- Define terminology related to end-of-life care, death, and dying; review theories of grief; the five stages of grief; and compare the different types of grief.
- Describe the signs and symptoms of grief and discuss the distinction between major depressive disorder and normal grieving.
- Explain how grief can manifest in nurses and identify the consequences of unhealthy grieving, including compassion fatigue and burnout.
- Identify personal and organizational strategies for helping nurses cope with grief and death and the impact of emotional resiliency on grieving.
- Briefly discuss grief during the COVID-19 pandemic.
Nurses assume various roles throughout a patient’s illness trajectory, whether it be an unexpected, acute illness necessitating care in the intensive care unit (ICU) or an extended period of chronic disease such as cancer. Regardless of the setting or precipitating event, nurses are routinely faced with death and dying in clinical practice and tasked with caring for patients and families at the end-of-life (EOL). Nurses provide comprehensive and compassionate care at the EOL, with responsibilities grounded in evidence-based nursing practice and clinical ethics. Nurses foster a therapeutic environment by managing the physical and psychosocial aspects of dying; alleviating pain and suffering; enhancing quality-of-life; addressing the patient’s psychological, emotional, and spiritual needs; and preserving dignity. Nursing care at the EOL eases the transition from aggressive, life-saving medical interventions to palliative care and hospice. Since the goal of care is no longer to restore health and well-being, nurses shift their energy to focus on satisfying complex needs throughout the dying process (American Nurses Association [ANA], 2016; Lowey, 2015). Nursing care provided during this poignant period often incites intimate nurse-patient-family relationships. Strong emotional bonds and attachment can develop for the patient, family, and the nurse, which can ultimately foster a positive death experience for the patient and their loved ones. While nurses can derive a sense of satisfaction and fulfillment from these connections, the death of a patient can also leave a profound and painful impact. Some nurses may experience overwhelming emotions, such as heartache, despair, and grief. Without the proper skill set, training, or support system in place, the nurse’s emotional, psychological, and physical health and welfare may become compromised. Nurses need to maintain emotional resiliency to continue to provide high-quality and compassionate care to patients. This module will explore the multifaceted aspects of grief following the death of a patient, the complex emotions that may arise during the bereavement period, and strategies to help nurses effectively recognize and cope with their feelings (Lowey, 2015; Yarbro et al., 2018).
The National Institute on Aging (NIA, 2017) defines EOL care as the support and medical care given during the time surrounding death. The term embodies the delivery of care within four domains: physical comfort, mental and emotional needs, spiritual issues, and practical tasks. The ultimate goal of EOL care is to manage symptoms and control pain so that the patient is as comfortable as possible throughout the dying process (NIA, 2017). The World Health Organization (WHO, n.d.) defines palliative care as “an approach that improves the quality-of-life of patients and their families facing the problems associated with a life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” Palliative care expands across the continuum of illness and neither hastens nor prolongs death; instead, it helps patients achieve the highest quality of life and live with their illness as long as possible (Yarbro et al., 2018). The term supportive care is often used interchangeably with palliative care, yet it has a crucial distinction; supportive care is treatment-focused and describes interventions delivered to patients receiving active treatment for illness. It refers to the measures taken to support the patient undergoing active therapy, such as the need for blood product support or anti-emetics in patients receiving chemotherapy. Supportive care typically has an endpoint, generally before the transition to hospice, at which time curative therapies and life-prolonging interventions are discontinued, and comfort becomes the primary objective. Hospice care is the most intensive, refined form of palliative care implemented only at the EOL, reserved for terminally ill patients with a life expectancy of six months or less. Hospice acknowledges that attempts to slow down the disease progression have failed, and that time is limited. Death is the expected outcome of hospice, and the preeminent goals include enhancing quality-of-life, aiding in comfort, and alleviating suffering for patients and their families (Yarbro et al., 2018).
According to the National Cancer Institute (NCI, 2020), bereavement is the state of having experienced a significant loss, or the objective experience following the death of a loved one. It is a period characterized by grief and mourning and is defined by Mental Health America (MHA, n.d.) as “to be deprived by death.” Grief is a person’s natural, internal, emotional response to the loss of something or someone that was valued. All people will experience grief and loss at some point in their lives, and the loss may be actual or perceived (Oates et al., 2019). It is the collection of thoughts, feelings, and emotions that occur when someone dies and includes physical symptoms associated with loss. The NCI (2020) defines grief as “the primarily emotional/affective process of reacting to the loss of a loved one through death,” whereas mourning is the external or public expression of grief. Prime examples of mourning include preparing for a funeral, wearing black clothing, or sharing memories about the person who has died. Mourning and grief overlap in many ways, as they are primarily interconnected, and both influenced by beliefs, morals, values, religious practices, and culture. The primary distinction between them is premised on the internal versus external nature of the processes. Figure 1 depicts these concepts as they apply across the trajectory of illness (NCI, 2020).
