Psychosocial risks of healthcare

professionals and occupational suicide

Shantel Sullivan and Marie-Line Germain

Abstract Shantel Sullivan is based at

Purpose – The purpose of this paper is to explore compassion fatigue and psychosocial risks among Mindpath Care Centers at
healthcare professionals, which lead to increased work-related costs, including occupational suicide. Carolina Partners, Raleigh,
Through this review and synthesis of the literature, the authors shed light on the causes that lead medical North Carolina, USA.
professionals to take their own lives. In addition, the authors explore the role of compassion fatigue as a Marie-Line Germain is
leading cause of self-inflicted death.
based at the Western
Design/methodology/approach – A systematic approach was used to guide the review and synthesis
Carolina University,
of the literature. Key bibliographic and review databases were searched from the fields of social work,
Cullowhee, North Carolina,
nursing, medical education, educational leadership, psychology, sociology and human resources.
USA.
Findings – In the USA alone, suicide has increased by 25 per cent since 1999, making it a leading cause
of death. Data indicate that medical professionals are prone to compassion fatigue, work-related stresses
and suicide at a greater rate than the general population, with surgeons reporting up to three times more
thoughts of suicide than the general population. The synthesis and analysis of the literature yielded the
following themes: compassion fatigue and suicides, burnout and compassion fatigue, career longevity
and moral distress.
Research limitations/implications – Job stress and its negative impact on the workforce is rather well
documented. Yet, job stress has shown to be a leading cause of workplace suicide, which represents a
commensurable human and economic loss and has a direct impact on multiple human resources
variables. Ongoing research is needed to see how the initial literature has evolved as new data emerges.
Practical implications – This paper presents best practices for training and development professionals
to better respond to psychosocial risks and reduce work-related costs in the medical profession and
beyond.
Originality/value – Studies on employee stress and suicide in the healthcare industry are scarce. Yet,
they have human and economic impacts on organisations.
Keywords Healthcare professionals, Psychosocial risks, Work-related suicide
Paper type Research paper

Introduction
According to a 2016 World Health Organization report, close to 800,000 people take their
own life every year and there are many more people who attempt suicide about one person
every 40 s, an increase of 60 per cent over the past 45 years. Suicide is one of the leading
causes of death across the world, with annual rates that are greater than homicides and war
combined (WHO, 2015). In a 2018 study by the Center for Disease Control, suicide was
ranked as the tenth leading cause of death among Americans (Centers for Disease Control
and Prevention, 2018), with individual state increases ranging from 6 per cent in Delaware
to nearly 58 per cent in North Dakota. Because of inadequate reporting methods, suicide is
actually estimated to be 50–60 per cent higher than the reported rates. In fact, according
the Substance Abuse and Mental Health Administration (SAMHA, 2017), almost ten million
adults reported having serious thoughts about suicide in the past year. Work-related
Received 28 August 2019
suicides have increased accordingly (up 22.2 per cent since 1995). It is estimated that Revised 17 September 2019
150,000 of these suicides are work-related (WHO, 2012). Between 2003 and 2010, in the Accepted 25 September 2019

