Introduction
Nurses go through a whole gamut of emotions in their career. They often experience the rewards of their hard work when their patients recover from their illness. It is very fulfilling for them to be able to take part in another individual’s healing and achievement of comfort and well-being.
On the other hand, they also go through difficult emotions such as anxiety and sadness for their very ill patients. This is heightened when they take care of end-of-life patients whom they know as having no more chance at recovery and are facing death any moment soon.
Often, they are privy not only to the physical but also the emotional pains of their patients. This may also extend to the patient’s close family and friends. Nurses are at hand to provide comfort and care. They are trained to empathize with their patients. They witness their patients’ journey and struggles with their health difficulties and even help them towards a peaceful and hopefully, painless death. However, little is done to give nurses the attention they also need when they grieve for the patients they have lost. These carers also need caring and understanding themselves. Although they are trained to project a professional stance by being strong in the face of death, they are still human beings who get affected when the people they care for pass away. It is difficult for them to bottle up their emotions as they should have the ability to mask their own pain in order to give comfort to the family left by their loved one.
This paper will discuss how nurses deal with their own grief when they lose a patient to death and what can be done to support such grieving nurses thorough those difficult times.
Main Body
Brunelli (2005) comments that in nursing courses, there is nothing that prepares nurses for the possible overwhelming grief they can experience over and over with patients who die. She defines the grieving process as how one deals with the great and all-consuming feelings of loss of someone they have cared for. Reese (1996) further adds that it is how a person develops his or her own peace with his or herself regarding the loss before moving on with life. The famous Kubler-Ross (1969) stages of the grief process have been used to explain the emotions that people go through after a devastating event in their life. She theorizes that people go through five stages of grief, namely: denial, anger, bargaining, depression and acceptance.
However, there is very little literature on how nurses deal with the grief they experience with patients they have lost to death. Petraki (2002) did an exploratory study of Greek nurses’ grief reactions to their patients who are children dying from cancer. It was reported that the nurses’ reactions to death ranged from mere crying for the deceased, sadness and anger at the event and constant thoughts of the child patient dying after suffering from pain. When the child eventually dies, the nurses took comfort from their colleagues who remind them of the positive qualities of the child and the nurse’s contribution to make the child’s life more comfortable and death more peaceful. Lenart et al. (1998) claim that nurses usually repress their grief. However, grief manifestations run from fatigue, disturbances in sleep patterns, anxiety, sorrow, mood shifts, and difficulty in concentrating (Brunelli, 2005). These symptoms become documented as unresolved grief responses. Grief that is repressed and unresolved is also known as “disenfranchised grief” or “grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported” (Doka, 1989, p. 4).
If nurses keep repressing their grief, it would then lead to burnout. That is why the therapy for unrecognized loss is to recognize and acknowledge it.
Brosche (2003) contends that when grief is not fully expressed, the consequences can range from burnout to damaging addictions such as alcoholism or drug addiction or even to suicidal thoughts. This affects the morale of the staff and possibly the delivery of patient care since such grief that is not properly expressed may lead to being emotionally distant, depressed, apathetic, angry and burnt-out. On a macro level, the hospital can experience a high turnover of staff and low customer service and satisfaction. This is especially true in settings where patient diagnoses are usually poor and the repetitive deaths of patients they care for cause nurses’ physical, mental, emotional and even spiritual burden. That is one of the main reasons why nurses shift to other professions, causing a nation-wide shortage of nurses (Brunelli, 2005).
As an intervention, Brunelli (2005) recommends a multidisciplinary approach involving disciplines such as nursing, physicians, pastoral care, and psychology. Periodically, memorial services for patients who have passed may be held in the chapel or church and after the service, everyone including the family members of the deceased and the nurses and staff who cared for them would get together to eat, drink, tell stories to remember the deceased and just have some closure together. This is a good start for the grieving nurses to move on and regain the vigour and efficiency they may have lost after their patients have passed away.
A nurse needs to be emotionally strong if he or she expects to stay in the career for a long period of time. Resilience is an attribute that needs to be developed since the work puts the nurse in a constant state of stress. Patients recover and/or their health condition worsens and the nurses who care for them would experience peaks and valleys of emotions. Resilience keeps them in control of their emotions because they are able to hold up over time under conflicting issues. They learn to thrive despite the pressures and manage to survive with the uncertainty of what happens next. Resilience helps nurses maintain their mental, physical and emotional health and their spirit for living life with joy (Boss, 2006).
Bonanno (2004) notes that resiliency is more than just recovery from a stressful situation. The individual is able to maintain normal functioning even when undergoing the situation. Resilience is not just part of one’s recovery after the crisis but is a continuous healthy functioning with regenerative growth and positive emotions (Bonanno, Papa & O’Neill, 2001). Another observation is that resilience is more common that we thought (Bonanno, 2004). Grief therapists seek the grieving individual’s under-reactions and overreactions of grief after the death of a loved one while trauma specialists focus only on the negative reactions of individuals after a traumatic event. Usually, the factor of resilience of such individuals is overlooked. Although what is manifested is usually the negative responses, it is highly possible that they have some level of resilience within them to push them forward to full recovery. Bonanno & Keltner (1997) found evidence that positive emotions enhance resilience and that resilient individuals who did well after a loss were actually ready for the eventuality (Boss, 2002). It is normal for them to go through negative emotions and even through Kubler-Ross’ stages of grief, but these emotions did not interfere with their normal functioning. Boss (2006) adds her observations of family caregivers of Alzheimer’s disease patients who showed resiliency throughout the duration of their care. Because Alzheimer’s disease presents ambiguousness in the patient’s recovery/ progression of illness, it allows for the patients’ caregivers to grieve gradually so by the time the patient eventually dies, the caregivers’ have shed all their tears and may even express relief as it is finally their turn to care for their own needs that have been neglected when the patient was still alive. It is now time to rebuild their own health and emotional well-being.
