*Review* **The Impact of Colleague Suicide and the Current State of Postvention Guidance for Affected Co-Workers: A Critical Integrative Review**

**Hilary Causer 1,\*, Johanna Spiers <sup>1</sup> , Nikolaos Efstathiou <sup>2</sup> , Stephanie Aston <sup>3</sup> , Carolyn A. Chew-Graham <sup>4</sup> , Anya Gopfert <sup>5</sup> , Kathryn Grayling <sup>6</sup> , Jill Maben <sup>1</sup> , Maria van Hove <sup>7</sup> and Ruth Riley <sup>1</sup>**


**Citation:** Causer, H.; Spiers, J.; Efstathiou, N.; Aston, S.; Chew-Graham, C.A.; Gopfert, A.; Grayling, K.; Maben, J.; van Hove, M.; Riley, R. The Impact of Colleague Suicide and the Current State of Postvention Guidance for Affected Co-Workers: A Critical Integrative Review. *Int. J. Environ. Res. Public Health* **2022**, *19*, 11565. https:// doi.org/10.3390/ijerph191811565

Academic Editors: Karolina Krysinska, Karl Andriessen and Yossi Levi-Belz

Received: 27 July 2022 Accepted: 8 September 2022 Published: 14 September 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

**Abstract:** People bereaved by suicide are affected psychologically and physically and may be at greater risk of taking their own lives. Whilst researchers have explored the impact of suicide on family members and friends, the area of colleague suicide has been neglected and postvention guidance for supporting surviving colleagues is often poorly developed. This critical integrative review explored the impact of colleague suicide on surviving co-workers and reviewed postvention guidance for workplaces. Systematic searches found 17 articles that met the inclusion criteria. Articles were appraised for quality and extracted data were analysed using a thematic network method. Article quality was moderate. Two global themes were developed: impact of a colleague suicide comprised themes of 'suicide loss in the workplace'; 'professional identities and workplace roles'; 'perceptions of professional uniqueness'; and 'professional abandonment and silencing'. Postvention following a colleague suicide comprised 'individualised responses'; 'the dual function of stigma'; and 'complex pressure on managers'. A unifying global network 'after a colleague suicide' describes the relationships between all themes. A series of disconnects between existing postvention guidance and the needs of impacted workers are discussed. This review demonstrates the need for robust, systemic postvention for colleagues impacted by the complex issue of colleague suicide.

**Keywords:** suicide; postvention; impact; loss; grief; bereavement; colleague; co-worker; guidance; review

### **1. Introduction**

Suicide is one of the leading causes of death around the world, with more than 700,000 people dying by suicide every year [1]. This means that 1% of all global deaths are due to suicide [2]. Suicide affects the physical and psychological health of the bereaved [3] and, compared to other causes of sudden death, those bereaved by suicide report higher levels of rejection, shame, stigma, and a need to conceal the method of death [4,5]. Every suicide impacts approximately 80 [6] to 135 [7] people, of which 1 in 30 may be deeply impacted and so can be considered bereaved [8]. Suicide bereavement has also been identified as a risk factor for attempted suicide [9–11]; approximately 7–9% of people bereaved by suicide subsequently attempt suicide [11,12]. There is also an association with occupational dropout [13].

Previous studies have measured and explored the impact of suicide on family members [14–17], friends [18], teachers [19], university staff [20,21], therapists, and other healthcare workers [22–24]. A recent UK-wide survey on the impact of suicide [4] found that 2% of participants reported being bereaved by a colleague's death. However, the impact of colleague suicide has not been widely investigated, even though the suicide rate in the UK is higher for certain professions; approximately 12 deaths per 100,000 were suicides between 2011 and 2015 while the risk of suicide for female healthcare professionals was 24% higher than this national average [25].

The support offered to those impacted by suicide is known as postvention [26–29]. Effective postvention has been shown to improve mental health and grief-related outcomes [30], help bereaved people seek and share support and information, and memorialise their loved ones [31]. While there is some postvention guidance for workers impacted by colleague suicide, see e.g., [28,32,33], existing guidance is limited and is not always evidence based.

Additionally, we argue that suicide research often focuses on the individual rather than the context in which suicide happens [34,35] or on preventing more deaths rather than improving quality of life [36,37]. Critical suicidology, an approach which considers the context and cultures in which suicides happen, such as the occupational factors or antecedents [35,37–39], provides a useful lens through which to explore the impact of suicide and support needs of those bereaved. We used this to inform our analysis.

Our review has drawn together empirical research and current guidance on colleague suicide, highlighting what we already know and what the gaps in the research are, signposting the next steps for researchers and support.

### *Review Aims*

Three questions guided the review:


### **2. Methods**

An integrative review is a robust methodology [40] that allows a comprehensive understanding of a topic via the synthesis of all available evidence [41]. It is suited to reviewing a combination of diverse methodologies, including experimental and nonexperimental research [42], and allows a broad sampling frame [43]. We followed the five steps set out by Whittemore and Knafl [42]: problem identification, through which we developed our review questions; literature search; data evaluation; data analysis; and presentation of conclusions.

### *2.1. Eligibility Criteria*

We were interested in reports of the impact of colleague suicide, postvention guidance for workers, and evaluations of that guidance. The eligibility criteria are shown in Table 1.

### *2.2. Search Strategy*

The databases listed in Table 2 were searched for the below terms between October and November 2021. The selection process ended in May 2022.

**Table 1.** Inclusion and exclusion criteria.


**Table 2.** Databases and search terms.


The reference lists of chosen papers were hand-searched for further relevant articles. We did not apply any search limiters in terms of dates or country as we wished to scope the literature as widely as possible.

### *2.3. Article Screening*

HC and JS independently screened all article titles, rejecting those that did not fit the criteria. We used the Rayyan.ai platform to support article screening. Duplicates were deleted. HC and JS accepted or rejected articles based on their abstracts. Disagreements were discussed until consensus was reached; had we not reached a consensus, a third reviewer (NE) was available to make a final decision. The full articles were read and any which did not fit the inclusion criteria were rejected. Seventeen articles were included in the review. The screening process is summarized in the PRISMA diagram in Figure 1.

The screening process is summarized in the PRISMA diagram in Figure 1.

**Figure 1.** PRISMA flow diagram of the selection process. Adapted from the preferred reporting items for systematic review and meta-analyses (PRISMA) flow diagram [44]. **Figure 1.** PRISMA flow diagram of the selection process. Adapted from the preferred reporting items for systematic review and meta-analyses (PRISMA) flow diagram [44].

#### *2.4. Quality Appraisal 2.4. Quality Appraisal*

Our purpose in appraising the quality of the included articles was not to exclude any articles that could usefully contribute to answering the review questions [45,46] but instead to be aware of the overall quality of the papers. Our purpose in appraising the quality of the included articles was not to exclude any articles that could usefully contribute to answering the review questions [45,46] but instead to be aware of the overall quality of the papers.

HC and JS appraised the 17 included articles using a range of tools, including the AGREE-II tool [47], Joanna Briggs Institute (JBI) qualitative appraisal tools [48], the Mixed Methods Appraisal Tool (MMAT) [49], and the Quality of Survey Studies in Psychology (QSSP) tool [50]. HC and JS appraised the 17 included articles using a range of tools, including the AGREE-II tool [47], Joanna Briggs Institute (JBI) qualitative appraisal tools [48], the Mixed Methods Appraisal Tool (MMAT) [49], and the Quality of Survey Studies in Psychology (QSSP) tool [50].

HC and JS conducted independent assessments of the quality of all papers, providing inter-rater reliability to check each other's assessments. Any disagreements were discussed and resolved. HC and JS conducted independent assessments of the quality of all papers, providing inter-rater reliability to check each other's assessments. Any disagreements were discussed and resolved.

#### *2.5. Data Extraction 2.5. Data Extraction*

Data were extracted to meet two aims. Firstly, HC extracted data from all articles to inform an overview of the article attributes. These data are reported in Tables 3 and 4. Data were extracted to meet two aims. Firstly, HC extracted data from all articles to inform an overview of the article attributes. These data are reported in Tables 3 and 4.


**Table 3.**Attributes of the included empirical studies, survey studies, case studies, and opinion pieces.


**Table 3.** *Cont.*


**Table 3.** *Cont.*


**Table 4.** *Cont.*


**Table 4.** *Cont.*

Secondly, HC and JS extracted relevant primary data, author opinion or interpretation, and any other major findings, such as links to existing theory, into a matrix for analysis. Data were organised under the headings impact of colleague suicide on staff members; postvention guidance; and evaluation of postvention guidance. We then uploaded extracted data into NVivo for coding.

### *2.6. Data Analysis*

Data were analysed following the thematic network method [64]. Thematic networks are 'web-like illustrations' that summarise themes and relationships between themes. We took the following steps as set out by Attride-Stirling [64]:

### 2.6.1. Coding the Material

HC and JS devised a coding framework based on the research questions and the critical suicidology literature [37,39]. Using NVivo, meaningful sections of the data were coded into that framework [64], which was discussed and refined as analysis continued.