DOI 10.1108/ICT-08-2019-0081 VOL. 52 NO. 1 2020, pp. 1-14, © Emerald Publishing Limited, ISSN 0019-7858 j INDUSTRIAL AND COMMERCIAL TRAINING j PAGE 1
 USA alone, a total of 1,719 people died by suicide in the workplace (Tiesman et al., 2015,
2017). Although some professions are more affected by work suicide, such as in the
protective services – the police, the army (Violanti et al., 2009), the farming industry, and the
medical industry, this phenomenon affects all industries and all levels of the organisation,
from unskilled workers to executives (Bureau of Labor Statistics, 2012a, b). Yet, the
scientific and research literature on employee suicide is scarce, reflecting the persistent
stigma attached to it. The upward trend of suicides in the workplace underscores the need
for additional research to understand occupation-specific risk factors and to develop
evidence-based programmes that can be implemented in the workplace (Tiesman et al.,
2015).
Scholars suggest a variety of reasons behind the steady rise in occupational suicides
(Germain, 2013). Two kinds of widely categorised risk factors can be focussed upon: First,
clinical risk factors such as mental illness, substance abuse, and/or previous suicide
attempts, and second, environmental or situational based risks such as stressful life events
or access or means to commit suicide (Vijayakumar et al., 2005; Germain, 2013). Pesticide
poisoning, hanging, and firearms are among the most common methods of suicide globally
(WHO, 2014a, b). The access to firearms at work is a cause of suicide. Scholars
(Vijayakumar et al., 2005; Germain, 2013; Cantor and Neulinger, 2000; Chan et al., 2001)
have further suggested that occupational suicides, especially over the last two decades,
have been exacerbated by the globalisation and technologisation of the workplace.
Of interest in this paper is the case of professionals in the medical industry, one of the most
impacted by occupational suicide. Nurses, for instance, are twice as likely to experience
depressive symptoms (a leading cause of suicide) compared to any other profession
(Branford and Reed, 2018). With shifts of ten or more hours, healthcare industry nurses and
doctors are two and a half times more likely to experience burnout and job dissatisfaction
than nurses with shorter shifts (Stimpfel et al., 2012). Approximately 400 physicians die by
suicide in the USA each year – two to three times more than the general population
(Gunther, 2016).

Significance of the problem

Employee stress and suicide have human and economic impacts on organisations
Job stress and its negative impact on the workforce is rather well documented. Yet, job
stress has shown to be a leading cause of workplace suicide, which represents a
commensurable human and economic loss and has a direct impact on multiple human
resources variables. Job stress costs US organisations over 300bn yearly. According to the
Institute of Medicine, the economic cost of suicide affects four areas.
First, workplace suicide affects medical expenses of emergency intervention and non-
emergency treatment for suicidality. These medical costs are borne by all of society through
higher health care costs. According to the American Institute of Stress, stress is responsible
for 80 per cent of medical visits and 70 per cent of work accidents (American Institute of
Stress, 2014). Loss of productivity, high turnover, absenteeism, feelings of failure, isolation,
and a host of negative workplace experiences are some of the symptoms indicating the
growing concern (Duff and Chan, 2013). When dealing with these “symptoms”, people have
choices. Suicide as a career response is one of them (Duff and Chan, 2013) and is
indicative of a “simple response” to a complex situation that cannot be fully explained. Few
studies have shown the financial impact of employee suicides on organisation. Suicide
attempts cost about four billion dollars via medical expenses and lead to a loss at the
bottom line. According to the Suicide Prevention Resource Center (2019), each
occupational suicide costs organisations about $1.3m in productivity and 97 per cent of this
cost is due to the lost in productivity. Thus, while suicide has been explored as a
phenomenon through the lens of sociology, psychology, anthropology, philosophy, and

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religious texts, scholars have just started exploring few other dimensions such as
workplace-influenced stress (through the intersection of management, technology,
sociology, psychology) that are directly connected with the increasing suicides.
Second, organisations experience a loss and/or reduced productivity of workers suffering
from suicidality. Specifically, suicide attempts in the USA represent about $70bn annually in
medical costs and lost earnings combined (CDC, 2018).
Third, death by suicide often occurs during the height of an employee’s productivity. The
greatest numbers of suicides occurring before retirement, the average work-loss and
medical cost per case can be as high as $1.3m (Research America, 2018). In the USA, the
value of lost productivity represents about $14bn annually. Job stress reduces employees’
productivity greatly.
And fourth, the human cost is significant. Lost productivity of the workers grieving a
colleague’s suicide should not be undermined. Oftentimes, the feeling of loss adversely
impacts employee motivation and morale. As seen in some recent examples in France
(France Telecom) in 2007 and 2008 (Willsher, 2014), and in China (FoxConn) in 2012,
workplace suicide may affect hundreds of people and the effects may reverberate through
an organisation for years (Heffernan, 2013). Coworkers may feel that they contributed to the
suicide in some way or blame themselves for not preventing it. They may feel angry,
rejected, or even betrayed by their co-worker’s fatal or near fatal act. Some employees who
return following the death of a co-worker may be sad, distracted, occasionally tearful, and
slow to return to productivity. Managers may feel they should have been in better touch with
their subordinates or may feel responsible for creating job stressors. Yet, most
organisations are ill-equipped to deal with occupational suicides. Few national and regional
associations exist and they rarely offer adequate and effective training materials to training
and development (T&D) professionals and managers. Employees affected by stress tend to
be absent or be present and not work to their full potential (EmpreinteHumaine.com).