Theories of Grief
Sigmund Freud proposed the earliest theory of grief in his 1917 publication, Mourning and Melancholia. Freud’s theory is premised on the concepts of attachment, specifically breaking the bonds that attached the survivor to the deceased (Freud, 1917). His work centered on ceasing ties with those who have died, acclimating to a new sphere of normalcy without the deceased, and building new relationships and experiences (Hamilton, 2016). In 1969, Elizabeth Kübler-Ross proposed the ‘stage theory’ of grief with the publication of her book, On Death and Dying. This book represented the culmination of hundreds of interviews with dying patients through which she cultivated the theory that there are five stages to the process of death and dying; denial, anger, bargaining, depression, and acceptance. Frequently referred to as DABDA, Kübler-Ross’ model has had a profound impact on the world and is among the most well-known and commonly taught systems for understanding the grieving process. Although it received criticism for originally being proposed as a linear model, the concepts have since been adapted and modified to allow for an enhanced perspective in which the stages are not strictly linear. Instead, the emotional states and adaptive mechanisms associated with the five stages of grief occur in a variety of patterns. Some people will not go through each stage, whereas others may repeat stages. There is often overlap between the stages, as they are not isolated events for the vast majority of people. Figure 2 provides further insight into the underlying emotions and concepts associated with each stage (Elizabeth Kübler-Ross Foundation [EKR Foundation], n.d.).
Signs of Grief
The signs and symptoms of grief vary widely interpersonally, as well as intrapersonally. In addition to those highlighted in Figure 2, grief can manifest across a spectrum of emotions, feelings, physical sensations, and behaviors. People who are grieving experience sadness and sorrow commonly, which may or may not be expressed by crying. Feelings of disbelief, helplessness, numbness, and shock are common. These feelings primarily serve as defense mechanisms to safeguard the bereaved from feeling overwhelmed by the pain of the loss. Guilt is common and may be related to survivor’s guilt, unfinished business, or grounded in irrational thoughts that the death could have somehow been prevented. Some people may feel emotionally isolated and detached from others, whereas others may intentionally detach from others to protect themselves from being hurt by the loss of another person. The most common physical manifestations of grief include fatigue, exhaustion, insomnia, headaches, joint pain, dry mouth, muscle aches, and gastrointestinal ulcers. Anxiety is one of the most common emotions experienced following the death of a loved one and is often accompanied by a plethora of symptoms, such as nausea, anorexia, chest tightness, irritability, and restlessness. Cognitive manifestations can include excessive worry, fear, feelings of impending doom, an inability to concentrate, and a sense of confusion. People may become preoccupied with the deceased, and some describe hallucinations. Behavioral symptoms can involve withdrawal in the form of emotional or physical detachment from others. Performance at work or school may become impaired, and the bereaved may avoid any setting, situation, or circumstance that reminds them of the deceased (NCI, 2020; Worden, 2018).
Types of Grief
There are several types of grief responses; some are considered normal and indicative of healthy grieving, whereas others suggest maladaptive coping with loss. The most common types of grief are described in this section.
Normal (uncomplicated) Grief
Normal grief is considered the most desirable and universal reaction to loss. It often includes a variety of signs and symptoms from the physical, emotional, cognitive, and/or behavioral domains of loss. Normal grieving generally centers on the gradual movement toward acceptance of the loss, as the bereaved eventually adjust to the loss and move forward with life. While there is no finite period of time that one is expected to navigate through the stages of grief, there is a gradual movement toward growth and healing in a normal grief experience (Oates et al., 2019). The duration of uncomplicated grief varies from person to person and is dependent on individual factors related to the bereaved and their relationship with the deceased (Lowey, 2015). Normal grieving occurs in 50 to 85% of people following a significant loss (NCI, 2020). Since the grieving process is unique to each individual and shares several of the same clinical features as depression, the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines the specific aspects of normal grieving in direct comparison to the clinical features of major depressive disorder (MDD), which are listed in Table 1. To protect against an inappropriate diagnosis of a mental disorder, the DSM-5 advises against diagnosing bereaved persons with MDD within the first two months following the death of a loved one (American Psychiatric Association [APA], 2013).
Anticipatory grief is the expectation of the death of a loved one and can start at the time of diagnosis and continue until the person dies. Anticipatory grief includes many of the same symptoms of normal grieving following death, but the distinction is that the patient is still alive and present when the grieving begins. It is commonly experienced by family members of loved ones with dementia, who grieve while the patient is alive due to the loss of memory and cognition. Dying patients can also experience anticipatory grief, foreseeing the loss of function, independence, or future absence from major live events, such as the marriage of their children or the birth of their grandchildren. This can be highly distressing to patients and accompanied by anxiety, fear, and heightened levels of perceived pain (Lowey, 2015). Not all patients with a terminal illness will experience anticipatory grief. According to the NCI (2020), approximately 25% of patients with incurable cancer endure anticipatory grief. Anticipatory grief is more likely to occur in people with dependent relationships, limited social support, lower levels of education, neuroticism, and those facing spiritual crises. Conversely, anticipatory grief is less likely to occur when death is accepted by the patient and the patient’s social network. Research has demonstrated that anticipatory grief may serve a vital and beneficial purpose for families and loved ones. It has been shown to reduce the negative impact of the bereavement period after death; patients and families who experience anticipatory grief and are able to accept death as an impending event endure less anxiety and depression and reacclimate to life following death with less difficulty (Lowey, 2015; NCI, 2020).