### 2.6.2. Identifying the Themes

Codes were refined and grouped into similar themes. This resulted in the final table of basic, organising, and global themes (see Table 5).


**Table 5.** Relationships and connections between the organising, global, and unifying global themes.

### 2.6.3. Constructing the Networks

HC and JS constructed two thematic networks ('impact of colleague suicide' and 'postvention following a colleague suicide'), which can also be considered as a single network under the unifying global theme 'after a colleague dies by suicide'. Networks were constructed by considering relationships between the three levels of theme.

### 2.6.4. Describe and Explore the Thematic Networks

HC and JS used the networks as a springboard to fully explore the concepts, connections, and findings arising from the analysis. The upshot of this discussion can be seen in the results section of this paper.

### 2.6.5. Summarize the Thematic Network

A summary of the thematic networks can be seen in the following section.

### 2.6.6. Interpret Patterns

Patterns across the two networks were identified and developed during the writing of the results section.

### **3. Results**

### *3.1. Quality Appraisal of Included Articles*

Despite some high and medium scores, we found that many of the papers had important methodological flaws. Regarding the guidance articles, which were assessed using the AGREE-II tool [47], authors [33,60,61] did not always consult with the target population. Austin and McGuinness [32] drew on case studies but did not report their sources. Only Kinman and Torry [28] and Samaritans [63] reported systematic methods of searching for evidence while no authors reported criteria for selecting evidence or described the strengths and limitations of their evidence. It was not always clear how recommendations were reached [32,33,60,61], recommendations were sometimes not evidenced [60,61], and work was not always peer-reviewed [33,60,61]. Only Berkowitz [33] and Kinman and Torry [28] considered facilitators and barriers to carrying out recommendations. Only Samaritans [63] provided any information about funders.

Regarding the empirical and other articles, six [36,51,54,56–58] were appraised using the JBI checklist for qualitative research [48]. All demonstrated congruity between the research methodology and question, although only three [51,56,58] stated the authors' philosophical perspective. Kleespies et al. [54] were unclear in reporting their methodology and offered little interpretation of their results; Pak [57] presented a 'conceptual model' but with no clarity on whether the model was constructed in response to review findings; and Sever and Ozdemir [58] reported their findings in a descriptive rather than interpretative style. Only two papers [51,58] addressed researcher influence on the research. Participants' voices were well represented by all authors except Gulliver et al. [36], who did not include any verbatim quotes and Kleespies et al. [54], who reflected on rather than reported their findings. Kleespsies et al. [54] were the only authors not to make any ethical statement while Gulliver et al. [36] and Małecka [56] offered no evidence of ethical approval for their research. Conclusions were clearly drawn from the analysis or interpretation of the data in all articles.

Two articles [53,55] were appraised using the JBI checklist for text and opinion [48]. They both met all criteria, although it was unclear whether the stated position of either article was the result of an analytical process. Carr [52] was appraised using the JBI checklist for a case study [48]. All criteria were met at least in part, although it is worth noting that this appraisal checklist assumes that the case study is a medical one, so criteria had to be interpreted broadly to accommodate the nature of the article. Overall, the literature appraised using JBI checklists was of mixed quality, but all met our requirement of making a useful contribution toward answering our review questions.

### *3.2. Thematic Network Analysis*

Our analysis resulted in the development of seven organising themes that sit within two global themes, as illustrated in Table 5. We identified several connections between and across the two global themes, which led to the development of a unifying global theme, 'After a colleague suicide'. The relationships and connections between the organising, global, and unifying global themes are illustrated in Figure 2.

### 3.2.1. Global Theme 1: Impact of the Loss of a Colleague to Suicide Suicide Loss in the Workplace

The suicide of a colleague impacts individuals in a variety of ways and brings the usually private process of bereavement into a professional realm. Intense, complex emotions, such as sadness, anger, shame, and guilt [63], may be experienced and heightened by the manner of death:

### *Bereavement after suicide is often called 'grief with the volume turned up'.* [63]

The most frequently reported emotions following colleague suicide are shock [28,32,52,53,55,56,58,62,63] and anger [28,52,55,57,63]. Anger may lead to further

feelings such as 'confusion, anxiety and shame' that arise from perceptions of anger as an inappropriate response [28].

*Int. J. Environ. Res. Public Health* **2022**, *19*, x FOR PEER REVIEW 12 of 24

#### **Figure 2.** Thematic network. **Figure 2.** Thematic network.

3.2.1. Global Theme 1: Impact of the Loss of a Colleague to Suicide Suicide Loss in the Workplace The suicide of a colleague impacts individuals in a variety of ways and brings the usually private process of bereavement into a professional realm. Intense, complex emo-Additionally, several authors [28,60–62] report behavioural responses, including altered eating and sleeping habits and a need to talk about the event [28]. Some behaviours may be visible and impactful within the workplace, such as absenteeism, presenteeism, or problem drinking [28].

tions, such as sadness, anger, shame, and guilt [63], may be experienced and heightened by the manner of death: *Bereavement after suicide is often called 'grief with the volume turned up'*. [63] The most frequently reported emotions following colleague suicide are shock [28,32,52,53,55,56,58,62,63] and anger [28,52,55,57,63]. Anger may lead to further feelings This combination of responses may contribute to the challenging work of grief [32]. Managers must understand that staff are not only experiencing the loss of a colleague by suicide but are also working through the multiple elements of that experience and will require space, support, and empathy. Workers in a 1993 study cited by Lynn [55] (p. 462) expressed the intensity of their experience:

#### such as 'confusion, anxiety and shame' that arise from perceptions of anger as an inappropriate response [28]. *as the same emotional burden experienced after the death of a family member*. [65]

Additionally, several authors [28,60–62] report behavioural responses, including altered eating and sleeping habits and a need to talk about the event [28]. Some behaviours may be visible and impactful within the workplace, such as absenteeism, presenteeism, or problem drinking [28]. This combination of responses may contribute to the challenging work of grief [32]. Managers must understand that staff are not only experiencing the loss of a colleague by suicide but are also working through the multiple elements of that experience and will Colleagues may feel they must 'carry on' after the suicide. This may be a positive way of getting 'back to normal' [61] or may present tension between the need to keep working and the need to grieve. For instance, Kinman and Torry (p. 6) note that the performative 'effort' of meeting workplace expectations and behaviours 'can be exhausting and compound grief reactions' [28]. A colleague's suicide may give rise to suicidal thoughts or behaviours:

#### require space, support, and empathy. Workers in a 1993 study cited by Lynn [55] (p. 462) expressed the intensity of their experience: *Sometimes the rationale for this increase in suicide or suicidal behavior occurs out of guilt, a distorted sense of loyalty, or a perceived false "permission" to do so.* [60] (p. 3)

*as the same emotional burden experienced after the death of a family member* [65]. Colleagues may feel they must 'carry on' after the suicide. This may be a positive way of getting 'back to normal' [61] or may present tension between the need to keep working and the need to grieve. For instance, Kinman and Torry (p. 6) note that the performative This is a particularly serious outcome. Leaders and managers ought to be aware of, and alert to, this potential risk. There is a danger that the 'carry on' narrative may detract from and indeed hide the real pain and suffering that some staff members may experience.

#### 'effort' of meeting workplace expectations and behaviours 'can be exhausting and compound grief reactions' [28]. A colleague's suicide may give rise to suicidal thoughts or Professional Identities and Workplace Roles

behaviours: *Sometimes the rationale for this increase in suicide or suicidal behavior occurs out of guilt, a distorted sense of loyalty, or a perceived false "permission" to do so*. [60] (p. 3) This is a particularly serious outcome. Leaders and managers ought to be aware of, and alert to, this potential risk. There is a danger that the 'carry on' narrative may detract Dilemmas arise when staff come face to face with loss, trauma, and grief whilst inhabiting their professional identities. Specific characteristics of job roles might bring colleagues into contact with dying or recently deceased colleagues, such as deployed military personnel [52] or ambulance staff who may have been called to an incident involving their colleague:

from and indeed hide the real pain and suffering that some staff members may experience. *the ambulance staff that attend the scene could have additional needs in relation to their efforts to help their colleague. There may have been a resuscitation attempt, for example. This places an increased burden on the clinicians present.* [63]

Professionals may feel they are attempting to navigate dual roles following a suicide. For example, doctors 'may experience dissonance' [28] (p. 6) between the roles of 'healer' and colleague of the deceased. These dual roles may be especially challenging for team leaders or managers:

*As the line manager, when a colleague dies suddenly you have a responsibility to all team members to assist them in coming to terms with the sudden death, whilst dealing with your own emotions*. [62]

A sense of impossibility is evident, as leaders report that no matter which approach they take, it is impossible to meet all needs, especially given the challenges of information containment in the social media age:

*It was already on social media, but the senior manager said it wasn't our place to tell colleagues, as the family may not know yet, so then you're chastised by staff for not letting people know. [* . . . *] It all got very messy. And all that was on me. It was a lonely place that day*. [63] (p. 22)

Further, leaders' responsibility to safely contain teams is highlighted by Pak [57], who discusses the broad roles that army captains play in nurturing commitment, trust, and good morale within military units.