Literature review
This paper’s central theme revolves around psychosocial risk factors, compassion fatigue
and stress of healthcare workers, all possibly leading to occupational suicide. Psychosocial
risk factors are defined as the characteristics at psychological, family, community or cultural
levels that precede and are associated with a higher likelihood of negative outcomes.
Among those negative outcomes are increased stress levels and individual behaviours that
lead to burnout and compassion fatigue, when unresolved, may lead to significant social-
emotional distress.

Burnout and compassion fatigue

Burnout has collectively been a psychological term that refers to long-term exhaustion and
diminished interest in work leading to feelings of helplessness, hopelessness, chronic
fatigue and one’s sense of being “trapped” in a job (Sabo, 2011; Perkins and Sprang,
2012). Burnout has been assumed to result from chronic occupational stress. Healthcare
professionals, especially those closest to complex case, may begin to demonstrate
irritability and resentment towards a patient, and towards colleagues (Perkins and Sprang,
2012). Unaddressed, with continued repetitive exposure to work related stress and no
means to address and discuss or debrief, nurse professionals and healthcare professionals
in general are at greater risk for experiencing compassion fatigue. Burnout has been
estimated to negatively impact 30–38 per cent of all physicians. Higher rates of burnout are
experienced by surgeons and medical students (Kuwada, 2016).
Compassion fatigue, unlike burnout, is indicative of specific behavioural changes
exhibited by nurses providing constant care to the sick, suffering and traumatised

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 (Smart et al., 2014). Working in high trauma environments has been referred to as
“chaotic and hectic” (Wentzel and Brysiewicz, 2014, p. 95). According to the research,
“the dominant theoretical model postulating the emergence of compassion fatigue
draws on a stress-process framework” (Sabo, 2011, p. 3).
Nurse professionals and healthcare institutions may have difficulty admitting the reality of
healthcare provider expressions of burnout and compassion fatigue yet according to the
research conducted by Erickson and Grove (2007), a substantial 86.9 per cent of emergency
response personnel reported symptoms (emotional, physical, mental and relational) after highly
distressing events with traumatised people. Further, 90 per cent of new physicians, between 30
and 39 years old, reported that their family life had suffered as a direct result of their work
(Erickson and Grove, 2007, p. 3). Mathieu and McLean (2015) estimate that “depending on the
studies, between 40 per cent and 85 per cent of helping professionals were found to have
compassion fatigue and/or high rates of traumatic symptoms” (p. 31). Analysis confirms that
“emotions are a pervasive feature of nurses daily occupational experiences” and “nurses who
covered up their true feelings were more burned out than nurses who did not cover up such
emotional experiences” (Erickson and Grove, 2007). Jonas-Simpson et al. (2013, p. 1) promote
that “the experience of grieving a loss is a significant human experience” and that grieving can
be experienced by those acting as healthcare providers. In fact, those who participated in
Jonas-Simpson et al.’s study indicated that their lives were impacted personally and
professionally as a result of being exposed to grief in the workplace. Nurses offered that they
were “sometimes overwhelmed” by their own grief reactions (p. 5).
To further understand the phenomenon of burnout and compassion fatigue among care
providers, three significant themes arose perpetuating ongoing behavioural expressions of
compassion fatigue; first, generational disconnect and perceptions of nursing values, second,
nurse professionals’ decrease in work and personal life satisfaction leading to intentions to
quit, and third, the overall cost on quality among organisational and hospital institutions as a
result of not addressing the implications of compassion fatigue among their workforce (Sabo,
2011; Perkins and Sprang, 2012; Erickson and Grove, 2007; Mathieu and McLean, 2015).

