the Stay Alive suicide prevention app. 
• There are also a range of counselling and coaching programmes available to NHS colleagues, including a dedicated coaching programme for colleagues working in primary care and a dedicated coaching programme for colleagues of an ethnic minority background, and a spiritual and faith based counselling programme. 
• For colleagues who are seeking further health and wellbeing support, including support for Long Covid, substance misuse, gambling and financial wellbeing. Please visit our information about support. 

Resources

Prevention toolkits for employers

• Euregenas Project – Preventing and managing suicidal behaviour: A toolkit for the workplace (PDF)
• Business in the Community’s Mental Health Toolkit for Employers
• World Health Organisation’s Preventing Suicide: a resource at work (PDF)
• Mind resources to support workplace mental health
• HSE Management Standards for work related stress
• Acas guide to bullying and harassment in the workplace (PDF)
• Nursing Minds: Mental health toolkit for nurses (from C3 Health)

Postvention toolkits for employers

• NHS employee suicide: a postvention toolkit to help manage the impact and provide support

Training and awareness

• Zero Suicide Alliance (ZSA) Training
• Supporting someone who feels suicidal (from Mind)
• Supporting a young person who feels suicidal (from Papyrus)
• How to start a difficult conversation (from Samaritans)
• Having a conversation in person (from Samaritans)
• Active listening (from Samaritans)
• ‘It’s safe to talk about suicide’ leaflet (PDF)  
• Business in the Community’s Crisis management in the event of a suicide: a postvention toolkit for employers

Support services

• Gamblers Anonymous  
• Advice if you are concerned that someone is self-harming (from Harmless)

Organisations

• Samaritans.org        
• International Association for Suicide Prevention (IASP)          
• Campaign Against Living Miserably (CALM)      
• National Suicide Prevention Alliance (NSPA)   
• Suicide Prevention Australia’s Work and suicide prevention  
• Heads Up Australia Suicide Prevention 
• City Mental Health Alliance             
• Employee Assistance Professionals Association         
• COHPA (association of occupational health and wellbeing providers)            
• Step Change (debt charity)             
• Hub of Hope
• SHOUT – Support line; confidential and available 24/7; Text ‘FRONTLINE’ to 85258
• Nurse Lifeline – The Listening Service 7pm to 10pm, Monday to Friday; call 0808 801 0455

Recommendations

• Develop a local healthcare workplace suicide prevention strategy which includes the below elements:
• Acknowledge that healthcare staff are at risk from death by suicide, and pledge to talk about suicide and suicide prevention to reduce stigma.
• Ensure all NHS staff are aware of the support options available to them, including local support and national support.
• Offer staff training in suicide awareness and how to be more confident in having difficult conversations such as Zero Suicide Alliance (ZSA) training and training provided by the people team.
• Offer staff timely access to restorative clinical supervision, trauma support and de-briefing after an incident or death of a colleague.
• Support staff and those with line management responsibilities ensuring they have access to training to enable them to confidently talk about and raise awareness about mental health, wellbeing, and suicide prevention.
• Consider cultural sensitivity in association with mental health, suicide, and suicide prevention and be mindful that not all colleagues will talk about and experience mental ill-health in the same way.

Case studies

Case Study: Humber, Coast & Vale Integrated Care System – #Talksuicide campaign

The Humber, Coast and Vale Health and Care Partnership (HCV) is a collaboration of 28 health and social care organisations working to improve health and care across the area. They have created the #Talksuicide campaign to reduce the stigma around talking about suicide by raising awareness of free suicide prevention training available from the Zero Suicide Alliance. The website includes downloadable assets. Since January 2019, over 18,500 people from across HCV have taken part in the training. The website also has access to services for anyone requiring suicidal support at www.talksuicide.co.uk.

Case Study: Formalisation of Association of Ambulance Chief Executives (AACE) – Suicide register

Building on the informal register introduced in September 2018 containing all deaths by suicide within the ambulance service with associated data captured locally; to enable the sector to understand suicide better with the intention of its ultimate prevention and effective postvention when incidents occur; creation and management of corresponding database with co-ordinator.

Introduction of suicide prevention pathway for ambulance service employees: to ensure dedicated 24/7 support for ambulance service staff when in crisis and on an ongoing basis where required; start date: summer 2022.

Case Study: West Yorkshire and Harrogate Integrated Care System – Suicide prevention campaign

West Yorkshire and Harrogate Health and Care Partnership are leading on ‘Check-In’ which is a long-term suicide prevention campaign being adopted and embedded in organisations across the ICS to support colleagues, volunteers, and staff.

Check-In launched in February 2020 on Time to Talk Day and aims to prevent staff suicide and promote a wellbeing culture by normalising the conversation around suicide and mental health, as well as providing training, resources, and signposting for support.

The Check-In campaign was co-produced with a project team made up of public health, local authority, NHS, voluntary and community colleagues, as well as suicide prevention specialists, psychologists, and people with direct experience of suicide, to provide training, resources, and signposting for support.

187 organisations and 450 individuals are signed up to the campaign, which was recognised at the 2021 NHS Communicate Awards, winning in the Internal Communications and Staff Engagement category.

Check-In follows a behaviour change framework and includes a toolkit which is provided to organisations and supports introducing the campaign objectives using a phased approach. These phases are:

• Educate – signposting to resources, support, and training for staff at all levels.
• Raise awareness – a campaign pack centred around starting the conversation about mental health and suicide.
• Promote lived experiences – a campaign pack and rich content (stories) helping to normalise the conversation around suicide.
• Remind and encourage – a campaign pack that helps maintain the conversation around suicide prevention.