Questions may be raised here around responsibility, not only for looking after staff following a colleague suicide but also for the colleague who took their life. The suggestion that a colleague suicide may be seen as a failure of leadership [57], potentially triggering mistrust, is a stark reminder that leadership is about creating and nurturing the cultures within which staff work.

Perceptions of Professional Uniqueness in Bereavement

Many authors [28,32,52,56–58,63] report on the experiences of certain professional populations or participants with specific traits, beliefs, or cultural values. Throughout these reports are perceptions of being 'unique' amongst the wider population of those impacted by suicide, making the experience of colleague suicide somehow harder to bear. Pak [57] describes a combination of setting and relationships to explain perceptions of heightened impact:

*military suicide may have an even greater impact than bereavement experienced in most collegial relationships due to the proximity and intimacy required for a unit to function in a combat environment* . . . *It is not uncommon for service members to refer to one another as "brother", "sister", "brother-in-arms".* (p. 189)

Interestingly, Lynn [55] also cites 'proximity' and shared experiences as 'unique' characteristics of healthcare workers' roles. Kinman and Torry [28] focus on the nature of small cohesive teams that nurture friendships for GPs. Finally, the shared professional identity and sense of 'family' is suggested as the reason for a 'deeper' impact on paramedics than others [63].

Perhaps this sense of kinship and shared identities explains professional groups' notion that their experience of colleague suicide is unique. Colleagues may struggle to articulate who it is they have lost; the deceased is more than a colleague but not a family member. There are challenges here for organisations and leaders in understanding the nature of the loss they are supporting staff to come to terms with. Again, the complexity of loss and need sits uncomfortably within the 'carrying on' narrative.

Personal beliefs and cultural norms can also shape a colleague's ideas about and responses to a death by suicide; diverse belief systems may be held by colleagues who work closely together [55]. Dominant discourses within belief systems may present colleagues with additional challenges:

*"You feel the closeness of death, as in every funeral. However, as a Muslim, I do not find this right. According to our religion, it (suicide) is a rebellion against God."* [58]

As Sever and Ozdemir [58] note, it is complex for individuals and leaders to understand and accommodate a range of belief systems. This poses the question of how diverse

belief systems might be accommodated within teams who are impacted by a colleague suicide.

Professional Unpreparedness, Abandonment, and Silencing

Organisational unpreparedness for responding to a colleague suicide due to skill and knowledge gaps shapes staff members' experiences, leading to perceptions of unmet needs:

*"It was very surreal–I had to deal with all of this, and I just acted on instinct. There was no help or guidance given to me. Suddenly I was in charge of everybody else's feelings and just expected to carry on as normal."* [28] (p. 7)

Unpreparedness may take the form of skill and knowledge gaps or lack of guidance:

*In the absence of any guidance, our interviewees were obliged to 'ring round' desperately hoping to receive help which was not forthcoming. This clearly intensified their distress and the difficulties that practices, especially small practices, experienced*. [28] (p. 17)

Placing the onus on individuals to seek support to meet their individual needs assumes that people experiencing shock, anger, guilt, and grief can identify and articulate what those needs may be. Whether these staff members knew what they needed, they knew they needed something, and the lack of resources within their organisation led to a wider search.

Małecka [56] reports that similar deficits were experienced in a Higher Education setting, where a colleague's suicide went unacknowledged, leaving staff members feeling abandoned, confused, and angry. Kinman and Torry [28] also report a 'reluctance' toward responding to need. It is unclear what drives this reluctance; perhaps not knowing how to respond or fear of doing it 'wrong'.

Yentis et al. [59] demonstrate the stark difference between the numbers of bereaved anaesthetists who felt supported (*n* = 22) and those who did not (*n* = 179):

*[participants] described absent or poor support and in some cases, deliberate attempts to prevent or stifle discussion and/or debriefing, although in some cases the issue of protecting the deceased's confidentiality and/or sparing the family further anguish was mentioned.* [59]

There is evidence here of a process of silencing, where no platform for acknowledging or discussing needs is provided. Bogle [51] reports the perception of US law enforcement officers who describe the administrative response to their colleague's suicide as 'avoidant':

*As long as you're doing your job, doing what you need to do and say, administration would acknowledge if you lost your life in the line of duty. You'd be a hero. But the moment [an officer] loses their life because of suicide, it's unspoken.* [51] (p. 97)

A similar response is reported by Belgian military service members [53], whose perceptions of social stigma act to silence them, thus further perpetuating the cycle of stigma. Silencing stigma is also noted by Małecka [56] in a Polish Catholic university; note that in Catholicism, suicide is considered a mortal sin. The conspiracy of silence experienced by these police officers, service members, and academics across organisational, social, and cultural contexts denies them opportunities to honour their deceased colleagues and process the impact of the suicide and risks psychological wellbeing [53]. Ultimately, silencing and stigma leave impacted staff alone with their need to find meaning and answers following their colleague's suicide.

### 3.2.2. Global Theme 2: Postvention Following a Colleague Suicide Individualised Responses

Currently, postvention guidance tends to focus on individuals and individual change rather than contexts and systemic change. Attempts to consider the context within which suicidal behaviours occur are often lacking. We see this as a flaw in existing guidance.

A common claim was that personal vulnerabilities and mental health challenges increased the risk of contagion, whereby one death by suicide increases the risk of subsequent

deaths by suicide among those who are affected [28,53,56,61,63], with no consideration of context. The following quote from a police officer [51] demonstrates a deep-seated belief that suicidal feelings are solely located within the individual:

*'We're all adults. You have entrusted us with the authority to take people's freedom and the authority to take lives, if necessary. [* . . . *] So aside from offering programs, there's nothing anybody can do to stop them'.* [51] (p. 106)

While this participant describes the culture in which the suicidal behaviour is occurring, they still feel the only available option, on which they place little worth, is individual support.

Strategies for communication about the reasons for suicide were also individualised:

*the important information is that the person mistakenly felt that they could not get help for his or her problems, when in fact help was possible.* [33] (p. 163)

Since suicide happens within a context, changes to culture (in addition to individual support) may also be beneficial for postvention.

Checklists of postvention tasks [28,32,33,53,61–63] or the utilisation of psychological or organisational models of support [28,32,33,53,57,61] similarly tended to focus on individual needs rather than culture.

Training was mentioned as a potential tool for effective postvention. Most proposed education focused on individual needs or signs of mental ill-health [32,33,51,63]. In contrast, Pak et al. [57] suggested training as a way for leaders to positively influence work culture:

*Military leaders can be encouraged and taught to recognize that to compartmentalize the unit suicide and to ignore it in the short-term, may also place their units at risk.*

We endorse positive cultural changes as part of postvention [37] whilst cautioning against putting unrealistic pressure on managers, who may also be grieving or operating within an under-resourced system.

### Dual Function of Stigma

Stigma both leads to inadequate postvention and arises from it. It leads to inadequate postvention since, if an organisation cannot talk about suicide, it cannot properly support those impacted by it. It arises following poor postvention because, if postvention is steeped in stigma, it perpetuates stigma at individual and organisational levels.

Authors reported that suicide was not properly acknowledged in the workplace [33,53,56,60–62]. However, it was widely agreed that this increased risk [28,32,33,57,60,63]. Discussion of suicide helps address stigma and so could aid postvention. However, one could question whether acknowledgement of suicide is enough without also acknowledging any difficulties with the context in which the suicide occurred.

Workers of various professions reported a culture of invulnerability [52,53,56], where mental ill-health was unacceptable. This could prevent education around suicide, impacting postvention:

*'To have training on officer suicide would mean that [suicide] would have to be talked about. And that's not going to happen.'* [51] (p. 96)

This culture may further challenge postvention by preventing workers from being open about emotions or asking for help [51,53].

Organisations operating from a culture of invulnerability could also perpetuate stigma:

*Personnel allowed to attend the service were limited [* . . . *]. Restricting access to the memorial service created a sense of shame about the death.* [52]

Additionally, it could be suggested that the term contagion, which was commonly used in reference to the statistic that one suicide may result in more [61–63], may perpetuate stigma and so hamper discussion and healthy postvention. Perhaps non-pejorative language such as 'further suicides' may be more useful. Given the prevalence of this narrative, it is perhaps unsurprising that contagion continues, and has:

### . . . *sometimes led to misguided efforts to maintain secrecy after a suicide death, including blaming or stigmatizing the deceased.* [33] (p. 168)

More helpfully, several authors made suggestions for how stigma could be combatted. These include the use of more sensitive terminology [63] and group counselling [58]. Several reported workplace cultures that were already supportive [53,58,63].