Psychosocial risk factors

Figure 1 illustrates the relationships between psychosocial risk factors, work-related stress
and negative outcomes, which, in turn, may lead to occupational suicide.
Workers in the medical field have shown to be more at-risk for work-related suicides
(Roberts et al., 2013). Medical providers – physicians specifically – have an increase ability
to “suffer” the emotional wear and tear of patient loss. According to founder of the West
Virginia Medical Professionals Health Program, Bradley Hall, physicians are “good at”
successfully committing suicide (Glaser, 2017). In addition to the emotional strain they
experience, their relatively easy access to drugs presents an increased risk for self-inflicted
death by poisoning.

Research questions
Although suicide-related deaths affect all industries, the medical profession is specifically
prone to occupational suicides. Through this review and synthesis of the literature, we aim
to understand the causes that lead medical professionals to take their own lives. In addition,
we explore the role of compassion fatigue as a leading cause of self-inflicted death. In light
of our literature review on the topic of compassion fatigue, stress and occupational suicide
in the healthcare industry, our paper aims to answer the following two questions:
RQ1. What are the psychosocial experiences among healthcare providers?
RQ2. How can T&D professionals actively respond to the psychosocial needs of
healthcare employees?

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 Figure 1 Relationships between psychosocial risk factors, work-related stress and
negative outcomes

Methods
A systematic approach was used to guide the review and synthesis of the literature in three
main phases: planning the review; conducting the review; and reporting the review. The
search strategy was initiated with articles published between the period of 2007 and 2017
and involved the keywords: job satisfaction, burnout, compassion fatigue, caregiver,
healthcare and quality care. The ten-year time frame selected corresponds to rapid
changes in the healthcare industry, and the aging of the population and a general increase
in the number of patients (Leggat and Smith, 2016). Doctors and nurses have increasingly
been required to fulfil multiple roles and responsibilities, treat increased volumes of patients
in shorter amounts of time, and address the growing complexities of chronic disease
(Kumar, 2014). In addition, with the passing of the Affordable Care Act in 2010, 17m
Americans gained access to health insurance, putting major stress on doctors throughout
the country (Sievert, 2016). Key bibliographic and review databases were searched
including ProQuest, ERIC, and Sage Publications, and were not limited to one discipline
area. Articles were gathered from the fields of social work, nursing, medical education,
educational leadership, psychology, sociology and human resources.

Quality assessment
The framework by Callahan (2014) postulates using a system for evaluating literature which
requires the researcher to critically select, read, synthesise, and evaluate literature
pertaining to the topic being studied. The “Five C’s” concise, clear, critical, convincing and
contributive provided a comprehensive, systematic approach to the evaluation process of
the literature reviewed on compassion fatigue (Callahan, 2014). Incorporating this
approach, each article was evaluated using the five characteristics with the author’s
personal interpretation.

Study selection
A total of 66 articles and two books were included in the initial review database search.
Following the title screenings and the quality assessment indicators using Callahan’s (2014)

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 five characteristics, 32 articles were omitted as they met the rubric for exclusion. The
articles selected met the criteria of examining cost and quality implications pertaining to
healthcare professionals’ burnout and compassion fatigue.

Findings
From the synthesis and analysis of the articles, several themes emerged. They include:
compassion fatigue and suicides, burnout and compassion fatigue, career longevity and
moral distress, this section further details these findings.

Psychosocial experiences among healthcare providers

Burnout, Compassion Fatigue and Suicide in the Medical Profession Sabo (2011, p. 1)
validates nurses, physicians, social workers and psychologists as healthcare providers
most likely to be exposed to occupational stress. The complexity and frequency of
exposure to individuals with serious life-limiting conditions requires the most energy and
attention by the nurse professional. Providing this high-level of intense caregiving increased
the potential incidence for burnout, compassion fatigue. Furthermore, the complexity and
frequency of exposure can in the most extreme cases, lead to vicarious traumatisation or
also known as secondary traumatic stress (Ford, 2014). Vicarious traumatisation or
secondary traumatic stress, occurs as a result of “negative consequences secondary to
fear and work-related trauma” (Stamm, 1999, p. 12).
The Nursing Times published an article entitled “Compassion ‘Exhausts’ Nurses” presenting
research conducted by the University of Bedfordshire in the UK indicating that “nurses can
suffer as a result of having to display compassion all the time” (Ford, 2014, p. 2). Nurse
professionals tend to bear witness to one’s experiences of loss, abuse and suffering. This
literature review was formulated as a means to better understand how people, particularly
nurse professionals, continue day after day to care for others and further, how it impacts
their physical, mental and emotional well-being. In the healthcare industry, trauma and loss
tend to be perceived as, this is just what we do, alluding to a notion of acceptance to this
phenomenon. These ideas support and perpetuate a mental model within healthcare
providers that such a profession requires one to simply suck-it-up and keep working.