Organisations have found four ways to embed check-In through:

1. Regularly promoting the campaign (especially during annual Time to Talk Day)
2. Embedding Check-In in their organisation’s strategy.
3. Embedding Check-In in their team engagement processes such as team meetings and one to ones.
4. Encouraging regular training.

Find out more at www.suicidepreventionwestyorkshire.co.uk. All campaign materials are open source so they can be shared across any organisation and branded to that organisation

Find out more at www.suicidepreventionwestyorkshire.co.uk. All campaign materials are open source so they can be shared across any organisation and branded to that organisation.

Acknowledgements

Trustee Chair: Laura Hyde Foundation

John Blake, Supporter Experience Director: Cavell Nurses’ Trust

Ethel Changa, Clinical Advisor – National Covid-19 Vaccination Programme: NHS England

Steven Colfar, Director of Nursing for Nursing & AHP Workforce (North West Region): NHS England

Linda Chibuzor, Director of Nursing, Allied Health Professionals (AHPs) & Quality: Northamptonshire Healthcare NHS Foundation Trust

Gemma Clay, Deputy Ward Sister/ Clinical Doctorate Fellow: University Hospitals Sussex NHS Foundation Trust

Amy Davidson, Health and Wellbeing Manager, North East and Yorkshire: NHS England

Dr Julie Dixon, Nursing Education Adviser: Nursing and Midwifery Council

Craig Ferris, Deputy Director of Safeguarding: United Lincolnshire Hospitals NHS Trust

Jo Gennari, Senior Programme Lead – Health and Wellbeing: NHS England

Kathryn Grayling, Assistant Director of Engagement: NHS Employers

Linda Hindle, Deputy Chief AHP Officer for England, Lead Allied Health Professional and National Engagement Lead for Public health in Police, Fire and Ambulance Services: Department of Health and Social Care

Stephen Jones, Professional Lead for Mental Health: Royal College of Nursing

Jodie Kirby, Lead Nurse for Mental Health: Walsall Healthcare NHS Trust

Felicia Kwaku, Associate Director of Nursing/Senior Head of Nursing for Acute Speciality Medicine: Kings Hospital NHS Foundation Trust and Interim Chair of the CNO’s Black Minority Ethnic Strategic Advisory Group: NHS England

Rachel Lees, Trustwide Clinical Lead for Suicide Prevention: Nottinghamshire Healthcare Foundation Trust

Sarah Legood, Senior Project Manager – Mental Health Nursing, Professional and System Leadership: NHS England

Itai Matumbike, Consultant Forensic Psychiatrist, Executive Medical Director: Northamptonshire Healthcare NHS Foundation Trust

Jacqui Morrissey, Assistant Director, Research & Influencing: Samaritans

Alison Owen, Registered Nurse: Laura Hyde Foundation

Claire Parker, Senior Programme Lead (Health and Wellbeing): NHS England

Nhamo Paz, Head of Safeguarding: Kettering General Hospital NHS Foundation Trust

Anne Prendergast, Lead for Clinical Risk and Suicide Prevention: C&W Partnership Trust

Terry Simpson, Senior Clinical Delivery Manager: NHS England – South East Region

Victoria Small, Senior Programme Manager: Growing Occupational Health and Wellbeing Culture: NHS England

Kirsty Smith, Matron for Mental Health & Learning Disability: University Hospitals of North Midlands NHS Trust

Will Smith, Head of Nursing Safety and Inclusion: Avon and Wiltshire Mental Health Partnership NHS Trust

Katie Taylor-Cross, Senior Project Manager – Mental Health Nursing, Professional and System Leadership: NHS England

Julie Thompson, Group Director of Nursing – Medicine and Emergency Care: Sandwell and West Birmingham Hospitals NHS Trust

Robert Tunmore, External Relations Lead: Cavell Nurses’ Trust

Adam Turner, Improving Health and Wellbeing Lead: NHS England

Laura Tyrrell, Programme Manager – Adult Mental Health Team: NHS England

Dr Emma Wadey PhD RN, Deputy Director of Mental Health Nursing: NHS England

Dr Simon Harold Walker – Suicidologist, University of Glasgow, Scotland.

Contact: england.mhworkstreams@nhs.net

References

[1] The Office for National Statistics (ONS) (2022) Statistical bulletin: Suicides in England and Wales: 2021 Registrations Registered deaths in England and Wales from suicide analysed by sex, age, area of usual residence of the deceased and suicide method.

[2] NHS Digital (2023) ‘NHS Sickness Absence Rates, August 2022’. 30 April 2009 to 31 August 2022.

[3] The Office for National Statistics (ONS) (2017) Suicide by occupation, England and Wales, 2011 to 2020 registrations.

[4] MIND (2016) One in four emergency service workers has thought about ending their lives.

[5] Lindeman, S., Läärä, E., Hakko, H. and Lönnqvist, J. (1996) ‘A Systematic Review on Gender-Specific Suicide Mortality in Medical Doctors’, The British Journal of Psychiatry, 168(3), pp. 274-279.

[6] National Health Survey (2022) NHS Staff Survey 2021: National results briefing.

[7] Greene, T. et al. (2021) ‘Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19’, European Journal of Psychotraumatology, 12(1), pp. 1882781.

[8] Ross, S. et al. (2020) Workforce race inequalities and inclusion in NHS providers.