Why a feminist perspective?

By: Dr Sarah Gillborn

The necessity of using a feminist perspective to study suicidality among nurses.

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As Dr Ruth Riley notes, to understand suicidality among women nurses, we must investigate the political, social, and economic conditions that nurses work and live within. The most common ways of investigating suicidality tend to focus on women as distressed and ill individuals. This ignores the oppressive conditions that affect women’s lives. On the other hand, feminist approaches to research focus on the importance of political and structural conditions. Using this approach means that we can explore issues such as violence and discrimination, poor working conditions, race and gender inequalities and other issues that contribute to women nurses’ distress.

Most often, research methods focus on the personal at the expense of the political. Even in interview studies, which are often assumed to be more attuned to wider conditions, suicidality may be seen as being related to an inherent cognitive shortfall or mental illness. Using feminist methods guides researchers to take a wider view rather than be drawn toward the dominant, individualised approach that often takes hold.

We need methods, in nurse suicide research that are based on feminist understandings of the wider political, social, and economic conditions and systems that are relevant. Two such approaches are Foucauldian discourse analysis and feminist relational discourse analysis.

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Why study discourses?

Foucauldian discourse analysis draws on philosopher Michel Foucault’s definition of discourses as ‘regimes of truth’ that form and sustain specific power relations. Discourses are ‘ways of talking’ that create a set of ideas about people and phenomena. Using Foucauldian discourse analysis informed by feminist ideas helps us in three ways: it helps us to understand the different ways of speaking about particular ideas or topics to show how these ways of speaking produce and shape knowledge and truth; and reveals what purposes or interests these ideas serve.

For example, in my explanations above and in Dr Ruth Riley’s blog post, we explain how suicidality is often constructed as the result of individual deficits. Understanding suicidality in this way serves to pathologise individual nurses while leaving the contexts, such as violence, discrimination, and poor working conditions, unaddressed. In fact, it is likely to draw on stereotypes – often maintained by men in positions of power - of ‘mad women’ who are prone to hysteria and less likely to handle the usual stresses of work. This victim-blaming paints women’s distress as a disease and maintains the systems that oppress women.

It is, therefore, vital to understand how suicide among nurses is understood by the people who influence public and political thinking in relation to suicide. That way, we can examine who is served by these ideas, and whether they will lead to positive structural change or support the continuation of current mainstream and patriarchal power structures. We can also get a sense of the ideas and stories that are available to nurses themselves who may want to understand nurse suicide. Therefore, we can begin to understand whether suicidality is understood as a structural and political issue or as an indication that something is ‘wrong’ with women. This is important because it will have an impact not only on how nurses seek help, and on their comfort in speaking about this issue more broadly.

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Feminist approaches to discourse analysis

Feminist relational discourse analysis offers a more powerful and feminist approach to understanding how ideas around suicidality affect women nurses. First explained by Dr Lucy Thompson and colleagues , from a feminist point of view, Foucauldian discourse analysis can pose problems when seeking to understand individual voices and experiences. While Foucauldian discourse analysis is good at identifying and questioning the ideas that inform policy and public debate on feminist issues, the voices of individual women can be lost; that is, we must be careful not to lose the personal when drawing attention to the political.

Using feminist relational discourse analysis, we can understand the different ways people talk about things, including the main ideas and the alternative viewpoints they use. This approach helps us see the problems with common ideas about suicide, the various challenges women nurses face, and how they can resist these issues. It shows how nurses' experiences and views are shaped by both mainstream ideas and alternative perspectives, and how these ideas about suicide affect them.

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Why a feminist perspective?

A feminist perspective is vital for this topic because nurse suicide is a feminist issue. As Dr Ruth Riley highlighted, the suicide rate among women nurses is 23% higher than women in other occupational groups. 89% of nurses are women, and a quarter are from the global ethnic majority. Despite this, the majority of suicide research and policy does not address the topics of gender, race, sexism, and racism.