Career longevity and moral distress

To further explore relationships between the reports of, experiences of, and exposure to
burnout and compassion fatigue, attention was placed on potential gender, age, education
and level of experience. The layered emotional and symptomatic responses of burnout,
compassion fatigue and moral distress have been noted as the “cumulative effects of
working in high-stress, high volume workplaces” (Mathieu and McLean, 2015, p. 32).
Mathieu and McLean (2015, p. 32) define moral distress as the state “when you believe you
know the right thing to do, but for whatever reason – pressure from superiors, fear of
retribution or circumstances beyond your control – you act against that belief; this is a deep
“emotional toll”.
In 2010, the US Department of Health and Human Services Health Resources as well as the
US Health Services and Resources Administrations (HRSA) released that, as of 2008, there
was a recorded 3,063,162 Registered Nurses in the USA and 84.8 per cent of them were
employed in nursing positions – the highest rate of nursing employment since 1977. Atefi
et al. (2014, p. 352) offer strong empirical evidence supporting a correlation between job
satisfaction, patient safety and quality care. Three main themes were identified impacting
nurses reported job satisfaction and dissatisfaction: spiritual feeling; work environment
factors; and motivation.

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According to the HRSA, 62.2 per cent of RN’s reported working in hospitals in 2008 with
10.5 per cent working in ambulatory care, the second highest care location. The HRSA
indicated that that there is a steady shift in care setting as nurses age. Specifically, “nearly
85 per cent of RN’s under 30 years old work in hospitals, but this percentage declines
steadily with age” (HRSA, p. 48). “More than 73 per cent of nurses reported that they
change positions or employment due to workplace issues such as stressful work
environments, lack of good management, or inadequate staffing” (p. 53). The cost
associated with nurse turnover is staggering. Pendry (2007) calculated that costs
associated with recruiting, training, and terminating a nurse can range anywhere between
46,000 and 145,000 dollars depending on demand and specialisation. Pendry (2007, p. 1)
draws from the earlier research of Corley et al., reporting “15% of the nurses in one study
reported resigning a position due to experiencing moral distress”. Even more disturbing,
“nearly one-third of participants in the study reported leaving their first nursing position
within 1 year; 57% left by 2 years” (Pendry, 2007, p. 3).
Fostering positive supportive relationships between colleagues, fellow nurses, staff in
general and/or hospital workers encourages and challenges fears to express emotion. The
act of creating a place for positive, supportive relationships would help to counteract what
Mathieu and McLean (2015, p. 33) describe as “the first casualty of burnout and
compassion fatigue in the workplace; collegiality”.
Peers may be the most effective form of support for physicians (Gunther, 2016). Positive,
supportive working environments offer opportunity to reduce negative emotional toxicity and
attribute to positive outcomes of satisfaction and performance Gountas et al. (2014). Graber
(2009) notes that it is the responsibility of the manager to recognise, assist and counsel
clinicians; it is when dialogue fails to occur or occurs sporadically that nurse professionals
are more likely to demonstrate compassion fatigue. Boev (2012) supports a framework
indicating the importance associated with the relationship between nurses and nurse
manager relationships positing patient perception and satisfaction are drawn from customer
service and nurse friendliness, and courtesy is present when there are positive relationships
between manager and organisation (Graber, 2009; Boev, 2012; Gray and Muramatsu,
2013). When nurse professionals report positive associations with their supervisor and/or
other colleagues, they are less likely to leave their place of employment. The deterioration of
work relationships or ineffective staff management leads to a shift from care and humanism
to that of annoyance, disconnect and a lack of compassion or empathy for those being
treated (Graber, 2009; Wentzel and Brysiewicz, 2014).
This section presented a response to our first question:
RQ1. What are the psychosocial experiences among healthcare providers?
The next section answers our second research question, which aims to answer how T&D
professionals can actively respond to the psychosocial needs of healthcare employees.

