Why are dominant suicidology approaches failing nurses? A call for a feminist critical suicidology perspective

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Abstract

In the UK, 90% of nurses are female, a figure replicated at the global level. A significant proportion are also from the global ethnic majority (NMC, 2023; ONS, 2019). Notably, the risk of suicide among female nurses is 23% higher compared to women in other occupational groups (NCISH, 2020). Despite this significant finding, our understanding of this phenomenon remains limited, in part due to how we interpret suicide in certain contexts. This has clear implications for potential solutions. Quantitative, retrospective paradigms using data from death registers have typically been employed to investigate suicides among healthcare professionals. This generates inferences that are based on individual-level data, for instance, individual health factors, coroners' verdicts, and limited contextual data. Critically, this overlooks key factors including demographic data not routinely collated on death registers (e.g. ethnicity); detailed occupational data (settings–community, acute, mental health settings); and relevant work contexts or events which contribute to distress or undermine resilience and may lead to feelings of hopelessness, despair or isolation. This results in a failure to investigate the potential impact of political, economic, social and cultural factors pertinent to nurses. Further, they ignore sociological theories that situate the roots of suicide as external to the individual. As such, alternative accounts and relevant contextual factors are overshadowed and potential solutions may therefore be overlooked. Dominant biomedical and psycho-centric approaches within suicide research typically focus on individuals' mental health status, inferring a causal relationship between diagnosis and suicidality. This is potentially divisive and problematic to individuals and societies. The pathologisation of individuals' symptoms may conceal contexts, working conditions and structural or systemic causes contributing to psychological distress, particularly those more likely to impact women and marginalized groups (Fullagar & O'Brien, 2015). Working through the COVID-19 pandemic magnified work-related injuries previously experienced by nurses, including moral distress, compassion fatigue, burnout, PTSD and suicidality (Maben et al., 2022). Evidence suggests that workplace factors contribute to psychological distress across the nursing community and include high workload compounded by low resources, poor work–life balance and workplace conflict and incivility (Maben et al., 2022). A recent report (NCISH, 2020) on suicide in female nurses in England evidence that, of nurses who were in contact with mental health services, 18% reported problems at work compared with 6% of women in other occupations. Urgent research is therefore required to investigate the nature of work-related events and their subsequent impact. Despite nursing being a female-majority profession, female nurses compared to male nurses are more likely to experience discrimination, bullying and harassment at work (RCN, 2022). They are also less likely to progress to senior roles and are paid less on average (Punshon et al., 2019). Female nurses are significantly more likely to experience gender-based violence inside the workplace and intimate partner violence, a known risk factor for suicide (Cavell Nurses Trust, 2019) outside the workplace. They are also more likely to hold multiple caring roles and responsibilities, including doing a ‘second shift’ of caring and domestic tasks requiring additional emotional labour. Further, they may experience perinatal mental health problems and adverse mental health menopausal symptoms. In the UK, as in many high-income countries, the nursing workforce includes marginalized communities from the global ethnic majority. These nurses experience the intersection of sexism and racism. They are disproportionately referred to the nursing regulator and are more likely to be the recipient of a complaint (West et al., 2017). Such experiences may be likely antecedents of trauma, psychological distress and suicidality yet rarely feature in narratives or research concerning nurse suicide. Given these injustices, an intersectional, de-colonialised approach is warranted. A critical suicidology perspective introduces the complex interplay of political, economic, socio-cultural and system-level contexts into the research paradigm. The enquiry is therefore focused beyond the individual and alternative interpretations of suicide are made possible (Fullagar & O'Brien, 2015). Framing nurse suicide within the contexts of social, environmental and economic challenges or historical injustices will help us understand the distress, inequality and injustice experienced by the female majority and ethnically diverse nursing workforce. Feminist methodology provides an opportunity to examine aspects of women's social lives and employment, previously excluded from the discourse and research on nurse suicide. It also maps an interconnected constellation of subjugation in women's lives, from oppressive social structures, violence, inequality, discrimination and marginalization to the production of knowledge. Feminism makes explicit the relationship between power relations, epistemology and the construction of knowledge, thus challenging dominant, often patriarchal, medical and individualized discourses (Wigginton & Lafrance, 2019). A Marxist-feminist lens additionally offers the potential to view employers as enabled to avoid responsibility for mitigating factors that impact the well-being of their female employees. As such, the dominance of medicalised, individualized approaches within suicide research may perpetuate a devalued societal position of nurse workers. To capture the range of experiences and contexts and to understand how they impact a diverse population of nurses, we advocate employing a qualitative, feminist critical suicidology approach, aiming to locate and illuminate existing gaps and silences in dominant paradigms (Fullagar & O'Brien, 2015). A feminist methodology aims to legitimize the historically unvoiced, unheard and unrepresented voices and experiences of women and therefore female nurses in the production of knowledge (Wigginton & Lafrance, 2019). This perspective can usefully inform workforce and suicide prevention policies, currently shaped by dominant voices and approaches in suicide research and focused on suicide among males (Fullagar & O'Brien, 2015). In continuing to individualize and medicalise contexts and experiences that impact nurses, potential solutions will continue to be overlooked in research and policy, leading to ineffective suicide prevention policies and practices. I confirm that all authors have made a substantive contribution and have agreed to the final submission. Ruth Riley: Conceptualization; Writing—original draft. Hilary Causer, Leanne Patrick, Rayna Rogowsky: Writing—original draft. None. The authors declare no conflicts of interest.

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