In April of this year, Unison union published a report revealing that one in 10 NHS health workers reported being subjected to unwanted sexual incidents at work. A further report from the charity BRAP and researchers at Middlesex University revealed that more than 70% of global majority staff who’d been trained in the UK, and 53% who’d been trained abroad, experienced racial discrimination at work. In both reports, this harassment was revealed to be rarely reported due to staff’s concerns about how they would be treated and their lack of confidence that anything would be done. Taken together, these reports reveal everyday environments where racist and sexist behaviours and attitudes are accepted as normal in the NHS. This undoubtably impacts women nurses; yet, these situations are overlooked when discussions and research about suicide focus only on individual women's mental health and ignore the environments they live and work in.

This is why a feminist perspective is necessary; It helps us to focus on the power imbalances and inequalities that harm nurses and then re-traumatise them through silence and inaction. This approach uses an intersectional, feminist perspective to understand the root causes of nurse suicide and supports real, meaningful changes in how we think about suicide and improve women's workplaces.

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If you are a nurse or health worker who is in need of support, we have a range of support links here.

Why is women’s distress classed as an illness?

By: Dr Ruth Riley, Anna Conolly, Hilary Causer

Women’s mental health

This blog explores why women’s distress is more likely to be seen as illness and what this means for women, and why this is relevant to women nurses. Women in high income countries are three times more likely to be diagnosed with depression and anxiety. For Black, lesbian and/or older women, these numbers are even higher. In the UK, one in five adults are prescribed antidepressants; and women are twice as likely to be prescribed them than men.

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Is the medicalisation of women’s distress a modern phenomenon?

Simply put, no. Historically, women’s bodies and minds have been seen and treated differently to men. Women are more likely to be institutionalized, in asylums and hospitals, receive psychosurgery, electroconvulsive therapy and psychotropic medication (e.g. antidepressants, anxiolytics). Such medical interventions can be harmful and come with side effects. Being sectioned, for example, is traumatic and stigmatising for individuals, and exacerbates any pre-existing distress. Medications come with side and/or withdrawal effects which include suicidal thoughts and feelings. To understand why this has happened, we need to understand why and how medical knowledge about mental illness is created and how it is enacted.

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The social construction of mental illness in the Western world

“Social constructionism” invites us to question or take a critical perspective towards taken-for-granted knowledge, including medical knowledge. Scientific knowledge, while often viewed as absolute fact, is still the result of social processes and open to interpretation. Sets of ideas, themes and arguments to explain or position or construct knowledge is known as “discourse”. It provides a way of viewing and understanding the world.

Western medicine is underpinned by the biomedical model which draws on ‘scientific’ models and discourses to cure patients through medications and/or surgery. There is an assumption that medical concepts such as depression and anxiety have an underlying pathology or problem, a chemical imbalance, for instance. The solution lies in ‘fixing’ or treating the underlying problem but this overlooks the root causes.  Let’s take a look at how distress and its causes are viewed in other cultures and what we can learn from framing the problem differently and more holistically.

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How is mental illness or distress constructed in other cultures

The construction of mental illness and distress varies significantly across cultures, shaped by beliefs, values, and socio-historical contexts, including colonial injustices.

Indigenous cultures, such as many Native American groups, often view mental and emotional distress within the context of the spiritual, natural, and ancestral worlds. The mind, body, spirit, and the environment are interconnected. Healing may involve rituals, spiritual ceremonies, and community-based practices to restore harmony.

Aboriginal and Torres Strait Islanders, for instance, view their wellbeing as interconnected to their land, culture, spirituality, ancestry, family and community. The contexts contributing to negative wellbeing include their colonial history and ongoing injustices and oppression linked to grief, loss, racism, discrimination and adversity. Preventing distress involves addressing spiritual, environmental, ideological, political, social, economic forms of oppressions and not the prescription of pills. The problem and the solutions are therefore located beyond the individual and not within.