Implications for training and development practice

Despite the steady increase of suicide in the past 45 years and its direct link to the
workplace and employee well-being (National Public Radio, 2015), most organisations are
ill-equipped to deal with psychosocial risk factors, work-related stress and their subsequent
organisational and human costs. Few national and regional associations exist and they
rarely offer adequate and effective training materials and support to T&D professionals and
managers. In other instances, only small scale crisis interventions have appeared as a
result of a workplace suicide. Yet, the National Institute of Health, the Society for Human
Resource Management, and some consulting firms such as Empreinte Humaine have
documented work on workplace suicides (EmpreinteHumaine.com). To address this gap in
occupational hazards awareness, mental distress, and suicide prevention and postvention
efforts, T&D action-research initiatives should be further developed to help organisations

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 formulate an organisational policy for suicide prevention in the workplace; and to identify
best practices for alleviating compassion fatigue and preventing stress and suicide among
their employees. Additionally, there are opportunities for policy improvement and strategies
to institute a culture of caring through the use of self-care practices to promote compassion
satisfaction and T&D professionals can play a significant role in assisting organisations
make these improvements.

Selected best practices for self-care, psychosocial risks and suicide prevention
organisational improvements
Healthcare organisations attempt to promote and maintain core values consistent with
professionalism, respect, integrity, compassion and empathy through encouraging care
and support for caregivers. With a growing workforce, there is a need to ensure healthcare
fields are able to sustain, retain and attract high performers to such professions. Day in and
day out, nurse professionals offer compassion and empathy to those whom they are
treating, this can lead to caregiver stress. Organisational improvements are the most
effective way to reduce burnout, rather than programmes that focus on individual resilience.
Effective organisational improvements include, increasing staffing, healthier shift schedules,
safe working conditions, and positive work relationships (Card, 2018). Graber (2009)
indicated that in order to make lasting and sustainable change to improve the over
satisfaction and quality of care, healthcare institutions will have to embark on “radical
cultural changes” and in fact, there are a number of organisations and hospitals that have
effectively made such changes to cultural perception and daily clinical practices by
focussing on the interpersonal skill development of staff (pp. 519-527). Culture change of
this magnitude requires authentic caring where nurse professionals are encouraged to be
increasingly aware of their intentionality, caring consciousness and heart-centred human
presence (Graber, 2009).
In order to effectively treat the community, healthcare organisations must start with caring
for the people within the organisations. The patient, employee and organisation as a whole
are being disadvantaged by not focussing on preventative self-care. Graber (2009, p. 531)
indicate that organisational culture is “the key element” to fostering “individual caring
among hospital clinicians”. The work of Griffin (2004) reveals the following negative effects
of lateral violence, lowered self-worth, decreased job satisfaction, and stress. Griffin
postulates “providing an educational forum on lateral violence for newly licensed nurses in
orientation is essential for raising consciousness” (p. 258). If compassion and excellence
are at the core of the healthcare delivery system, organisations must address these issues.
Nurse professionals cannot perform high quality care if they are not being cared for by their
places of work and by themselves. When healthcare organisations begin to educate about
the signs and symptoms of burnout, nurse professionals will be better at recognising the
symptoms. Preemptive measures could significantly impact their personal and professional
lives to reduce negative outcomes.

Institutional policy
There are opportunities for policy improvement and strategies to institute a culture of caring
through the use of self-care practices to promote compassion satisfaction. Three poignant
problems were identified through the review of the literature relating to perceptions of
supporting nurse professionals: a lack of standard procedure and hospital wide
communication (possible duplication of services and confusion of resources and roles); a
culture mental model of “I don’t need help, my job is to help others”; and a disconnect
between nurses understanding of problem vs management’s understanding of problem.
Instituting and promoting policy to care for nurse professionals in the event of a critical
incident and following an exposure to an unforeseen event connects us reminds us we are
human and fosters dialogue to sustain physical, mental and emotional well-being.

