PERT Program

Tip of the Month: October 2003


A Grief of One's Own


Staff in long-term care are no strangers to loss and grief. Loss is commonly defined as the absence of a possession, role, or ability.1 Grief can be described as the individualized physical, emotional, and spiritual response to the experience of loss.1 Care providers in nursing homes readily recognize the grief experienced by many residents when they are first admitted to a facility.

In his PERT session on grief and bereavement, Mark Bonnema describes the kinds of losses residents experience that may result in grief, including the loss of:
Often, the move to a nursing home is precipitated by a significant loss, such as the loss of a spouse, or family caregiver. Thus, the resident may be dealing with multiple losses. Families also experience grief as they adjust to the physical move of their loved one, or prepare to lose a family member to progressive dementia or other chronic illnesses. The PERT Program curriculum emphasizes ways that staff can assist and accompany grieving persons, particularly those residents and families with whom we work.

But what about our own grief? Nurses and nursing assistants (NACs) also experience grief, particularly in those environments where death occurs frequently. How we respond to loss and the grieving process depends upon many factors. Our personality, previous experiences with death or loss, our culture, the availability of a support system, and current external stressors such as family or financial concerns will all influence our experience of grief.

Grief can affect nurses and NACs before, during, and after a resident’s death. Anticipatory grief can occur when staff members prepare to lose a resident. Grief then often continues after the actual death. In a study of oncology nurses, the term “chronic compounded grief” was used to describe the stress resulting from constant exposure to death and dying.3 The authors used this phrase to more accurately describe what laypersons often refer to as “burnout.” “Cumulative loss” has been defined as a succession of losses experienced by nurses and other caregivers who work with patients facing life-threatening illnesses.2 The terms cumulative loss or chronic compounded grief are used interchangeably to describe the experience that may occur when staff are unable to process the loss of one resident, before another one dies.

Unresolved grief can significantly affect staff’s ability to provide care and heal from loss. In an attempt to shield him- or-herself from the pain of losing another resident, the nurse or NAC may focus on providing only task-oriented physical care. Avoiding conversations with residents and family about emotional topics, or withdrawing or distancing from families and other staff can also be self-protective measures to avoid further feelings of hurt. As a result of these actions, residents or families may feel abandoned at a particularly vulnerable time. Skilled interpersonal interaction is necessary to provide symptom management and relief of suffering to residents at the end of life. When unresolved grief hinders staff’s ability to relate to residents, care is compromised. Therefore, addressing staff grief is important to ensuring quality care. Moreover, chronic grief may also negatively impact the care provider’s health and personal relationships.

There are many ways to provide staff with opportunities to experience and work through grief. Unfortunately, peer pressure and attitudes pervasive in health care may encourage staff not to “dwell on their loss.” If grief is neither recognized nor affirmed, nurses and NACs may be deprived of positive ways to cope with loss.3 As Matzo et al state, “building in support systems is not just a feel good idea, but imperative to the well being and functioning of staff.”2 (p.74) The following table lists some ideas that may assist staff to experience and work through their grief:


Strategies for Assisting Staff to Cope with Grief
Strategies Interventions
Resident Care
  • Invite staff to be part of a rotating vigil during the resident’s last hours, particularly if there is no family present. This may require juggling schedules, pulling in administrative staff to assist on the units, and utilizing volunteers.4
  • Create a mentoring system to ensure that staff who are less familiar with care at the time of death have a “buddy” to assist them.2
  • Utilize an agreed upon symbol, for example a cross or flower, on the resident’s door to acknowledge their last hours. This enables staff to come in and say their goodbyes.4
  • Allow 24 hours before filling the bed with a new resident. Place a flower or special quilt on the bed as a symbol of remembrance.
Memorials/Remembering
  • Create a memory station or remembrance box where the resident’s photo is displayed; locate it in an area where spontaneous memory sharing can occur.4
  • Have a card available for staff to sign expressing their condolences and goodbyes to family members. Mail 1–2 weeks after the death.4
  • Enable as many staff as possible to attend funeral services or memorials; again, this requires support of the administration that may need to provide coverage in staff’s absence.
  • Offer scheduled memorial services at the facility.
  • Encourage “remember when” sessions at staff meetings to share stories and anecdotes about individual residents. Encourage humor as well as sharing of tears or sadness.
  • Post “thank-yous” from family members. Verbally acknowledge the provision of good care.
Support Groups
  • For staff that have been particularly close to a resident and have the day off, call to notify them of the death. A quick phone call can spare the shock of coming into work and finding a special resident gone. (This policy should be discussed with all staff, as some may prefer not to be called at home.)
  • Encourage social services or spiritual care providers to specifically reach out to staff upon the death of a resident.
  • Set the stage for informal sharing among team members; for instance, if a particular staff person is feeling very emotional, allow for a 10-minute “tear break.” Provide a setting that is safe to express a range of emotions so that staff will not feel judged or shamed.
  • Be aware when staff withdraw from co-workers and residents. Approach the subject of grief and encourage more specific support such as counseling if needed.


Providing palliative care can be both challenging and rewarding. Nurses and nursing assistants need to recognize and face their own grief in order to provide excellent care at the end of life. When staff take time to grieve and seek support, they are able to “carry the lessons learned from those who have died forward into the care of those they have yet to meet.”1 (p.658)



References
  1. Ferrell B, Coyle N, eds. Textbook of palliative nursing. New York: Oxford University Press; 2001.
  2. Matzo ML, Sherman DW, Lo K, Egan KA, Grant M, Rhome A. Strategies for teaching loss, grief, and bereavement. Nurse Educ. 2003;28(2):71-76.
  3. Feldstein MA, Gemma PB. Oncology nurses and chronic compounded grief. Cancer Nurs. 1995;18(3):228-236.
  4. Tomsic K. Bedside vigils, remembrance boxes, sympathy card: practices that support families and staff. Innovations in End-of-Life Care [on-line journal]. 4-26-02. Available at: http://www2.edc.org/lastacts/archives/archivesMarch02/reflections.asp. Accessed 10/6, 2003.