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Women’s distress as a problem within

Scientific models and discourse have given the medical profession the power and control to define and treat illness and disease, including women’s distress. It does this by locating the problem within the woman and not on the root causes such as sexism, racism, violence against women, workplace injustices (gender-pay gap) and other forms of oppression and inequality.

Women are then expected to take responsibility for their distress whether through adherence to prescribed medications (e.g. antidepressants), having to attend counselling or therapy or expectations to be ‘more resilient’ and/or by being gaslighted. Frequently, women are expected to “put up and shut up” or made to feel that they are the problem. Women then internalise the consequences of oppression and injustices contributing to their distress or unhappiness.

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Why we need to take a critical feminist perspective on women’s distress

Feminist critics suggest that feelings of distress and unhappiness are understandable responses to the challenges that women face. Blaming these feelings on an internal problem, dismisses women's perspectives and experiences.

When we give centre-stage to women’s experiences and their voices, we are more likely to understand why they may be experiencing distress. A feminist perspective allows us to see how social structures, such as gender inequality, unpaid caring roles, and the emotional weight of caregiving, contribute to women’s emotional and psychological struggles. It also highlights how their distress is not a personal or individual issue, but one rooted in systemic and historical oppression. By acknowledging these factors, we can begin to challenge the pathologisation of women's emotions and instead advocate for changes that address the root causes of women’s suffering.

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Why is this relevant to nurses

The NHS is the largest employer of women and nurses in Europe. Nurses, in particular, are on the front line of healthcare. The NHS can be viewed as a microcosm of society, reflecting broader social structures, inequalities, and dynamics, such as those related to gender, race, and class. Thus, the NHS encapsulates the challenges faced by women in the workforce, such as the gender pay gap, work-life balance issues, and workplace discrimination. Women nurses experience these inequalities first-hand, with staff from the global majority reporting higher rates of discrimination, lower promotion rates, and fewer leadership opportunities.

The pressures nurses face in the NHS such as chronic understaffing and long and disruptive shift patterns intensify the stress of the emotional burden of caring for patients with complex needs with limited resources. The role of nurses in the NHS reflects traditional gender roles associated with caregiving and emotional labour, roles that are disproportionately occupied by women in both professional and personal contexts. Unpaid caregiving tasks often fall upon women, and nurses frequently deal with expectations of nurturing and providing emotional support on top of their clinical duties. Perhaps, it is unsurprising, therefore, that women nurses are experiencing higher rates of distress. Maybe we can learn from indigenous societies’, older than Western medicine, that the solutions lie beyond the individual.

We will continue elements of this blog which we’ve touched on in our next editions. In our November blog, Dr. Lucy Thompson will discuss violence against nurses and institutional trauma. In our December blog, Dr. Sarah Gillborn, talks in more detail about the power of discourse and its effects, particularly on women’s mental health.

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If you are a nurse or health worker who is in need of support, we have a range of support links here.

What feminism means to me

Welcome to the first blog of our series, ‘What feminism means to me’. We will be inviting a range of contributors to share their thoughts, ideas and experiences on this topic. A feminist ethos sits at the heart of our research and the ways that we work within our team and with our collaborators and participants. Using our blog to explore this question is one way that we are hoping to contribute to feminist narratives.

 Our first contributor is Leo Conolly..

I am a Year 10 student. I often think deeply about social issues and why the world is the way it is. I am a boy who lives alone with my mum and my two brothers, but I have always had girls as friends who I spend lots of time with. Growing up I have considered myself to be a role model for my two brothers. Because of this I am careful of how I behave because I want them to behave in a similar manner. I now go to a boys’ school, and this has made it even more important to me that women are treated respectfully. I think the world needs to be fairer, with the government putting laws into place to help women achieve equality. For example, lots of women, like my mum, are carers.  I know my mum had to give up work for a long time because of this and her life can sometimes be difficult. I think feminism is really useful because it helps people to think about the issues that might overly affect women, and it can help us to think about how to make things better.