### Complex Pressure on Managers

Complex pressure is placed on managers of workplaces in which a colleague dies by suicide, as the delivery of postvention support becomes their responsibility. Specific tasks that managers might be expected to undertake included regularly checking in with staff, looking out for affected colleagues [28], and being visible to workers [61]. Additionally, leaders may be expected to undergo training to deliver postvention [33,51,61,63].

Managers must also provide practical support such as accompanying employees during inquests [32], offering meals and transport [33], or arranging alternative duties for staff [63]. Some authors provided detailed explanations of ways for employers to emotionally support grieving workers [28,32,53,62,63], such as engaging in empathic listening and sharing stories. Several agreed that leaders must guide employees through the grieving process [55,61,63]. Further pressure on leaders is added by the suggestion that they should be "a role model for healthy grieving" [32,61].

Various authors acknowledged that managers, who are also grieving, must also be supported [28]. Suggestions included covering time off [28,63], regular check-ins with HR [63], and reassurance that it is OK to express emotion [63]. We feel that these are worthy suggestions that may help combat that toxic culture of invulnerability. Working with teams within [52,61] and outside of [28,32,33,53,62,63] the organisation to deliver postvention may also relieve pressure. Such support for managers, who are uniquely pressured following the suicide of an employee, is sorely needed.

### 3.2.3. Unifying Global Theme

Thus far, we have described two thematic networks: Impact of a colleague suicide and Postvention following a colleague suicide. Both networks are illustrated in Figure 2 in blue and green, respectively. In line with the thematic network methodology [64] (p. 393), this figure is intended to explore and illustrate the deep meaning and relationships behind the reviewed texts rather than to demonstrate causal relationships. We found that both networks describe events that occur simultaneously following a colleague suicide, and that these networks feed into and inform each other. Thus, they can be illustrated as being connected by a unifying global theme: After a colleague suicide, represented in Figure 2 in orange. The orange arrows indicate how individual experiences and needs following a colleague suicide are shaped by the availability and content of postvention support. Likewise, the design and delivery of postvention impact how workers respond to and heal from the suicide of a colleague as illustrated in Figure 2.

Specifically, the impact of suicide loss in the workplace can be heightened or ameliorated by the response of the organisation. Our findings evidence that staff experiences occur within the contexts and cultures of workplace settings, identities, and roles. Guidance, however, promotes individualised approaches to responses that fail to acknowledge these factors. A holistic approach, looking at the context and systems within which the suicide occurred and support for teams and whole organisations, in addition to any necessary individual responses, may reduce overall distress. Further, stigma is linked to organisational unpreparedness, abandonment, and silencing. Teams who are delivering postvention that is marred by stigma will, as our findings demonstrate, find it harder to acknowledge and respond to suicide, leading to a silencing, which, in turn, perpetuates stigma. Solving organisational unpreparedness may fall to managers, adding to their complex pressure; equally, if managers cannot fulfil the unrealistic battery of tasks assigned to them following an employee suicide, the organisation may continue to be unprepared and silence grieving workers. Finally, the organising themes of complex pressure on managers and professional

identities and workplace roles are intertwined, as the dual roles that managers must inhabit whilst simultaneously grieving and caring for bereaved employees further add to their complex pressure.

### **4. Discussion**

We reviewed and synthesised 17 articles, including empirical studies (*n* = 7), case studies (*n* = 1), opinion pieces (*n* = 2), and guidance (*n* = 7). We explored the impact of a colleague death by suicide across a range of workplace settings; reviewed the current guidance for workplace postvention support following a colleague suicide; and developed an understanding of what kinds of postvention support have been offered, or authors think should be offered to staff affected by a colleague suicide. We found that the workplace impact of colleague suicide and associated postvention has been sparsely explored, and published articles are of an overall moderate quality. Published guidance is rarely underpinned by empirical evidence while the guidance included in this review cite each other (with and without full acknowledgement and referencing). Some guidance appears comprehensive, but it is not always clear where the underpinning knowledge has come from. Experiences of loss and bereavement by suicide were shaped by workplace contexts, cultures, and job-role identities. Further, organisational responses, or lack thereof, created additional struggles for staff.

In this discussion, we explore three (dis)connections between staff experiences of impact following a colleague suicide and the postvention guidance currently available to managers and organisations, as illustrated in our thematic network (Figure 2).

### *4.1. Workplace Cultures, Professional Contexts, and Individualised Responses*

Suicide loss is shaped by perceptions of professional identity and workplace settings. However, this is unacknowledged in postvention guidance, which takes an individualised view of cause and impact. Whilst the emotional impact reported by staff following a colleague suicide reflects the wider literature [66–69], experiencing this impact within professional identities and workplace settings complicates individual responses.

For instance, perceptions of professional identity and uniqueness shape staff experiences of grief. We reviewed the experiences of police officers, firefighters, military personnel, and primary care health professionals. Such professionals may be working within a culture of invulnerability [70], whereby perceptions of being impervious to work-related stresses become part of a professional identity. Staff who perceive themselves as invulnerable are less likely to find psychological safety following a colleague suicide. Researchers have concluded that talking about vulnerability and illness reduces perceptions of isolation and promotes coping mechanisms for GPs [71]. It is likely that such openness may also promote healthy coping in other professions. Furthermore, we found that staff across a range of professions believed that their experience of suicide loss was more impactful due to their perceptions of the unique traits of their job role or professional identity. While several professions perceived themselves as unique for similar reasons, this indicates that these 'unique' attributes and their impact on professionals' experience of a colleague suicide ought to be understood, acknowledged, and incorporated into support to meet staff needs for all groups.

Currently, workplaces do not provide the time and support required by employees to undertake the emotional work that arises following a colleague suicide. We found that a 'carry on' narrative dominates, prioritising work tasks and productivity over emotional needs. Similarly, when exploring the experiences of bereaved staff on their return to work, Bento [72] used the phrase 'the show must go on' to describe employees' perceptions of silence or pressure to catch up with work tasks. It may be that leaders working in '24/70 professions such as medicine or the military are expected to keep working to prevent the fallout from a depleted workforce, meaning they must put work ahead of their wellbeing.

Hochschild [73,74] utilises the concept of 'feeling rules' to describe the processes of emotion management that occur in workplace settings. Similarly, Doka [75] talks about 'grieving rules' that describe societal norms around loss and grief behaviours. Together, these concepts may provide a framework for better understanding how staff are expected to manage grief in the workplace and how organisations operate to direct grieving processes away from the workplace. Within the social model of individualisation, we are expected to do our emotional work in the privacy of our homes [76]. However, when grief occurs at work, this expectation generates further stress and an understandable disconnect for staff. We found that staff must work to navigate these complex expectations surrounding grief after a colleague's suicide. Similarly, Grandey [77] identified that employees suppress or regulate emotions following a stressful event to deliver an appropriate emotional presentation for the workplace. Such emotional management has been conceptualised as emotional labour [73]. When expressed emotions differ from those that are felt, emotional dissonance and internal tension may result [78]. As such, emotional labour is stressful and may lead to burnout [79].

As Pitimson [80] points out, UK legislation regarding compassionate leave does not recognise the death of a colleague, meaning any leave is at the discretion of the employer. In response to this point and the findings of our review, we argue that time must be offered in workplaces to accommodate the emotional work that may follow a colleague suicide and avoid the risk of emotional burnout.

It would be beneficial for authors of postvention guidance to offer strategies for addressing these specific staff experiences and needs following a colleague suicide. Overall, the guidance we reviewed did not take an organisational perspective, nor did it address professional identity and working spaces as the contexts within which loss and grief must be navigated and postvention support delivered. As previously noted, current guidance has drawn only sparsely on empirical evidence, which may explain this disconnect between need and delivery. We argue that postvention guidance must draw on the lived experiences of the people it aims to support. The reviewed guidance largely misses an opportunity to support organisations and staff by meeting them at the point of their experience.

### *4.2. Unpreparedness, Abandonment, Silencing, and the Perpetuation of Stigma*

We found that organisational unpreparedness for suicide loss generates feelings of abandonment and perceptions of silencing that further complicate experiences of grief and perpetuate perceptions of stigma. Managerial or organisational failure to acknowledge colleague suicide and its impact leaves staff feeling abandoned in navigating their path to recovery. Pitimson [80] reports that a lack of workplace acknowledgement leaves bereaved staff with fears of being judged and a need to find safe places at work for privately expressing grief. As Lattanzi-Licht [81] states, the workplace requires the bereaved to be silent, hiding their feelings. Disenfranchised grief [82] refers to instances of dismissal when either the relationship with the deceased, the nature of the loss, or the griever themselves are not recognised. Doka [82] proposes that acknowledgement of grief is necessary for bereavement to be completed. The silence and silencing found in our review leave staff unable to talk about or process their experiences. Thus, the idea of suicide as a taboo [83] topic is perpetuated, staff are unsupported in their grief, and their trauma remains unacknowledged and unaddressed. Our findings illustrate that, alongside the absence of organisational response, the event of a colleague suicide and attempts by staff to mourn and remember their colleague were actively silenced. Staff grief in the workplace is not just disenfranchised; it is actively stifled [84].