Complicated grief is exactly as it sounds: more complex and challenging to navigate and potentially requiring professional help to overcome depending on its severity. The feelings of loss are debilitating and do not improve over time, as expected with normal grief. Instead, the bereaved person has significant trouble recovering from the loss and resuming their life (Oates et al., 2019). Complicated grief is often characterized by anger and bitterness, recurrent painful emotions, and an inability to face death as a reality. The bereaved are often preoccupied with thoughts of the deceased, unable to focus on anything other than the loss, experience distressing or intrusive thoughts related to the death, and an intense yearning and longing for the deceased. The bereaved may lose the meaning associated with their life and their sense of purpose, making it difficult to carry out normal daily activities. Complicated grief consists of four major subtypes or patterns, as outlined in Table 2 (Oates et al., 2019).
People at higher risk for complicated grief include those who have endured repeated loss or deaths that are sudden or traumatic, such as fatal accidents, homicide, or suicide (Lowey, 2015). Additional risk factors for complicated grief include a lack of social support, survivors’ age younger than 60, lower-income, history of depression, and the presence of concurrent life stressors (NCI, 2020). According to Li and colleagues (2018), specific types of relationship losses are also associated with a higher risk for complicated grief; the loss of a first-degree relative, such as a child or spouse, increases this risk. Losing a loved one with whom the bereaved has unfinished emotional ties, such as in cases of infidelity, betrayal, or divorce, is also associated with complicated grief (Li et al., 2018).
Unresolved grief occurs as a result of failure to move through the stages of grief and come to terms with the loss. Many theorists consider unresolved grief to be a component of complicated grief, as it shares many similar features to those described above. Unresolved grief lasts much longer than normal grief, does not improve with time, and interferes with the ability to function in daily life. It is usually associated with a lack of formal closure, such as if the loved one’s body was never found or laid to rest, or due to multiple or concurrent losses, such as the loss of several family members in a fatal accident. Bylund-Grenklo and colleagues (2016) explored the consequences of unresolved grief by conducting a nationwide population-based study of youth who lost a parent to cancer during their teenage years. They discovered that those with unresolved grief endure significantly more depressive symptoms, negative intrusive thoughts, fatigue, and sleep disturbances (Bylund-Grenklo et al., 2016).
Disenfranchised grief is also referred to as hidden grief, as it describes a loss that is not validated, openly acknowledged, publicly mourned, or socially supported (Luchterland, 2019). This type of grief commonly occurs in people who have lost loved ones to stigmatized illnesses such as AIDS, mental health disorders, or through socially unacceptable or controversial modalities such as abortion or suicide. Disenfranchised grief can occur with the death of a partner in an unrecognized relationship, such as those in a same-sex relationship who have not yet revealed their sexual preference to their family and friends. It can also occur with miscarriage, stillbirth, the loss of a pet, or a previously severed relationship, such as with the death of an ex-spouse (Lowey, 2015).
Nursing Grief and Loss
The nurse is a dedicated caregiver who is trained to provide physical, emotional, and psychological care to the patient and family. Nurses care for patients through all stages of their illness and treatment, which ultimately leads to the restoration of health or death of the patient. When death is a possibility, nurses strive to empathetically help patients and families come to terms with the impact of their illness, discuss wishes, set realistic goals of care, and make appropriate EOL decisions (ANA, 2016). For nurses, each connection that is formed during this period will be accompanied by a subsequent loss once the patient dies. The toll and impact of this loss on the nurse can vary tremendously and is primarily grounded in the nurse’s unique perspectives on death, beliefs, values, prior experiences with death, as well as several nursing-related factors. Some of the most prominent nursing-related factors that contribute to the grief response in nurses include the clinical practice subspecialty, the amount of exposure to patient death and dying in the workplace, the perceived comfort and skillset providing care for patients and communicating with families at the EOL, and the manner in which the death ensues. Oncology and hospice nurses are exposed to death and dying on a much more frequent basis than nurses practicing in labor and delivery or maternity specialties. Therefore, experienced oncology nurses are often at greater ease in communicating with patients and families about EOL care, advanced directives, and managing expectations surrounding the dying process. ICU nurses are exposed to death in a manner that is dramatically different from those nurses practicing in oncology or hospice settings as death may ensue rapidly and without notice. Families may be unprepared, and death is often more traumatic if the goals of care are not discussed ahead of time. Further, evidence demonstrates that the details surrounding the death experience (i.e., traumatic with several life-prolonging interventions versus an expected death with comfort care measures) can directly impact the nurse’s emotional response and subsequent grieving process (Al-Majid et al., 2018).