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Last year, in History I learnt about the suffragettes and the actions of women such as Emily Davidson at the Epsom Derby. Through direct action the suffragettes were able to raise awareness of the issues they believed in so strongly which eventually led to women being given the vote. For me this shows the powerful effect that thinking about issues, then acting, can have. Having a more equal society, with equality between men and women will benefit everyone in the country. For example, making sure women get equal pay would make everyone richer! I know that feminism is about creating a fairer world for all, and I think everyone should be happy to get involved with that.

By Leo Conolly. September 2024.

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If you would like to write for us about your thoughts on feminism, you can get in touch here: info@nursesuicidestudy.com

Don’t give us a sticking plaster

by Dr Anna Conolly

About a month ago I was sitting in a packed cinema.

As the pre-film adverts played in front of me, I was distracted and I started to feel guilty about being there on a Sunday afternoon – was all my children’s school uniform ready for Monday morning or had I left some in the washing machine? Then, suddenly my attention was held by the large image of an ambulance, covered with bloody tissues, after treating a trauma, with a member of an ambulance crew, slightly removed, looking at the mess then walking away.

Still from 'Sicker than the patients' by Frontline19, 2024.

This was followed by similar scenarios such as family members on a hospital ward singing happy birthday to their father, supposedly a cancer patient, as a male member of staff watched or a nurse broke bad news to a couple in a side room. These scenarios were followed with individual shots of healthcare workers being overcome with emotion in various places, such as a nurse who broke down in a supermarket. All filmed as if taken by CCTV cameras with loud sound editing which captured the healthcare workers unsteady breathing, the film appeared very realistic and was completely effective in making you feel real empathy for healthcare workers.

I was pleased to see such a successful film had been made and was receiving widespread coverage when the jarring tag lines drifted onto the screen:

With over half suffering from poor mental health many NHS staff are sicker than the patients. Not that they would ever let you see it. Donate now so we can provide the therapy they urgently need.

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Sticking Plaster

I almost screamed No! at the cinema audience. The advert, made by Frontline 19, an organization who received backing from Boris Johnson to help healthcare workers during and after the pandemic, positioned mental health support, paid for by charitable donations from the public, as the solution for the healthcare workers mental health crisis in the UK.

I am a researcher, and I have been working on workforce wellbeing for the last 3 and half years. The images that the advert displayed did not surprise me, however, I was more than a little irritated by the messaging used at the end. Because the images shown in the advert were so emotive I was cross that such a powerful film could be used to support an agenda that only represents a ‘sticking plaster’ approach to providing support for healthcare workers in the UK. I believe that chronic underfunding has led to systemic and cultural failings within the NHS. It is the organisation that requires healing, in order for the workforce to have a healthy environment in which to do their jobs.

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Social Justice

Social justice has always provided the bedrock of the provision of healthcare in the UK. Founded in 1948 on the principle that healthcare services ‘are free for all at the point of delivery’ the NHS was, for decades, the envy of many countries. However, decades of little or no workforce planning, underfunding of the health service workforce, and massive staffing shortages have led to significant structural challenges.

Even before the pandemic, pressure in the health and care system was taking its toll on staff and was not sustainable. Reports described staff as running on empty and as the shock absorbers in a system lacking resources to meet rising demands. Excessively over-worked staff who suffer from mental distress and trauma due to not being able to provide the care they feel their patients are entitled to does not chime well with the social justice principles the NHS was founded upon.  

I would argue that the chronic underfunding has gone too far and sticking plasters are no good to those who work within the NHS. Our government must acknowledge the scale of investment and organisational culture changes that are needed to keep the NHS going and ensure the health of both our healthcare workers and patients.

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If you are a nurse or health worker who is in need of support, we have a range of support links here.

Why ‘only’ women nurses?

by Dr Hilary Causer

We have been asked why our research focuses solely on women nurses.