This active silencing has an impact. As our findings demonstrated, stigma both leads to and arises following inadequate postvention. When organisations do not deliver postvention, they perpetuate stigma around suicide by failing to provide forums for conversation, acknowledgement, understanding, and healing. Paradoxically, it is the stigma surrounding suicide, and associated fears, that may contribute to organisations failing in this way. There is a fear of acknowledging suicide due to misunderstandings around risk of 'contagion' and the likelihood of further deaths by suicide [11]. We argue that it is the role of guidance

to address these naïvetés. However, if guidance is not underpinned by evidence, it may be difficult to convey these messages robustly.

### *4.3. Managers: Identities, Roles, and Complex Pressures*

Colleague suicide generates complex challenges for managers. This is exacerbated by perceptions of professional identity, whereby managers are perceived as strong and knowledgeable, and further, by postvention guidance, which situates managers as supporters of other staff. Balancing the needs of their team alongside managers' own needs, expectations that the workplace should continue to function as usual alongside staff grief, and the need to communicate clearly to staff whilst balancing the preferences of the deceased's family and the need to protect the deceased's privacy are all factors that generated this complexity. The wider literature also identifies the manager as a key provider of support and comfort when a staff member is bereaved [85–87].

Several authors highlight that, with proactive support and compassion, the workplace can facilitate healing following bereavement [85] and that bereaved staff may feel safe in the familiarity of the workplace [80]. Compassion is defined as 'an active orientation towards the well-being of others who are in pain' [88] (p. 168). Kanov [89] suggests that managers are well placed to offer compassion by noticing the suffering of others, feeling empathic concern, and acting to alleviate suffering. The manager must be alert, empathically in tune with others, and knowledgeable about appropriate proactive responses. It is often assumed that managers will provide this support and compassion whilst managers' struggles are not acknowledged [80,85,89].

The agency of bereaved staff within the supportive relationship is recognised by Dutton et al. [90], who posit that compassion requires both parties to interpret and understand each other's circumstances to make sense of the situation. Even here, however, there is no acknowledgement that the manager may be experiencing their own grief. We propose that, importantly, postvention guidelines provide guidance for the support of managers whilst they, in turn, support their teams. Additionally, guidance can identify external sources of postvention support (the availability of which, we acknowledge, varies), so that the weight of being the expert and supporting staff can be lifted from the potentially grieving manager.

Considering the broader contexts that underpin the complexity faced by managers allows for insights into the competing pressures of meeting staffs' emotional needs alongside the demand for the business to function. Pitimson [80] notes that individualism and capitalism can shape the experiences of grief in the workplace. Peticca-Harris [86] highlights this in her first-person account of restaurant managers' responses to the sudden death of a staff member. She describes how the need to keep the restaurant open blinded managers' ability to see, or relate to, the distress staff were experiencing [86]. Granek [91] suggests that control of grief in workplaces is political in terms of the expectation that staff will continue to contribute within capitalist societies. Peticca-Harris [86] (p. 608) concludes that 'managers did not know what to do and how to do it, and that brought about shame and embarrassment because it was at odds with the archetypes of leadership that dictate that leaders should just know [92]'.

These multiple juggling acts are addressed in part in postvention guidance, which often suggests the formation of a postvention committee or group, meaning postvention tasks are planned for and shared (see e.g., [62,63]). This may be feasible in a larger organisation. However, it is likely that one team manager would still need to provide information, identify staff who need support, and facilitate the implementation of support resources. In smaller organisations, or those that have not implemented a postvention team, individual managers are likely to have to implement postvention support to team members whilst also having to deal with their own responses to the loss. Effective, evidence-based training may help lessen managers' load. Attendees of postvention training for clinicians who support parents following the suicide of a child reported increased knowledge, skills, and confidence following the session [9]. We propose that similar outcomes might be achieved if training was provided to managers and leaders following colleague suicide. However, it

must be considered whether such training is available before recommending it as a solution. As Tehan and Thompson [87] acknowledge, managers need to feel knowledgeable, skilled, and equipped.

This is the first review to specifically explore the impact of colleague suicide and related postvention guidance. The robust methodology utilised in this review allowed us to bring together a wide range of source literature and first-person experiences alongside associated guidance. This has enabled us to identify areas of disconnect between experience and response, and make recommendations for improving the guidance and, therefore, the care of staff bereaved or affected by a colleague suicide. A limitation of this review is that we were unable to include papers written in languages other than English, due to time and budget constraints. Additionally, although a comprehensive search strategy was used, we may have missed literature not storied in the searched databases.

We recommend the following steps for practice, policy, and research:


### **5. Conclusions**

We suggest that colleague suicide can impact workers in healthcare and other settings and that perceptions of grief are complicated by professional identities and workplace cultures. A burden is placed on managers to be knowledgeable, skilled, and available to support staff. Current postvention guidance, and the postvention offered to colleagues, whilst well-meaning, is not evidence-based, takes an overly individualistic view and may perpetuate stigma, and has not often been evaluated. As such, we call for more evidencebased, systemic postvention guidance for workers and managers.

**Author Contributions:** Conceptualization, H.C., J.S., N.E., S.A., C.A.C.-G., A.G., K.G., J.M., M.v.H. and R.R.; Methodology, H.C., J.S., N.E., S.A., C.A.C.-G., A.G., K.G., J.M., M.v.H. and R.R.; Validation, H.C., J.S., N.E. and R.R.; Formal Analysis, H.C., J.S., N.E. and R.R.; Investigation, H.C., J.S., N.E. and R.R.; Data Curation, H.C., J.S. and R.R.; Writing–Original Draft Preparation, H.C., J.S., N.E. and R.R.; Writing–Review and Editing, H.C., J.S., N.E., S.A., C.A.C.-G., A.G., K.G., J.M., M.v.H. and R.R.; Visualisation, H.C., J.S. and R.R.; Supervision, R.R.; Project Administration, H.C., J.S. and R.R.; Funding Acquisition, R.R. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by NIHR HS&DR grant number 129341. Carolyn Chew-Graham is part funded by West Midlands ARC (Applied Research Collaboration).

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** No new data were created or analyzed in this study. Data sharing is not applicable to this article.

**Acknowledgments:** The authors are grateful for the support of James Barnett at the University of Birmingham library for his assistance in designing the search strategy.

**Conflicts of Interest:** The authors declare no conflict of interest. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

### **References**


## *Article* **Postvention as Prevention: Coping with Loss at School**

**Nikita Khalid 1,\*, Nicole Zapparrata <sup>1</sup> , Kevin Loughlin <sup>2</sup> and Glenn Albright <sup>3</sup>**


**Abstract:** Many Pre-K through grade 12 (PK-12) students have experienced traumatic events throughout the pandemic in a myriad of ways including the death of family members and peers, loss of social interaction and increased violence at home. The consequences can be traumatic and manifest themselves in fear, anxiety, anger, isolation, and loneliness. Too often this leads to depression, anxiety, grief, substance use disorders, post-traumatic stress disorder, suicidal ideation and even suicides. This study assesses the impact of an innovative virtual human role-play simulation that prepares PK-12 educators, administrators, and school staff to respond to a student death in the school community by creating communities of support to help manage traumatic loss. The simulation addresses crisis response planning, postvention plans, and provides learners with role-play practice in using evidence-based motivational interviewing communication strategies in conversations with students and colleagues after the occurrence of a death. The sample consisted of educators and staff who were recruited from geographically dispersed areas across the US between January 2021 through December 2021. Matched sample t-tests and ANOVAs were used to assess quantitative data, and a qualitative analysis software, MAXQDA, was used to assess open-ended response data. Results show statistically significant increases in school personnel's preparedness and self-efficacy to recognize signs of trauma in their students and colleagues, and to approach them to talk about concerns and, if necessary, make a referral to support services. Simulations such as this hold tremendous potential in teaching educators how address trauma due to a student death.

**Keywords:** postvention; trauma; mental health; simulation; professional development

### **1. Introduction**

### *1.1. COVID-19 and Traumatic Loss*

Throughout the COVID-19 pandemic, globally, individuals have been impacted by traumatic loss with increased exposure to grief, loss of social connectivity due to mandated quarantines and lockdowns and increases in suicidal ideation and suicides. COVID-19 has widened the gaps already existing in physical health disparities and contributed to declining mental health. Worldwide, approximately five million deaths occurred from the start of the pandemic, and 5.2 million children lost either a parent or a caregiver [1]. These estimates are based on global reports of COVID-related deaths, some of which come from countries unable to accurately report death rates; thus, the loss of life and corresponding impact on children and adolescents could be even greater. In the United States, COVID-19 related orphanhood resulting from caregiver death impacted over 140,000 children, with the rate of experiencing loss 4.5 times higher among children of racial and ethnic minority groups when compared with non-Hispanic white children [2]. Dependent on geographic region, COVID-19-related death of parents and caregivers is highest for Hispanic children, Black children, and for American Indian/Alaskan Native populations. Children who are orphaned by COVID-19 face adverse consequences such as poverty, abuse, and institutionalization [1].