How Grief Can Manifest in Nurses
Regardless of the practice setting, when a patient dies, the nurse may experience overwhelming emotion and grief; however, it is often ignored and suppressed. In fact, unresolved or disenfranchised grief is very common among nurses, as they usually do not have the time or capacity to mourn the loss of a patient prior to moving on to care for the next patient. Research has demonstrated that nurses consciously and subconsciously develop strategies to avoid grieving the death of a patient, allowing them to continue providing supportive nursing care to other patients (Tranter et al., 2016). Nurses often continue working despite their grief as they continue to serve as the support system for bereaved families in the immediate post-death period. Suppressing feelings associated with the death of a patient can inflict a heavy burden that can accumulate over time. In addition to disallowing themselves time to grieve, nurses often deny themselves compassion. They are hesitant to seek help due to the misguided understanding that a good nurse is one that remains tough and develops “thick skin.” Eventually, the compilation and burden of unresolved grief can manifest in a complex array of emotional, cognitive, psychological, and physical symptoms. In addition to the symptoms described earlier, nurses may experience intense physical and emotional exhaustion, high moral distress, lack of concentration, unhappiness, depersonalization, burnout, and compassion fatigue (Boerner et al., 2017; Yilmaz, 2017).
Compassion fatigue is a broadly defined concept that is well-cited in the field of nursing, as up to 40% of nurses will experience it at some point in their careers. Compassion fatigue is characterized by the physical, emotional, and spiritual exhaustion and distress that results from caring for patients and witnessing recurrent human suffering and death. It can manifest as a plethora of physical and psychological health ailments and induce interpersonal and psychosocial problems. Compassion fatigue is commonly associated with an inability to provide compassionate care or the depersonalization of care. This not only leads to a decline in the quality of patient care, but also job dissatisfaction, decreased morale, and burnout. Continued unaddressed emotional distress and grief can lead to decreased productivity in the workplace through increased absenteeism and increased staff turnover; this has a ripple effect on the remaining staff who need to absorb the impact of fewer nurses. Further, these consequences subsequently fuel a rise in healthcare costs to the institution and society and contribute to the nursing shortage (Fallek et al., 2019; Houck, 2014; Perregrini, 2019; Schulz, 2017).
Gibson and colleagues (2018) determined that among nurses providing EOL care to infants in the neonatal ICU (NICU), avoidance and attempts to rationalize the death were identified as the most common ineffective coping strategies. Some nurses used compartmentalization to purposefully ignore their emotional distress to meet the family’s needs. However, the inability to reflect on personal grief and loss signifies ineffective navigation through the emotional stages of grief, which is necessary to provide optimal care to dying patients over time. These nurses endure higher levels of stress, failure, and moral distress during their careers (Gibson et al., 2018). Moral distress encompasses the anxiety, tension, and behaviors that result from the repeated loss, specifically in response to personal beliefs and values that conflict with the circumstances surrounding the patient’s care. Ethical issues at the EOL are a significant source of moral distress among nurses; this includes the continued delivery of aggressive interventions to dying patients despite minimal or no clinical benefit as well as decisions to withdraw care. These responsibilities can heighten stress and trigger feelings of powerlessness, hopelessness, and vulnerability (Boerner et al., 2017; Lewis, 2017). For more information on this topic, please refer to the NursingCE course entitled Ethical Issues at the End of Life.
Emotionally exhausted caregivers may experience symptoms similar to a post-traumatic stress disorder, such as recurrent recollections, distressing dreams, and anxiety. Unresolved grief in nurses is associated with reduced cognitive ability, medication errors, and impaired clinical judgment. Feelings of isolation, anger, and guilt can develop, in addition to a loss of self-worth and purpose (Fallek et al., 2019). Some additional signs of declining physical and mental health may include behavioral changes and mood swings. These may be observed by peers or by patients, communicated through complaints and dissatisfaction with the care they received. Nurses may appear lethargic, become disinterested in patient care, demonstrate a decreased response time to patient needs, or neglect certain patient care responsibilities. They may become more vocal in their job dissatisfaction, complain about patient assignments, or disengage in unit-based activities and committees. These changes can also affect one’s personal life as acknowledged by family and friends, and present as increased conflict, arguing, and irritability with close contacts, or alternatively by a disinterest, withdrawal, or not spending time with loved ones. Dietary and exercise patterns may change, such as a lack of desire to exercise, weight gain, and overall neglect of personal health. In the most extreme cases, nurses may develop addictive behaviors, such as diverting or abusing drugs or alcohol (Perregrini, 2019).
The nursing environment, expectations surrounding death, and the type of death also contribute to the severity of the nurse’s grief. Several sources cite that it has been perceived as taboo to grieve the loss of a patient in an ICU setting due to the relatively short duration of these caregiving relationships. However, when patient outcomes are less than expected, it can lead to a loss of self-image or professional identity for the nurse (Al-Majid et al., 2018). There is an abundance of literature dedicated to grieving patient loss among dialysis and oncology nurses, who regularly care for patients over weeks, months, or even years. Over time, caring relationships are fostered by nurses, generating strong emotional bonds and attachment between the nurse and the patient and family. Ultimately, this can lead to the death of the patient feeling like a personal loss to the nurse. Repeated encounters with patients who are suffering and dying can make grieving more complex and remind nurses of their own mortality or the mortality of their loved ones (Luchterland, 2019).