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Organisations can improve healthcare and service providers’ perceived effectiveness and
job satisfaction by supporting programing that enhances healing relationships leading to
the retention of high performers (Kulkarni et al., 2013, p. 126). Addressing issues of job-fit,
workload, continued education, support services and positive relationships with co-workers
can improve employee engagement and satisfaction scores inevitably reducing intentions
to quit (Leary et al., 2013). Leaders who encourage staff participation in the development of
policies increase the sense of autonomy improving satisfaction and level of justice within the
organisation (Kumar, 2014).
Ying (2009) supports the following definition, indicating self-compassion as “one’s ability to
be open to the emotional experience of exposure to ones suffering and personal reaction of
suffering without the behavioural response to disconnect from such suffering” (Ying, 2009,
p. 310). Although there is attention to burnout and compassion fatigue associated with
emergency related outcomes, care providers also experience positive, beneficial purpose
and meaning in their work. Ying (2009, p. 311) addresses “[in] high stress workplaces self-
compassion has the ability to positively affect an individual’s ability to cope with
professional stressors”. Individuals who are able to demonstrate self-compassion tend to
exhibit qualities of positive self-orientation; mindful awareness, belief in common humanity,
and self-kindness (Ying, 2009). Nurses tend to put others needs before their own,
increasing their risk and vulnerability towards burnout and compassion fatigue (Wentzel
and Brysiewicz, 2014). The promotion of self-compassion can be taught, and, through
dialogue and practice, care providers will begin to recognise the implications of caring for
others and be more cognisant to their mental, emotional, and physical reactions. This
cultural shift can occur through organisational response to implementing wellness
programmes, strategic case assignment, informal opportunities to debrief, and asking
employees what it is they need to do their job well (Sprang et al., 2007, p. 209).
Organisations can further prevent the conflicting expectations between nurse professionals
and the interdisciplinary team by “fostering good relationships between staff, collaboration
for end-of-life care with an interdisciplinary team, and allowing for ethics consultations can
decrease feelings of moral distress” (Hanna, 2004, p. 73).
As far as suicide prevention, initiatives can and should be supported by local, regional and
national efforts, which tend to be more effective. An improved reporting system for
occupational suicide (by industry) is essential to better understand the causes of suicide
and develop appropriate interventions. The US Army, on its part, is known to have a high
suicide rate among soldiers. Every year, it is estimated that 20 per cent of veterans commit
suicide. Many suffer from psychological disorders upon their return from combat. To
address this problem, in 2007, the US government created a toll-free phone number for
veterans and their families. It also has put into place support groups and resilience training
sessions. Army leaders are asked to provide psychosocial support to soldiers and foster
mentoring relationships. Yet, as it is often the case, soldiers are reluctant to admit their need
for emotional support due to fears of being labelled as “sensitive”, which could prevent
them from being promoted to more visible and emotionally demanding positions within the
Army. Other initiatives have been put into place to address suicide at the national level. For
instance, in 2010, the National Action Alliance for Suicide Prevention was created to put
forth a National Strategy. These initiatives are still at the embryonic stage and effectiveness
has yet to be proven. In the meantime, the National Strategy suicide prevention model,
aimed at reducing suicides by 20 per cent, suggests the following three interventions: first,
keep firearms away from individuals who are susceptible to use them to commit suicide;
second, limit the access to CO2 and poisonous substances, and third, facilitate therapy
sessions in emergency services. It is important to note that some suicide prevention
initiatives may work very well in some cultural contexts but not in others. A copy-and-paste
approach to a suicide prevention campaign in the workplace should not be done without
first considering national culture, the culture of the industry, and the culture of the
organisation.