Firstly, let me clarify that when we talk about women in the context of our research, we are referring to anyone who identifies as a woman. This definition has been developed in collaboration with nurses who have experience of suicidality, and we will use it when recruiting nurse participants into our studies.

We made the decision to focus specifically on women nurses for a range of reasons:

1. In response to the statistics regarding suicide rates by women nurses

2. Because women’s and men’s experiences of being a nurse are different

3. Because suicide is a gendered experience and there is a notable lack of research that specifically explores women’s experiences.

4. Because historically, women’s experiences and distress are more likely to be understood as medical problems.

5. Solutions and interventions to address women’s distress and suicidality have been individualised. This suggests that women are seen as being responsible for their own problems, whereas the root cause may lie in the ways that society and the workplace are organised.

In this blog I will focus on the first three.

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Women nurses have a heightened rate of dying by suicide

This project came to fruition in response to the heightened rate of suicide among women nurses who have a 23% greater risk of dying by suicide than women in other professions. This statistic is echoed in other western countries such as Australia and the USA. However, male nurses, health care assistants, or midwives do not demonstrate a similarly heightened rate.

“women nurses have a 23% greater risk of dying by suicide than women in other professions”

Whilst the statistics tell us ‘what’ is happening, we don’t currently understand ‘why’ it is happening. Therefore, we are undertaking five distinct studies, using qualitative and mixed research methods, that focus on the experiences of women nurses. Our research findings will not only add to current knowledge, but also identify necessary changes to the working lives and environments of women nurses to address this longstanding anomaly.  

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Gendered experiences of being a nurse

Research tells us that there are distinct differences in the experience of being a nurse according to gender. Almost 90% of UK nurses are women, thus nursing is a female majority profession. Despite this, women nurses are less likely to progress to senior roles than male nurses and are paid less on average than male nurses.

They are also more likely than their male counterparts to experience discrimination, bullying, and harassment at work and are significantly more likely to experience gender-based violence inside the workplace and intimate partner violence, a known risk factor for suicide outside the workplace. Women health staff, including nurses, were also more likely to experience anxiety, depression, and sleep disorders after working through the Covid-19 pandemic. A recent report on suicide in female nurses in England states that of nurses who were in contact with mental health services 18% percent reported problems at work compared with 6% of women in other occupations.

“Almost 90% of UK nurses are women”

For some women nurses these gendered experiences occur at the intersection with other factors, which further complicate their experiences. For instance, 40% of the NHS workforce, and 60% in social care, are workers from the global majority, many of whom gained their nursing qualifications before migrating to work in the UK. Nurses who identify as Black are disproportionately referred to the nursing regulator.

It is clear, that while the experiences of male nurses are valid and important, they will not helpfully contribute toward growing our understanding of what is happening for women nurses.

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Gendered experiences of suicide and gendered suicide research

There are also gendered differences in suicidal experience. The most significant being that nearly three quarters of all people who die by suicide are men. Paradoxically, incidents of self-harm and suicidal thoughts and attempts are more frequent for women. The means by which people die by suicide also differ between men and women, as do the most likely age at which people die by suicide.

These differences have shaped the research agenda. Specifically, as most deaths by suicide are men, research has focused on seeking to understand risk factors and preventative factors that pertain to men. This has resulted in a dearth of research into women’s suicide in any cohort.

“suicide research has focussed on risk factors and preventative factors that pertain to men”

This is problematic as it means that certain contexts or life events which are specific to women remain unexplored. These include the care burden and the ‘second shift’; menstruation, pregnancy/infertility and menopause; dominance of patriarchal messaging and systems in society and workplaces; sexual and domestic violence and coercive control; violence in the workplace; and experiences of working in female majority professions.

Our research, by focusing on women nurses, will provide novel and valuable evidence that will grow our collective understanding about how suicide might be experienced differently for women.