Grieving Bad Deaths
The term good death emerged in the US in the 1960s and was primarily used as a synonym for euthanasia, where life was deliberately put to an end. Today, nurses and other direct healthcare professionals view death as good when it is aided by physical comfort, emotional and spiritual well-being, and centered on respect and dignity. The patient and family are prepared for the approaching death and perceive their needs as met. The patient is surrounded by loved ones in a peaceful environment and receives interventions in accordance with their personal wishes (Gawande, 2014). Conversely, bad deaths are characterized by physical suffering, social isolation, psychological and emotional anguish, and care that may be discordant with the patient’s and family’s preferences. Bad deaths are more difficult to grieve, as they destroy the expectation and vision of an ideal and peaceful death. Bad deaths can preclude loved ones from having meaningful conversations, resolving unfinished business, or receiving closure. Nurses who witness bad deaths observe human suffering and pain on disturbing levels; they may internalize these traumatic experiences, fueling their personal fears of death, dying, and suffering (Carr et al., 2020).
Strategies for Coping with Death and Grief
Unaddressed grief has serious consequences and is more complex for nurses who lack the proper skill set, training, knowledge, attitudes, and support system to facilitate healthy coping. Nurses who lack the coping skills to effectively manage patient death may be inadequate in supporting dying patients and their family members. Nurses who recognize and confront their own feelings and reactions to death are able to develop healthier coping skills and provide higher quality care and support to their patients (Zheng et al., 2018). Nurses who allow themselves to go through the grieving process are healthier overall and lead more fulfilling lives and careers. Alternatively, those who do not allow themselves to grieve eventually struggle with sustaining satisfying careers and positive relationships. They also tend to become more distant and are more reluctant to get close to their patients (Houck, 2014; Letvak, 2014).
A critical step in preventing the potential negative consequences of unresolved grief is recognition (Houck, 2014). It is important for nurses to take the time to acknowledge each patient’s death. By developing insight into and awareness of their personal feelings surrounding death, nurses are better positioned to make judgments about navigating through grief more positively. Nurses are encouraged to take time to acquire a heightened awareness and understanding of their personal beliefs and values surrounding death, as well as their preexisting coping strategies, both the good and the bad. These mindfulness activities can help nurses develop stronger coping skills and ensure personal beliefs do not negatively impact or influence patient care. The fundamental aspects of coping with patient death include engaging in self-care, maintaining a work-life balance, enhancing communication skills, developing a social support network, and building emotional resiliency. Ideally, this should begin in nursing school so that the new graduate nurse is already prepared and equipped with strategies to preserve their own health and well-being prior to entering the workplace (Houck, 2014).
Self-care is a core value of holistic nursing and is a proactive and personalized approach to foster well-being. It refers to any activity that one engages in to deliberately promote overall health. Nurses who care for themselves grieve better, endure significantly fewer negative consequences of grief, and have an enhanced capacity to provide compassionate care to patients and families. It is important for nurses to recognize that effective self-care is a continually evolving work-in-progress that should remain a priority in both personal and professional environments (Mills et al., 2018). There are countless ways nurses can engage in self-care, but some of the most well-cited strategies include the following:
- Take breaks and time to disconnect periodically, especially during long shifts;
- Engage in healthy lifestyle choices and behaviors, including adequate sleep, rest, hydration, exercise, and healthy eating habits;
- Identify ways to rejuvenate well-being, such as through music, yoga, relaxation therapies (mindfulness, meditation, reiki, hot bath, massage);
- Engage in enjoyable activities as desired (reading, gardening, socializing, etc.);
- Seeking support from colleagues, friends, or loved ones;
- Spiritual or religious practices such as praying, attending religious services, or retreats;
- Develop an appropriate work-life balance by establishing and maintaining boundaries within and outside of the workplace:
- Do not neglect personal life;
- Allow space for non-nursing activities;
- Take dedicated time away from work;
- Shed the professional role at the conclusion of the workday;
- Build and maintain positive and healthy interpersonal relationships within the professional environment and personal life;
- Manage personal life stressors (Houck, 2014; Gibson et al., 2018; Mills et al., 2018; Perregrini, 2019; Phillips & Welcer, 2017).
Communication and Social Support
It is important for nurses to identify social support networks and lean on them when needed. Effective communication skills and social support are critical to fostering healthy grieving. Communication cultivates robust connections within the team. Adapting a workplace environment of “share and care,” with regular debriefing, grief counseling sessions, and support from supervisors and colleagues, is a valuable grieving strategy. Nurses who have access to supportive environments to effectively debrief following an arduous clinical experience are better positioned to maintain health and professionalism and are less likely to endure compassion fatigue. Bereavement literature consistently demonstrates that support and understanding from fellow nurse coworkers is a key way of effectively coping with loss. Debriefing with nursing colleagues following a patient’s death is one of the most effective tactics for processing and getting through difficult experiences. Informal debriefing sessions are preferred over formalized ones, as they produce a higher level of intimacy among colleagues who are faced with similar situations. These informal debriefing sessions allow for the provision of mutual support between colleagues, creating a safe environment for processing painful emotions and facilitating open discussion of the distressing events surrounding the loss. These sessions have been shown to foster emotional growth and aptitude among nurses. Informal debriefing with coworkers is preferred over support from family and loved ones. Nurses perceive debriefing with coworkers as more validating, effective, and cathartic than support received from significant others or spouses. Many feel their loved ones often cannot fully comprehend or understand their experiences, and therefore are unable to provide sufficient acknowledgment or validation of their loss (Barbour, 2016; Gibson et al., 2018). In addition, some nurses find it therapeutic to grieve with the family, either through crying, prayer, or by attending the funeral or memorial services (Houck, 2014; Lewis, 2017).