**Citation:** Khalid, N.; Zapparrata, N.; Loughlin, K.; Albright, G. Postvention as Prevention: Coping with Loss at School. *Int. J. Environ. Res. Public Health* **2022**, *19*, 11795. https://doi.org/10.3390/ ijerph191811795

Academic Editors: Karolina Krysinska, Karl Andriessen and Yossi Levi-Belz

Received: 28 July 2022 Accepted: 15 September 2022 Published: 19 September 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

According to the Centers for Disease Control and Prevention [3], experiencing loss during COVID-19 is similar to experiencing loss in other types of disasters or traumatic events. Grief occurs when there are disruptions to daily routines, loss of life, and any other way in which individuals feel that their stability has been compromised. Grief can include experiencing feelings of shock, anger, sadness or denial, heightened anxiety and distress, and changes in sleeping and eating patterns. Due to the heightened number of bereaved individuals associated with COVID-19, prolonged grief disorder is also a major concern [4]. Specifically, individuals experience more intense acute grief when deaths are associated with COVID-19 than when they are related to other natural illnesses not related to the pandemic [5,6]. The consequences of COVID-19 materialize in heightened rates of trauma, loss and grief for children and have long term impact [7]. In addition, because of higher bereavement rates, individuals are at a higher risk of psychological impairment, especially when experiencing separation distress, grief, and posttraumatic stress [8].

Multiple studies conducted globally demonstrate the negative outcomes of tragic loss, prolonged grief exposure, and heightened anxiety as a result of the pandemic. For example, a qualitative study conducted in Italy, one of the first COVID-19 hotspots with a dramatic rise in mortality, demonstrated that abandonment, anger, guilt, dehumanization, and rumination about the pandemic were key themes that emerged when participants were interviewed regarding their experiences losing family members during lockdown [9]. Participants indicated that online social support and connectivity were extremely valuable in helping them to process grief during this time.

### *1.2. The Mental Health Impact of Suicide and Bereavement during COVID-19*

The pandemic has clearly affected youth mental health as evidenced by elevated levels of depression, stress, anxiety, and suicidal ideation. Prior to the pandemic, the rate of suicide for youth ages 10–24 was already high. This rate increased almost 60% from 2007 to 2018 and is the third leading cause of adolescent death for ages 15–19 [10]. In addition, youth suicide attempts and visits to the emergency department for self-harm have increased since the start of the pandemic [11]. Suicide risk increased when accounting for COVID-19-related post-traumatic stress [12], and for individuals with lower perceived social support [13]. Bereaved individuals who have experienced loss due to suicide and other pandemic-related deaths are at risk of developing complicated grief, or prolonged grief disorder, which is characterized by experiencing major difficulties in accepting the death of a significant other, family member, or close friend [14–16]. Studies have also linked COVID-19 bereavement to intensified psychological distress, especially for those individuals who had previous psychiatric diagnoses [17]. Altogether, COVID-19-related deaths, including those by suicide, have resulted in heightened instances of poor mental health, lack of social connectivity, increased presence of environmental stressors such as financial burden, and lack of access to support services. Thus, the pandemic has put us at the forefront of a mental health crisis where evidence-based approaches to address trauma, loss, grief, and suicide are important to implement in school communities.

### *1.3. Educator and Student Mental Health*

Educators, being on the front lines, were impacted by the pandemic both personally and professionally. School closures have resulted in fewer student resources such as access to school counseling centers, afterschool activities, and tutoring services [18]. Educators experienced disruptions to their jobs with one of the biggest hurdles for many being learning how to teach and engage students through distance learning. This is a difficult transition due to student learning loss and the impact on social and emotional learning and the mental health needs of both students and educators. Due to quarantine, lockdowns, and restrictions on social gatherings during the pandemic, students and educators both experienced social isolation and lack of connection [19]. The only way in which people were able to interact was virtually, which was challenging the viability of technology.

Throughout the pandemic, many children reported increased levels of depression, anxiety, fatigue, and distress [20–22]. Some factors related to poor mental health outcomes in children included living in rural areas, having friends or family members in the healthcare field, knowing someone infected with the virus, and belonging to lower socioeconomic status households. In addition, trauma associated with the pandemic may have a lifelong impact on student learning, behavior, and student social, emotional, and psychological functioning [23]. Additionally, the impact of trauma required many children and adolescents to focus on basic needs such as safety and a sense of security rather than social and academic needs. This can lead to a higher likelihood of attention issues, lower cognitive functioning, behavioral problems, decreased school attendance and difficulty in social relationships [23–26].

### *1.4. Need for Postvention*

Based on the amount of loss that society has experienced in the last several years due to the pandemic, it is important that researchers continue to examine the impact of crisis-response and other preventative programs on children and adolescents, especially those at risk for suicide. According to a survey conducted by the American Federation of Teachers and the New York Life Foundation [27], educators indicate that they would benefit from having more resources to support students' social and emotional needs and that insufficient training is by far the top barrier to supporting grieving students. In total, 91% of educators stated that if there were bereavement training provided in their school or district, they would be interested in participating in it, while 92% stated that there should be a greater focus on supporting grieving students [27]. There is a clear desire from educators to be trained in grief and bereavement support for students, which underscores a critical need for postvention.

When responding to a death in the school community, whether it's by suicide or related to COVID-19, we must address the social, emotional, and mental health consequences that includes creating a community of support amongst students, educators, and parents. This support is vital among bereaved individuals for loneliness is significantly associated with the probability of a post-bereavement suicide attempt and suicidal ideation [28]. This extends into social networks of support which are critical to promoting mental wellbeing and help students and educators in coping with traumatic loss. In addition, it is crucial to integrate evidence-based coping skills into prevention and postvention programs to promote protective factors and resilience. Evidence exists supporting postvention programs in augmenting mental health outcomes for those impacted by suicide, sudden death, and tragic loss [29]; however, there are gaps in the literature for postvention, as well as for the general use of trauma-informed approaches in schools not specific to suicide postvention [30]. Teaching educators postvention strategies through easily accessible online training where they can engage in active learning in applying motivational interviewing (MI) skills through role-play with virtual students holds great promise in augmenting postvention protocols and ultimately, supporting the student health and wellness.

### *1.5. Hypotheses*

The objectives of this study were to examine the effectiveness of an online virtual roleplay simulation designed to teach educators and staff to respond to a death in the school community. Specifically, we hypothesized that as a result of the simulation, as indicated by perceived preparedness and self-efficacy Likert-scales, participants would be better prepared and confident to (1) identify students in psychological distress, (2) talk to students about their concerns and allow them to open up about their feelings of loss, (3) make a referral to support services if necessary, and (4) motivate students and colleagues to engage in self-care. We also hypothesized, based upon Likert-scale measures, that the training would result in (1) high satisfaction ratings; (2) a decrease in stigma related to discussing suicide with others, and (3) an increase in self-reported gatekeeper behaviors two months following completion of the training that include identifying students in psychological

distress, helping them to open up to talk about their feelings of loss, and connecting them to support services.

### **2. Materials and Methods**

### *2.1. Design and Measures*

The study followed a repeated measures design with pre-, post, and two-month followup surveys and was based on Kirkpatrick's training evaluation model [31,32]. Kirkpatrick's model comprises four levels: (1) satisfaction, (2) learning, impact on attitudes, knowledge, and/or skills (3) behavior changes, and (4) results including the long-term benefits derived from the program or intervention such as shifts in school mental health culture. Level two and level three are interconnected for improvements in skills, knowledge and especially changes in attitudes influence changes in behaviors. This study includes assessing the first three levels and not the fourth due to limitations in implementation and lack of accessibility of more global metrics such as school climate.

Level one satisfaction measures were assessed in the post survey and included:


Level one items also included school climate measures collected at post survey and were based on a 5-point Likert scale ranging from "Strongly Disagree" to "Strongly Agree". They included items where participants were asked how much they disagree/agree with the following statements that began with:

If I apply the skills taught in the training:


Level two measures were in the pre-, post, and follow-up surveys and included modified items from the validated Gatekeeper Behavior Scale (see Tables 2 and 3 for items) [33]. The Gatekeeper Behavior Scale (GBS) measures attitudes and intentions that have been shown to be related to changes in gatekeeper behaviors. This survey included two dimensions or subscales that were part of the original validity study: participant preparedness and self-efficacy to engage in gatekeeping behaviors. Lastly, three items measured perceived stigma assessing beliefs about suicide (see Table 4 for items).