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 The creation of awareness should include reducing the stigma around mental health, thus
providing counselling and other leisure activities that allow for self-connectedness. In an
organisational context, executive management needs to be made aware of the impact
occupational stress and related suicide may have on the effectiveness of a company. T&D
professionals, department leaders and employee representatives should be trained to
recognise the basic signs of suicide and on how to best react. That is, they should have
prevention and postvention plan. Organisations should offer psychosocial-medical support
adapted to the needs of the employees, with the creation of a toll-free hotline. Finally, T&D
professionals and organisational leaders should assiduously track the success of Employee
Assistance Programs to determine their effectiveness and whether they truly address the
needs of employees. But prevention must occur at all levels of the organisation, including at
the leadership level. Leaders must make employee well-being a priority. Team leaders
should be encouraged to foster “proximity management”, that is, management in which
they encourage open communication with their team members. Organisational culture is
defined by the very actors at all levels of the organisation. It is a pyramid, the base of which
needs to be solid. For many employees, colleagues are a support system. They are a
source of psychological support for some vulnerable employees, those who are grieving,
and those who are not at their best. Managers should be educated on how to detect and
address signs of distress. Suicide attempts or threats made by employees, for instance,
should not be dismissed. Rather, they should be encouraged to listen, detect behaviours
that could signal a suicide attempt, advise, and protect, and report to the T&D division.

Conclusion
This paper has highlighted the psychosocial impacts on healthcare providers (doctors and
nurses) as a result of work-related stress possibly leading to occupational suicide. Work
stress has been evaluated using the three factors: psychological job demands, decision
latitude (job control) and social supports at work. The literature suggests that people
experiencing job strain, who are simultaneously socially isolated, are more susceptible to
negative and long-term implications in in both their personal and professional roles, these
individuals carry higher risks than their counterparts; personal stressors in combination with
professional stressors place healthcare providers at greater risk for reduce expression of
quality of life (Chandola et al., 2010). This is motivated by expectations that are “too high or
unrealistic” (Perkins and Sprang, 2012). Repetitive exposure to critical incidents qualifies as
work stress, take into consideration that as a healthcare worker, there is no way to be
certain of the potential level of stress one may experience from shift to shift. Awareness of
the physiological changes caused by work stress should serve as just cause to ensure that
those working under such stressed conditions have access to health and wellness training
to prevent undesired outcomes and safeguard against work related psychosocial hazards.
Although suicide is a complex and multifactorial phenomenon (personal life, mental health,
family issues, work and so on), occupational suicide has direct and lasting effects on the
victims’ co-workers at all levels of the organisation and on the health (including economic) of
the organisations themselves. This review confirms that, in the medical field, specifically, failure
to act on addressing caregiver stress and burnout has significant financial ramifications on the
institution. In an organisational system positioned with a commitment to excellence,
compassion and innovation; high absenteeism, changes in co-worker relationships, lack of
flexibility, negativity towards management, reluctance towards change, and lack of vision for
the future all point to caregiver burnout and compassion fatigue. Accordingly, increasing
programmes for peer support and debriefing offers opportunity to build colleague alliance and
organisational support. The same factors that negatively contribute to employee satisfaction
also correlate to a decrease in patient satisfaction scores. With knowledge of reimbursement
measures, poor patient satisfaction scores lead to revenue loss; nurse professionals and
healthcare institutions cannot expect to provide quality care if those who provide care to others

PAGE 10 j INDUSTRIAL AND COMMERCIAL TRAINING j VOL. 52 NO. 1 2020

are exhausted. Larger population-based studies of self-care and debriefing among healthcare
providers should develop further theoretical and empirical evidence to develop interventions to
improve care provider mental and emotional wellness counteracting symptoms of burnout and
compassion fatigue. Suicide prevention and postvention at work should be part of a global
initiative, one that caters to the prevention of employees’ psychosocial risks. A large majority of
organisations still favour financial returns over employee well-being. They often react in terms
of “cost”. Cost from a public relations standpoint, in terms of corporate image and the press,
and cost strictly in financial terms. The cost of stress, compassion fatigue, suicide and the
return on investment of suicide prevention campaigns could serve as an entry point to educate
and sensitise leaders, managers and training and development professionals about
occupational suicide. Yet, before T&D departments can inform others, they need to be
informed themselves. They need to encourage a culture of “care” where the individual/
employee is placed at the centre of the organisation and where the organisation plays a
protective role. In essence, human resources should be just that: human resources.

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Corresponding author
Marie-Line Germain can be contacted at: mgermain@wcu.edu

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