At the core of coping with death and grief is the concept of emotional resiliency, which is an important protective factor against compassion fatigue, emotional exhaustion, burnout, and disenfranchised grief in nurses. Resilience is defined as an individual’s ability to overcome or adapt to highly difficult circumstances in a manner that preserves health, well-being, and fosters personal growth. It refers to the individual’s capacity to respond to the pressure and demands of daily life and is a survival skill (Yilmaz, 2017). Some people are innately more resilient than others, and some develop resiliency over time through hardship and life experience. By maintaining emotional resiliency, nurses are better equipped to provide the best care for themselves and others experiencing grief (Oates et al., 2019). Rushton and colleagues (2015) determined that positive social relationships, hope, optimism, spirituality, and having a resilient role-model had a positive impact on nurses’ resilience level. Further, moral distress serves as a significant predictor of nursing burnout, as there is a strong association between burnout and those with low levels of resilience. A higher level of resiliency protects nurses from emotional exhaustion, is associated with increased hope, reduced stress, and contributes to heightened personal accomplishment. Correspondingly, nurses with a low resilience level experience more compassion fatigue and job dissatisfaction (Rushton et al., 2015).
According to Yilmaz (2017), self-care factors such as work-life balance, control, maintaining hope, a sense of professional identity, and perceived emotional support contribute to nurses’ resilience. Higher resilience levels are linked to enhanced self-efficacy, coping, and competence. The ability to cope effectively with pressure, trauma, and uncertainty is premised on underlying behaviors, thoughts, and actions. Many strategies that contribute to increasing emotional resiliency are also strongly grounded in the principles of self-care. Some of the most effective ways to build emotional resiliency include the following:
- Cognitive restructuring centered on generating optimism and positive attitudes;
- Psychotherapy to resolve underlying anxieties, fears, or unresolved issues;
- Journaling or blogging;
- Exercise, yoga, meditation or mindfulness;
- Spirituality and religious beliefs;
- Shift mental focus towards the things that are within the nurse’s locus of control, and away from the things that are not;
- Improve self-confidence, as a person and as a nurse;
- Lean on social networks for support (colleagues, spouse, family, friends);
- Engage in open communication in the workplace and within the nurse’s personal life to maintain more fulfilling relationships;
- Anything that promotes or facilitates the development of inner strength that can be used to maintain health and well-being (Yilmaz, 2017).
Although nurses need to take responsibility for developing effective personal strategies to manage grief and facilitate successful coping and emotional resiliency, organizational support is also an integral element to helping nurses cope with loss (Schulz, 2017). Unfortunately, loss and bereavement remain insufficiently addressed across healthcare settings. A review of the literature reveals a lack of emotional support and resources consistently available to nurses when patients die, even in fields such as oncology, where death is commonplace. Lack of nurse manager support with regards to acknowledging and dealing with patient loss, grief, and bereavement is a recurrent theme across the literature (Gibson et al., 2018). Hospital administrators and nurse leaders are fundamental to the early identification of nurses at risk for compassion fatigue and complicated grief. The development and implementation of bereavement programs specifically designed for nurses can provide the time, environment, and skills training to help nurses channel emotions surrounding patient death in a healthier manner. By generating a supportive environment and providing education on how to recognize and properly manage personal bereavement, leaders can reduce burnout, turnover, compassion fatigue, and enhance job satisfaction (Perregrini, 2019). Strategies proposed in the literature include the following:
- Monthly grief rounds;
- Facilitated discussion groups, offering outlets for sharing emotional expressions, remembrance ceremonies, debriefings, retreats, professional counseling, and pastoral care services;
- Staff training through a bereavement care service or other programs, providing education and training to develop behaviors that aid in coping, effective communication, and healthy ways of working through grief and loss.;
- Group processing through writing, storytelling, journaling, memory boards, or books;
- Skills training to build resilience, compassion, and effective self-care practices;
- Interventions centered on creating more a supportive work environment, ensuring adequate nursing breaks and time off, and adjusting patient care assignments (Boerner et al., 2017; Fallek et al., 2019; Houck, 2014; Perregrini, 2019; Phillips & Welcer, 2017; Schulz, 2017).