Level three measures of behavior were measured at the two-month follow-up where participants were asked whether they believed that as a result of the training there were increases in the number of students: (1) identified as showing signs of psychological distress, (2) helped to open up about their feelings of loss, and (3) connected to support services. In addition, participants were also asked if as a result of the training, there were increases in the number of colleagues: (1) identified as showing signs of psychological distress, (2) helped to open up about their feelings of loss, and (3) connected to support services. Lastly, participants were asked if as a result of the training, there were increases in the number of conversations they have had with other teachers, staff and/or administrators (1) regarding students they were concerned about, and (2) about overall mental health in their school. Lastly, participants were asked to respond to the open-ended question "Now that you have completed the training, can you recall a situation where you used the skills learned in the training? Please describe what happened and be sure not to include any identifiable information."

All participants agreed to an informed consent and then completed a pre-survey, then the 40 min simulation which was followed by the post and two-month follow-up surveys.

> health in their school. Lastly, participants were asked to respond to the open-ended question "Now that you have completed the training, can you recall a situation where you

*Int. J. Environ. Res. Public Health* **2022**, *19*, x 5 of 14

### *2.2. Methods*

#### 2.2.1. Simulation Overview used the skills learned in the training? Please describe what happened and be sure not to include any identifiable information."

*Resilient Together: Coping with Loss at School* is a virtual role-play simulation developed by Kognito (www.kognito.com). This simulation follows a similar learning methodology to other virtual role-play simulations that have demonstrated to be effective in training educators and staff in communication techniques that produce attitudinal and behavioral changes. For example, elementary school educators who were trained via simulated roleplay reported an average increase of 25% in feelings of preparedness to recognize students in psychological distress and approach their parents to discuss referrals to support [34]. In this same study, educators reported a 36% increase in the number of students recognized as being in distress, a 54% in number of students with whom they had discussions about concerns, and a 72% increase in the number of parents with whom they had discussions about referrals to support for their children. Additional studies demonstrate similar findings for training via virtual role-play simulators [35–37]. In the *Resilient Together: Coping with Loss at School* simulation, participants enter an online environment where they practice role-playing with emotionally responsive intelligent virtual students coded with memory, personality, and will respond like real students who have experienced a loss. The 40 min simulation involves participants practicing role-playing one of two conversations, dependent on their students' grade levels, one is with a virtual student and the other with a virtual teacher. These virtual humans model behaviors that school personnel often see during a highly sensitive time such as after a student suicide in the school community. A virtual coach provides ongoing feedback on effective and ineffective communication strategies and though practicing the role-plays, participants learn how to support students impacted by a death and support their colleagues experiencing compassion fatigue. Several studies have demonstrated the efficacious impact of role-play simulations that have implemented similar learning models as the one examined in this study [34–37]. A more detailed description of simulation design and learning methodology can be found in Albright et al. [38] as well as an overview on simulations in PK-12 [39]. Figure 1 shows a screenshot of the simulated role-play. All participants agreed to an informed consent and then completed a pre-survey, then the 40 min simulation which was followed by the post and two-month follow-up surveys. *2.2. Methods* 2.2.1. Simulation Overview *Resilient Together: Coping with Loss at School* is a virtual role-play simulation developed by Kognito (www.kognito.com). This simulation follows a similar learning methodology to other virtual role-play simulations that have demonstrated to be effective in training educators and staff in communication techniques that produce attitudinal and behavioral changes. For example, elementary school educators who were trained via simulated roleplay reported an average increase of 25% in feelings of preparedness to recognize students in psychological distress and approach their parents to discuss referrals to support [34]. In this same study, educators reported a 36% increase in the number of students recognized as being in distress, a 54% in number of students with whom they had discussions about concerns, and a 72% increase in the number of parents with whom they had discussions about referrals to support for their children. Additional studies demonstrate similar findings for training via virtual role-play simulators [35–37]. In the *Resilient Together: Coping with Loss at School* simulation, participants enter an online environment where they practice role-playing with emotionally responsive intelligent virtual students coded with memory, personality, and will respond like real students who have experienced a loss. The 40 min simulation involves participants practicing role-playing one of two conversations, dependent on their students' grade levels, one is with a virtual student and the other with a virtual teacher. These virtual humans model behaviors that school personnel often see during a highly sensitive time such as after a student suicide in the school community. A virtual coach provides ongoing feedback on effective and ineffective communication strategies and though practicing the role-plays, participants learn how to support students impacted by a death and support their colleagues experiencing compassion fatigue. Several studies have demonstrated the efficacious impact of role-play simulations that have implemented similar learning models as the one examined in this study [34–37]. A more detailed description of simulation design and learning methodology can be found in Albright et al. [38] as well as an overview on simulations in PK-12 [39]. Figure 1 shows a screenshot of the simulated role-play.

**Figure 1.** Screenshot from Resilient Together: Coping with Loss at School program.

### 2.2.2. Sampling and Sample Demographics

The sample initially consisted of 4500 educators and staff who were recruited from geographically dispersed areas across the US between January 2021 through December 2021 from district superintendent offices, principals, and by word-of-mouth. Participants gained free access to the simulation via institutional licenses purchased directly from the vendor by school districts or by state departments of education, health or public health,

and mental health organizations, and could take the simulation at a time of their choosing and in a convenient location such as their home or office. Participants first completed the pre-survey followed by the simulation, then a post survey and two months later, a follow-up survey. Overall, the final sample size was 383 participants who completed all three surveys. Participants were able to opt out of any survey question they did not want to complete, including demographic information; therefore, demographic information is listed for only those participants who chose to fill out the information. Participants were primarily white female teachers. Table 1 provides complete demographic information. The average age of the sample was 51 years, with 62% being teachers, 12% staff members, 10% administrators, and the remainder of the sample consisting of mental health specialists (3.1%) and paraprofessionals (3.4%).



### 2.2.3. Analyses

To determine whether preparedness and self-efficacy increased overtime as a result of the intervention, a series of one-way repeated measures ANOVAs were run on each item. Post hoc tests using a Bonferroni correction were used to make pairwise comparisons between pre-test and post-test means, pre-test and follow-up means, and post-test and follow-up means. Partial eta squared was calculated for each repeated measures ANOVA as a measure of effect size for each item to determine the magnitude of the effect of the training over time. Frequencies were calculated for satisfaction measures, level two measures regarding application of the skills learned in the training, and behavioral measures.

To incorporate qualitative data, MAXQDA 2020 software was used. This software combines quantitative processing with manual coding. We were able to thematically code the qualitative data and produce frequency tables to directly illustrate the research findings. The qualitative analysis involved coding for reoccurring themes using a joint inductive-deductive coding process. This process involved two independent coders, with each coder reading through responses individually and identifying common themes with the MAXQDA 2020 software. Once a final coding template was established by both coders independently, both coders coded the responses into the full set of thematic categories,

refining themes based on overlapping categories. The coders resolved any discrepancies through discussion with one another and reported all thematic categories and the frequency of responses for those categories. Some statements could fit into multiple themes, thus percentages reported do not add to 100%. Statements have been copied directly as reported, without correcting for typos.

### **3. Results**

### *3.1. Level One Satisfaction Measures*

Overall, participants found the simulation to be very effective with 98% stating it was good (37.9%), very good (41.3%), or excellent (18.8%) and 92% indicating that they would recommend the simulation to colleagues. A total of 82% of participants indicated that the training is based on relevant scenarios.

### *3.2. Level Two Measures*

There were significant mean Likert-scale increases (see Tables 2–4 for means and *p*-values)) from pre- to post-survey and pre- to follow-up survey in preparedness and self-efficacy to (1) recognize when a student is showing signs of psychological distress (such as being anxious, depressed or disengaged), (2) recognize changes in behavior in response to a loss (such as losing interest in activities, declines in grades or social isolation), (3) help a student open up to talk about their feelings of loss, (4) motivate a student to connect with support services, (4) motivate a colleague to connect with support services, and (5) engage in self-care (such as supporting a healthy mindset, acknowledging your emotions or maintaining close relationships), (6) motivate a colleague to engage in self-care, and (7) motivate a colleague to connect with support services. Partial eta squared (η<sup>p</sup> 2 ; effect size measure) is reported in Tables 2–4 for each item to demonstrate the magnitude of the effect of the training over time. This effect size scale indicates 0.01 as a small effect, 0.06 as a medium effect, and 0.14 as a large effect.

**Table 2.** In response to a real or possible death in your school or community, please indicate your preparedness to.


Note. This note is relevant for the table above. Items were on a 5-point scale. \*\*\* *p* < 0.001, \*\* *p* < 0.01, \* *p* < 0.05, ns = not significant. Items were scored using a scale from "Very Low = 1" to "Very High = 5".

**Table 3.** In response to a real or possible death in your school or community, please indicate how much you disagree/agree with the following statements that begin with "I feel confident in my ability to".


Note. This note is relevant for the table above. Items were on a 5-point scale. \*\*\* *p* < 0.001, \*\* *p* < 0.01, \* *p* < 0.05, ns = not significant. Items were scored using a scale from "Strongly Disagree = 1" to "Strongly Agree = 5".