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Our answer to your question

We have given a great deal of consideration to the design of the studies within this project, including consulting with nurses and our project stakeholders. Our answer to your question, ‘why only women nurses?’, is, because they face greater risk of dying by suicide, and have distinctly different experiences to men nurses, and because women’s experiences around suicide are currently under-researched and poorly understood.

To learn more about the approach that we will be taking in our research, and the feminist and critical arguments that underpin our approach, take a look at our previous blog post by our Principal Investigator Dr Ruth Riley.

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Supporting bereaved healthcare workers.

by Jules Lewis RGN MSc

My name is Jules Lewis and I am a Swan End of Life Care Lead Nurse at The Shrewsbury and Telford Hospital NHS Trust and PhD Student at Staffordshire University. I am also bereaved by suicide, my beautiful best friend Janet took her own life in February 2019 aged 47, a caring and compassionate friend and nurse for over 20 years.

I set up, with the support from our lead volunteer & our administrator, a staff bereavement support service at the hospital where I work. This intervention includes 1-2-1 support sessions, a safe space to be heard, with compassion, kindness, understanding, support and signposting to other support services as required.

Funding for this service was gained from Health Education England following a successful business case application. This money is used to backfill my hours to allow me to do this work for a few hours per week, and to cover the cost of room bookings to ensure we have a safe space to support staff. We are lucky enough to have a perfect venue on the hospital site but not in the main building. 

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Bereavement support cafes.

We also offer an ongoing peer support group, in the form of staff bereavement support cafes, these run every few months throughout the year.  This support is for all bereaved staff who work at the hospital, it is to support staff with personal bereavement or professional deaths (the death of a person they cared for). This can range from expected, unexpected, traumatic & bereaved by suicide. I am currently supporting several staff who have been bereaved by suicide.

“It has proved more valuable than I ever thought. Just to have the space and time to process and talk about my feelings following my bereavement I have found incredibly helpful.”

Bereavement café attendee    

At the December café each year we have a tree of hope where staff who attend the café and others can write a bereavement memory tag and place it on the tree in memory of their loved one. It remains in our conference centre for several weeks over the Christmas and New Year period.

“Having a safe, secure and confidential person to speak with has really helped me work through some of the difficulties of my recent bereavement.”

Bereavement café attendee

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The aim of my PhD pilot project is to evaluate the effect a bereavement intervention has on healthcare staff’s health and wellbeing.

In addition to our bereavement support we have also set up a walk and talk session, available to all staff, once a month at lunchtime. On a 20–30 minute walk we offer a listening ear and kindness. Signposting to further support as appropriate and required. We aim to encourage staff to get into nature and boost their health and wellbeing.

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Poetry.

I’d like to share two poems by my friend Brendon Feeley. We gift the first beautiful poem – ‘No Judgement Here’ to staff at our bereavement cafes.

Jules Lewis and Brendan Feeley

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No Judgement Here

This is a safe environment.

There is nothing for you to fear.

There is no need to worry.

There is no judgement here.

If you feel you need a friend,

reach out and you will find

this world can be incredible,

with people caring and kind.     

By Brendon Feeley

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This 2nd poem is one that I hope will give nurses and others the hope to get help and support for the future.

Not Today

When the darkness falls around you

and the light has all but gone,

it’s then that you dig deepest

for the strength to carry on.

With the biggest smile you can muster,

stare into the darkness and say,

I’ve bested darker days than this,

and you won’t win today. 

By Brendon Feeley

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Thank you for reading this blog, we hope it makes a difference at the hardest of times.

Best wishes,

Jules and Brendon.

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On the death of a colleague.

by Leah Hosie RMN

Working with individuals who experience suicidal ideation or intent is an integral aspect of mental health, and it is probable that all registered nurses working in this field will come across a person in this situation at some point, irrespective of the specific area in which they develop their career.