Managing Grief During the COVID-19 Pandemic
Research demonstrates that society as a whole is experiencing grief in response to the novel coronavirus (COVID-19) pandemic. According to Carr and colleagues (2020), COVID-19 personifies the earlier described concept of bad death. The lack of understanding of the pathophysiology of the virus and inadequate interventions has led to tremendous patient suffering at the EOL, coupled with the inability of the family to be present at the bedside to provide support and comfort to the dying. According to the Centers for Disease Control and Prevention (CDC, 2020), approximately 75% of COVID-related deaths take place in hospitals or nursing homes, despite survey results that more than three-quarters of older adults prefer to die at home. The impact of COVID-19 has been tremendous, inducing multiple losses on a daily basis: loss of human lives, loss of financial security, loss of autonomy to move freely in the world, and a loss of security and safety. There is the perpetual fear, anxiety, and anticipation surrounding the spread of the virus, inflicting anticipatory grief on individuals, communities, and healthcare professionals who worry about loved ones being affected by the virus (Wallace et al., 2020).
COVID-19 has been associated with high moral distress and traumatic stress among nurses and other healthcare professionals. The pandemic has created a scenario in which the pain of loss is amplified by concurrent and uncontrollable life stressors of social isolation and financial loss. This distress associated with bereavement is further compounded by social isolation, several changes and stressors occurring simultaneously, and the loss of face-to-face mourning rituals. Nurses report anticipatory grief as they plan for a potential surge in the volume of patients, the lack of resources and supplies to care for patients, the overburdening of the healthcare system, the rise in patient deaths, and anxiety about one’s own mortality. Nurses have been tasked with communicating with families virtually due to restrictive visitation policies. Discussing sensitive topics such as advance care planning, do-not-resuscitate (DNR) orders, clinical decline, and impending patient death have been cited as a major source of stress among nurses. Virtual communication omits the humanistic approach to breaking bad news, which often involves physical displays of empathy such as touch, eye contact, nonverbal expression, and the simple yet powerful act of being there. Delivering bad news over the phone without this critical, face-to-face, and physical aspect that personifies nursing causes distress for the nurse. Families have been unable to say goodbye to loved ones who are hospitalized due to restrictions surrounding social distancing and the need for close contacts to quarantine based on exposure to an infected loved one. The grieving process for bereaved families and loved ones has been dramatically disrupted, with customary practices of social support, burial rituals, and funerals prohibited in many geographic locations. Additionally, nurses describe anticipatory grief with regards to the potential decline in their own health and well-being if they are exposed to the virus while caring for infected patients. As a means to protect their family members, many have opted to isolate themselves from loved ones and support systems. During this period of heightened stress, the repeated exposure to suffering and death, lack of social support, and isolation have laid the groundwork for complicated and disenfranchised grieving (Wallace et al., 2020). While the COVID-19 pandemic is continually evolving, the following strategies have been proposed to help mitigate grief in nurses during these unprecedented times:
- Take advantage of virtual communication technology, including virtual family meetings and other support meetings for nurses and healthcare professionals;
- Engage in advance care planning discussions with patients as early as possible, including discussions of desired ritual or spiritual practices, funerals, and memorial plans based on restrictive social distancing guidelines to help facilitate closure;
- Become familiar with local resources and available services to connect patients and families with resources to help them consider how to plan for death as well as additional grief support through telehealth services;
- Practice self-awareness and self-care strategies to mitigate accumulated stress and compassion fatigue;
- Participate in virtual memorial services, telephone support groups, and other innovations to provide short-term support (Carr et al., 2020; Wallace et al., 2020).
Al-Majid, S., Carlson, N., Kiyohara, M., Faith, M., & Rakovski, C. (2018). Assessing the degree of compassion satisfaction and compassion fatigue among critical care, oncology, and charge nurses. The Journal of Nursing Administration, 48(6), 310-315. https://doi.org/10.1097/NNA.0000000000000620
American Nurses Association. (2016). Nurses’ roles and responsibilities in providing care and support at the end of life. https://www.nursingworld.org/~4af078/globalassets/docs/ana/ethics/endoflife-positionstatement.pdf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
Barbour, L. C. (2016). Exploring oncology nurses’ grief: A self-study. Asia-Pacific Journal of Oncology Nursing, 3(3), 233-240. https://doi.org/10.4103/2347-5625.189817
Boerner, K., Gleason, H., & Jopp, D. S. (2017). Burnout after patient death: Challenges for direct care workers. Journal of Pain and Symptom Management, 54(3), 317-325. https://doi.org/10.1016/j.jpainsymman.2017.06.006
Bylund-Grenklo, T., First, C. J., Nyberg, T., Steineck, G., & Kreicbergs, U. (2016). Unresolved grief and its consequences. A nationwide follow-up of teenage loss of a parent to cancer 6-9 years earlier. Supportive Care Cancer, 24(7), 3095-3103. https://doi.org/10.1007/s00520-016-3118-1
Carr, D., Boerner, K., & Moorman, S. (2020). Bereavement in the time of coronavirus: Unprecedented challenges demand novel interventions. Journal of Aging & Social Policy, 32(4-5), 425-431. https://doi.org/10.1080/08959420.2020.1764320
The Centers for Disease Control and Prevention. (2020). Coronavirus Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html
Elizabeth Kübler-Ross Foundation. (n.d.). 5 stages of grief. https://www.ekrfoundation.org/5-stages-of-grief/5-stages-grief/
Freud, S. (1917). Mourning and melancholia. Metapsychology, IV, 152-170. http://www.columbia.edu/itc/hs/medical/clerkships/psych/misc/articles/freud.pdf
Gawande, A. (2014). Being mortal: Medicine and what matters in the end. Macmillan.