Note. This note is relevant for the table above. Items were on a 5-point scale. \*\*\* *p* < 0.001, \*\* *p* < 0.01, \* *p* < 0.05, ns = not significant. Items were scored using a scale from "Strongly Disagree = 1" to "Strongly Agree = 5".

There were also significant decreases from pre- to post-survey, and pre-to followup survey (*p* < 0.01) in the beliefs that (1) talking about suicide will increase the risk of suicide, and significant decreases from pre-test to post-test in the idea that (2) talking about suicide with someone who has lost a family member or friend by suicide should be avoided (*p* < 0.01). These measures had medium effect sizes. Tables 2–4 present the quantitative results.

Participants also either agreed or strongly agreed in the post-survey that if they apply the skills taught in the simulation, there would be increases in (1) student academic success = 72%), (2) student attendance = 64%, (3) classroom safety = 82%, (4) the school learning environment will become more supportive = 91%, and (5) relationships with students will improve = 90%.

### *3.3. Level Three Behavior Measures*

Participants self-reported reported in the two-month follow-up survey that as a result of applying the skills they had learned in the training, they either agreed or strongly agreed that: (1) student attendance increased = 32%, (2) student academic success improved = 36%, (3) the school learning environment became more supportive = 61%, (4) classroom safety improved = 57%, and (5) their relationship with students improved = 61%. Additionally, respondents reported that as a result of taking the training, there has been an increase in the number of students and colleagues that they identified as showing signs of psychological stress (students = 24%; colleagues = 21%), helped open up to talk about their feelings of loss (students = 32%; colleagues = 28%), and connected to support services (students = 27%; colleagues = 17%).

### *3.4. Qualitative Measures*

At the two-month follow-up, participants were also asked to respond to the question "Now that you have completed the training, can you recall a situation where you used the skills learned in the training? Please describe what happened and be sure not to include any identifiable information."

A total of 348 open response comments were examined for this analysis. Respondents may have provided multiple themes if they discussed utilizing more than one skill during the incident they wrote about. Qualitative analysis was conducted via MAXQDA 2020, a software designed to streamline the process of coding qualitative data into useful themes. The coding process was primarily manual; however, the MAXQDA 2020 software assisted the qualitative coding process through key word lexical search capabilities and color coding after themes were identified by researchers. Frequency counts and proportions of responses that were related to each theme were created.

First, the manual iterative coding process was completed by two researchers separately, after which results were combined to reflect the themes which emerged. Results from both researchers were compared using reliability analysis in a two-way mixed model. Intraclass Correlation Coefficient (ICC) was used to determine the level of agreement between the two researchers. The ICC for this qualitative analysis was 0.996, indicating a high level of agreement between the researchers.

Results of the qualitative analysis revealed that a large portion of respondents had not had a chance to utilize the skills learned in the training or virtual instruction prevented them from doing so. However, of those who did, the most mentioned themes included recognition of distress in students, discussing concerns with distressed students, ability to implement open communication, knowing when to refer counseling, recognition of distress in colleagues, dealing with students who lost a family member, and discussing student mental health concerns with parents. The full results of this analysis are displayed in Table 5 below.

**Table 5.** Now that you have completed the training, can you recall a situation where you used the skills learned in the training? Please describe what happened and be sure not to include any identifiable information.



#### **Table 5.** *Cont.*

### **4. Discussion**

The main objective of this study was to examine the effectiveness of an online virtual role-play simulation designed to teach educators and staff to respond to a death in the school community. We hypothesized that as a result of the simulation, participants would be better prepared and confident to respond to death in the school community.

Quantitative results demonstrated that *Resilient Together: Coping with Loss at School* was an effective tool for teaching learners how to recognize signs of psychological distress, and improved learners' preparedness and self-confidence in their ability to engage in conversations with students and colleagues regarding support services. These findings align with findings from similar studies that assess the efficacy of simulated virtual role-play programs, specifically in significantly increasing attitudes regarding recognition, approach, and referral behaviors [34–39]. However, this study differs in that it also incorporates the importance of identifying the impact of loss and grief on school communities, differing from typical interventions that aim to improve mental health awareness. An important finding to note is that not only did the program assist learners in helping others, but it also increased their preparedness and confidence in their own self-care. The self-care component provides additional support for simulated role-play that previous papers do not. Coping with loss is difficult in any context, especially the death of loved ones. Our school communities have been heavily impacted by loss due to COVID-19 and are experiencing prolonged effects of stress and loss in students' and educators' reintegration into the academic environment. In addition, because the program resulted in significant mental health and suicide stigma reduction, this could help lead to potential changes in institutional climate toward greater acceptance of having conversations about mental health and suicide, thus creating a safer and more trusting educational environment.

When asked about using the skills learned in the simulation, participants reported instances of recognizing distress in students, colleagues, and other school community members. Additionally, they reported increases in approaching and referring students in distress to support services. Lastly, participants mentioned how helpful the program was specifically in helping others deal with the loss of family members or other members of the school community. For specific frequency of the occurrence of these behaviors, please see the qualitative data reported in Table 5. The qualitative data show that participants were able to better understand the impact of simulated role-plays in training school community members how to recognize those in distress and how to engage them in conversations to augment their behavioral health as well as create communities of support within their schools. The benefits of building rapport between students and teachers, and between teachers and administrators themselves cannot be overstated due to potential impact of fostering a positive and safe school climate.

Lastly, many respondents, nearly half in the qualitative data, mentioned that they have not had a chance to utilize the skills learned in the training due to needing to take necessary precautions because of the pandemic as well as virtual classroom instruction. At the same time, a substantial number of respondents reported that they utilized the skills practiced. This observation is important as many school settings are still taking measures to protect students from COVID-19 and ensuing co-variants. This study provides evidence that the use of virtual role-play simulations such as *Resilient Together: Coping with Loss at School* are an effective approach to augmenting prevention and postvention programs within school districts that are vital in supporting student and faculty mental health and well-being.

### **5. Limitations**

As in many field studies, recruitment of subjects for experimental and control groups through random assignment was not possible. Thus, one limitation is that we implemented an experimental design that examined within-group differences that did not include a control group. Another limitation is that behavioral data were self-reported. Ideally, we would have preferred access to school records on classroom attendance, student academic performance, and incidences of school safety, etc. Additionally, the data collected in this study are specific to educator and staff perceptions of student mental well-being; thus, incorporating student data would have allowed us to further assess the efficacy of the intervention. Another limitation was that although the items used to assess attitudinal change were based on the validated Gatekeeper Behavior Scale, the scale used in this study was not previously validated. Thus, although convergent validity has been established for the Gatekeeper Behavior Scale [33], since the scale used in this study was modified, future studies should examine the convergent validity of the modified scale. Lastly, to increase interrater reliability in the qualitative analysis, ideally, we would have liked more researchers to code responses to ensure accuracy. Given these limitations, the results reported in this paper are assumed to represent the population of those who participated in the *Resilient Together: Coping with Loss at School* program.

### **6. Conclusions**

As evidenced in the postvention literature, there is an overwhelming need for schoolbased interventions. Adolescent and young adult populations are at the highest risk for suicide clusters and contagion effects. Without proper postvention protocol, it is difficult to address a death in a school community, particularly a death by suicide, which can increase the occurrence of suicide clusters and directly impact already at-risk students by amplifying negative emotions (e.g., feelings of hopelessness, anxiety, loneliness). The data from this study provide encouraging evidence that simulations such as *Resilient Together: Coping with Loss at School* can augment postvention efforts. The current use of online virtual role-plays to manage postvention conversations had a positive impact on the perceived preparedness and self-efficacy of educators and staff on their postvention efforts. Overall, the impact of death and the loss of loved ones effects the entire school community, and postvention techniques are essential in coping with the loss. The results from this study provide support that postvention efforts are strengthened through the use of virtual interventions that promote recognition, approach and referral behaviors and can be effective when helping

school communities to cope with loss, which has been especially prominent during the COVID-19 pandemic.

**Author Contributions:** N.K. authored the initial draft and was involved in conducting the qualitative analysis, writing the results of this analysis, survey creation, and coordinating the research activity. N.Z. conducted the quantitative analysis which included data cleaning, conducting the statistical analysis, producing the visualization/data presentation, and writing up the results of this analysis. K.L. was involved in conducting the qualitative analysis and writing the results of this analysis. G.A. was involved in survey creation and the critical review and revision of the manuscript. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Ethical review and approval were waived for this study due to the reason that it was not considered human subject's research.

**Informed Consent Statement:** Not applicable for study involved archived deidentified data.

**Data Availability Statement:** Restrictions apply to the availability of these data. Data were obtained from Ascend Learning and are available from glenn.albright@baruch.cuny.edu with the permission of Ascend Learning.

**Conflicts of Interest:** We are reporting that the authors have employment agreements with Ascend Learning, the company that developed the simulation used in this study. Ascend Learning had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

### **References**