As an RMN working in a crisis resolution team, this was a common concern. Whether borne out of situational crisis, a deterioration in a mental health condition, or any other number of contributing factors, a thread to the narrative of these service users was a sense of feeling hopeless and overwhelmed. Initially, when doing my risk assessments and asking people what had got them to this point, this decision, I would tread carefully with my language, use euphemisms and metaphors and be so tentative as to be ineffectual.

But my nursing skills developed, and my confidence grew. Towards the end of my clinical career, I was able to say to a service user ‘Death comes to us all, why rush that process?’ and feel competent that I could manage the response, whatever it might be. I became skilled at navigating emotions and attuned to subtle shifts in body language, I know when to speak and when to remain silent. I took professional pride in my ability to assess risk and provide something of use to that person based on their need at that precise moment.

A colleague suicide.

And then I had a colleague and friend end her life. Suddenly, abruptly, without warning. She was a fellow mental health nurse, and we had worked together on the crisis team before parting ways when this service was disbanded. We stayed connected though, largely through messaging and social media. A few weeks before her death, we had spent an evening talking about her desire to explore other avenues of nursing, and perhaps consider health visiting.

For all my skill, for all my competence, for all my confidence – I never saw this coming. I had never envisioned it, never thought or felt for a second that she was at any risk. I was devastated. All my crisis team colleagues were… What could we have said? What could we have done? How did we not know?! What did we miss?

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Practice what we preach.

I do not understand why she didn’t reach out for help, but I wonder if it was because as mental health nurses, there is the expectation that we have our sh*t together so that we are able to help others. So, what then happens to those of us that are also struggling, overwhelmed or hopeless? How easy is it for us to practice what we preach? To reach out for support from the mental health professionals in our lives? Even if we work alongside them, rather than in a patient-provider capacity.

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Reach out.

I would like to be able to write this blog post as a nurse who has gone through this experience and be able to say here is what I would do differently… but I cannot. I do not know. I do not know what went wrong, and I don’t know how (or if) I could have helped. Heaven knows I have contemplated this for hours, but I am none the wiser.

So instead, I write this blog as a person who grieves and who may never get the answers. But as for you, dear reader, if you see something of yourself in my friend and colleague’s story, please, please, please, do not suffer alone. Do not suffer in silence. There are barriers thrown up in life and there can be days, weeks, months or longer when it is all just too much. But with love and support might come the option to break those barriers down, to master that which overwhelms us. Professionally, I have witnessed remarkable transformations when people in need engage with that support. And personally, I have been devastated by the effects when people do not.

Please ask for help if you are in need. Please.

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If you are experiencing distress or suicidal thoughts, please take a look at our support page.

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How our understanding of context informs our understanding of nurse suicide; and why we need change.

by Dr Ruth Riley

There are 30 million nurses world-wide and the NHS, the largest employer in Europe, employs more women than any other organisation. It is also the principal employer of nurses of whom, 89% are women and one in four are from the global ethnic majority. Yet, the majority of suicide research and policy is gender- and colour-blind.

The suicide rate among women nurses is 23% higher than women in other occupational groups.

These numbers are more than just statistics but speak of human stories of distress and suffering in women nurses across continents. Yet their voices, experiences, and stories are largely unaccounted for in dominant suicidology approaches and suicide prevention policies.

High suicide rates in women nurses have been documented for over 20 years in the UK and in other high-income countries too. Yet workplace practices, policies and research have failed to address the realities and contexts of nurses’ lives.

Current approaches and why they are failing women nurses

Deaths by suicide are often what we see or hear about but hidden beneath the surface are the diverse contexts that contribute to distress and suicidality. Our studies will argue that mainstream research approaches are not only gender- and colour-blind, but also focus on individual-level characteristics and the mental health of individual nurses and rely on methods which fail to account for wider contexts.

In North America, there is a trend which advocates screening for mental illness in nurses which may further label and individualise women’s (and others’) distress. This may compound stigma and increase shame, leading to the concealment and non-disclosure of feelings and distress and presenteeism, particularly in healthcare cultures which lack compassionate leadership and psychological safety.