Gibson, K., Hofmeyer, A., & Warland, J. (2018). Nurses providing end-of-life care for infants and their families in the NICU: A review of the literature. Ethical Issues in Neonatal Care, 18(6), 471-479. https://doi.org/10.1097/ANC.0000000000000533
Hamilton, I. J. (2016). Understanding grief and bereavement. British Journal of General Practice, 66(651). 523. https://doi.org/10.3399/bjgp16X687325
Houck, D. (2014). Helping nurses cope with grief and compassion fatigue: An educational intervention. Clinical Journal of Oncology Nursing, 18(4), 454-458. https://doi.org/10.1188/14.CJON.454-458
Kavan, M. G., & Barone, E. J. (2014). Grief and major depression: Controversy over changes in the DSM-5 diagnostic criteria. American Family Physician, 90(10), 690-694. https://www.aafp.org/afp/2014/1115/p690.pdf
Lewis, S. L. (2017). Exploring NICU nurses’ affective responses to end-of-life care. Advanced Neonatal Care, 17(2), 96-105. https://doi.org/ 10.1097/ANC.0000000000000355.
Li, T., Wang, S. W., Zhou, J. J., Ren, Q. Z., & Gao Y. L. (2018). Assessment and predictors of grief reactions among bereaved Chinese adults. Journal of Palliative Medicine. 21(9), 1265-1271. https://doi.org/10.1089/jpm.2018.0001
Lowey, S. E. (2015). Nursing care at the end of life: What every clinician should know. OPEN SUNY Textbooks. https://textbooks.opensuny.org/nursing-care-at-the-end-of-life/
Luchterland, C. (2019). Health care professional as griever: The importance of self-care clinical tool. https://wholehealth.wisc.edu/wp-content/uploads/sites/414/2020/03/Health-Care-Professional-Griever.pdf
Mental Health America. (n.d.). Bereavement and grief. Retrieved August 1, 2020, from https://www.mhanational.org/bereavement-and-grief
Mills, J., Wand, T., & Fraser, J. A. (2018). Exploring the meaning and practice of self-care among palliative care nurses and doctors: A qualitative study. BMC Palliative Care, 17(63). https:/doi.org/10.1186/s12904-018-0318-0
National Cancer Institute. (2020). Grief, bereavement, and coping with loss (PDQ®)–Health professional version.
National Institute on Aging. (2017). Providing care and comfort at the end of life. https://www.nia.nih.gov/health/providing-comfort-end-life
Perregrini, M. (2019). Combating compassion fatigue. Nursing2019, 49(2), 50-54. https://doi.org/10.1097/01.NURSE.0000552704.58125.fa
Phillips, C., & Welcer, B. (2017). Songs for the soul: A program to address a nurse’s grief. Clinical Journal of Oncology Nursing, 21(2), 145-146. https://doi.org/ 10.1188/17.CJON.145-146
Rushton, C. H., Batcheller, J., Schroeder, K., & Donahue, P. (2015). Burnout and resilience among nurses practicing in high-intensity settings. American Journal of Critical Care, 24(5), 412-420. https://doi.org/10.4037/ajcc2015291
Schulz, M. (2017). Taking the lead: Supporting staff in coping with grief and loss in dementia care. Healthcare Management Forum, 30(1), 16-19. https://doi.org/ 10.1177/0840470416658482
Tranter, S., Josland, E., & Turner, K. (2016). Nurses’ bereavement needs and attitudes towards patient death: A qualitative descriptive study of nurses in a dialysis unit. Journal of Renal Care, 42(2), 101-106. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jorc.12147
U3173699. (2019). Kubler-Ross grief cycle. [image]. Wikimedia. https://commons.wikimedia.org/wiki/File:Kubler-ross-grief-cycle-1-728.jpg
Wallace, C. L., Wladkowski, S. P., Gibson, A., & White, P. (2020). Grief during the COVID-19 pandemic: Considerations for palliative care providers. Journal of Pain and Symptom Management, 60(1), e70-e76. https://doi.org/10.1016/j.jpainsymman.2020.04.012
Worden, J. W. (2018). Grief counseling and grief therapy: A handbook for the mental health practitioner (5th ed.). Springer Publishing Company, LLC.
World Health Organization. (n.d.). WHO definition of palliative care. Retrieved August 1, 2020, from https://www.who.int/cancer/palliative/definition/en/
Yarbo, C. H., Wujcik, D., & Gobel, B. H. (2018). Cancer nursing: Principles and practice (7th ed.). Jones and Bartlett Publishers.
Yilmaz, E. B. (2017). Resilience as a strategy for struggling against challenges related to the nursing profession. Chinese Nursing Research, 4(1), 9-13. https://doi.org/10.1016/j.cnre.2017.03.004
Zheng, R., Lee, S. F., Bloomer, M. J. (2018). How nurses cope with patient death: A systematic review and qualitative meta-analysis. Journal of Clinical Nursing, 27(1-2), e39-e49. https://doi.org/10.1111/jocn.13975