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Why we need to revision our understanding of distress and suicidality in women nurses

In contrast to these approaches, the ambition of our project is to address these under-researched contexts using critical suicidology which questions the mainstream approaches that locate ‘the problem’ within the individual. Our position argues that by individualising distress, attention is distracted from the political, social and economic contexts and systems within which nurses work and live. Solutions aimed at addressing these wider contexts and systemic problems – which include deep-rooted violence against women, both inside and outside the workplace, discrimination, poor working conditions, and other workplace injustices, are overlooked.  Employing a feminist approach will enable us to better understand the patriarchal, social and structural systems which impact women nurses, nurses from the global majority, and othered communities. This is a timely project as we witness continued distress compounded by ongoing injustices, the pandemic and workforce and resource shortages.

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Joining the dots – politics, mental health, and women.

Individualising distress and labelling distressed women as unwell goes hand in hand with current – neoliberal – political mindsets. For example, we are expected to maintain ‘good’ mental health despite changes in political and organisational systems which contribute to and sustain inequality and injustices for women and othered communities.

Messages about self-care, help-seeking and individual resilience are all examples of the drive toward individual responsibility for mental wellbeing. Therefore, the unjust systems that oppress and disadvantage women and others are excused any responsibility.

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A feminist understanding of ‘mental illness’

Mainstream approaches to treating distress or ‘mental illness’ and the messages surrounding it are largely uncritical – relying on taken-for granted knowledge. Such approaches, as above, are underpinned by biological and medical models and are predominantly understood from a medical and male viewpoint. This poses a problem for women and for marginalized and minoritised communities.

In the UK and other high-income countries, women are three times more likely than men to be diagnosed with depression and anxiety.  This proportion increases when women are also Black, lesbian and/or older. Historically, women are more likely to be institutionalized, in asylums and hospitals, receive psychosurgery, electroconvulsive therapy and psychotropic medication (particularly antidepressants), which can be accompanied by harmful side and withdrawal effects, including suicidal thoughts.

Medicalizing women’s distress and focusing on the individual is a form of institutionalized gaslighting, as their distress symptoms are reduced to a diagnosis yet their voices, experiences and the contexts contributing to their suffering are overlooked. In feminist research, women participants often resisted a medicalized diagnosis of depression as they attributed the cause of their misery to structural factors, including poverty and violence.

We argue that focusing on the personal, overlooks the political, and fails to hold to account those systems, structures and cultures which contribute to and sustain social, colonial and economic injustices, gender-based violence or the impact of work cultures and working conditions on women. This includes women nurses and ethnically diverse nurses and will apply to women working in other occupations, including doctors.

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What is the ambition of this project?

This ground-breaking project has five different studies which will capture the diverse experiences and accounts of a range of women nurses and those from the global majority. We will also be capturing the views of the public, including friends and families of nurses to explore their understanding of what contributes to nurse distress and suicidality.  In providing space and opportunities for new perspectives, we will gain a more nuanced understanding of relevant contexts while providing a voice and platform for under-represented nurses.

The project aims to transform research approaches, and trends in suicidology and significantly shift our understanding of the contexts that contribute to distress and suicidality within the nursing population. This research may also have direct implications for women working in other occupational groups. We wish to launch a more nuanced approach and debate about the contexts that impact women inside and outside the workplace.

The project will lead to societal benefits too by increasing public understanding of these issues. We want to change hearts and minds so that suicide is no longer viewed as an individual problem and its contexts are more widely understood.

I am proud to be leading this ambitious project with a passionate and experienced team, who include international experts, award-winning creative artists and, crucially, nurses themselves, who have shaped the project and research priorities. Over the next 5+ years, we will be working with nurses, for nurses, to radically revision our understanding of distress and suicidality within the nursing community.

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We are grateful to the Wellcome Trust for funding this project.