A third observation of Bonanno (2004) on resilience is that there are various paths to achieving it. Some people use repression of sad feelings as a way of coping while others resort to laughter and optimism to build their resilience (Bonanno, et al, 2003; Bonanno et al, 2002). Kobasa et al (1982) found that some people develop hardiness to buffer extreme stress. Bonanno (2004) suggests that pathways to resilience are affected by an individual’s development, genetics, environment, gender and other yet undetermined risk/protective factors.
Boss (2006) notes that community-based therapy with extended family groups much like practices done by American Indian tribes may be more effective than individual therapy for people undergoing much grief. However, in these more contemporary times, it may not always work because independence and self-sufficiency is highly promoted. Boss (2006) observes that treatments may have swung too far away from family and community approaches.
Williams (2008) planned out a grief and loss program for a remote village in Zambia, Africa for people who constantly lose their loved ones to HIV/AIDS. Her program planning followed a modified version of the nursing process – assessment, planning, implementation and evaluation (Williams, 2008).
In the assessment stage, Williams gathered insights from home-based care volunteers about adults and children who undergo overwhelming sadness and stress and have no resources for assistance. Williams (2008) was informed that feelings of loss that prevail long after a loved one dies does not easily dissipate and even continue to affect people’s ability to lead healthy, productive lives. It should be remembered that these individuals are constantly battered by death in the family due to the prevalence of HIV/AIDS in the area. Such a case may be paralleled to nurses who are constantly exposed to patients’ deaths after a lingering disease that involved their care. The volunteers in the Zambia study add that supporting the physical needs of the grieving individuals is not enough and addressing emotional needs is what is more important.
Next in Williams’ agenda was the planning stage. She followed Kirpatrick’s (2006) steps in laying a strong foundation for program development. This included identifying the objectives of the program; selecting the subject content for the seminar-workshop; selecting and preparing audio-visual and training materials, selecting the facilitator and workshop helpers, identifying the participants who will benefit from the workshop; determining a feasible schedule; selecting the facilities, and, finally, coordinating the workshops (Kirkpatrick, 2006).
Specifically for the Zambia Grief and Loss Program, Williams (2008) enumerated the following to serve as the objectives of the program:
- Define grief and associated emotions.
- Discuss strategies that adults can practice to assist other adults in achieving healthy grieving.
- Participate in a role-play situation focusing on assisting another adult through a difficult time following the loss of a loved one.
- Distinguish between grief and mourning as associated with children’s perceptions of loss.
- Discuss strategies for helping children to cope with death, grief, and loss.
- Identify guidelines for selecting appropriate strategies to assist children with understanding their perceptions of death.
- Use specific situations to identify practical solutions for helping children prepare for impending death of a loved one, and prepare for the aftermath when a loved one dies.
(Williams, 2008, p. 227)
Williams (2008) program was tailored to the culture of the participants in the grief and loss program. That entailed her to include their preference of dance, prayer and song in the implementation of the program since the participants related better with these practices. The program also included the strategies of storytelling, role-playing, sharing experiences, group work and individual presentations which were all aligned with the participants’ learning styles. The program was able to thresh out some difficult issues of coping and dealing with deaths of loved ones. They were showed ways of how to move on and help out others who are likewise grieving. This includes children who do not have full understanding of death.
The lesson to be learned from Williams’ (2008) report is to honour the grieving individual’s family and cultural background as well as his/her personality when delivering support. Nurses come from various perspectives and it is important for hospitals to consider these in developing grief intervention programs for them.
In relation to respecting cultural backgrounds, cultural beliefs, ceremonies and rituals of grieving family members of patients should likewise be taken into account if full support is intended to be provided them. Lobar et al (2006) studied cross cultural beliefs, ceremonies and rituals surrounding death and interviewed participants from various cultural backgrounds.
A pervasive theme was that beliefs about the soul of the deceased lead families to perform rituals and ceremonies that foster passage to God, the “light” or another life. The stronger the beliefs, the more dedicated the family is in completing the rituals and ceremonies in the way dictated by their religion or culture. Participants had difficulty separating the influence of culture and religion on these practices (Lobar et al., 2006, p. 44).
Nurses with patients from another culture may find it difficult to do their role in comforting the family members the patients have left behind due to language and cultural barriers. It is important for nurses to be aware of their cultural beliefs and practices so they may better understand what they are going through and support them in their time of grief. Engler et al (2004) conducted studies of how nurses perceived the bereavement and end-of-life care of the families of sick and dying infants. It was found that the nurses were not comfortable in providing culturally sensitive care due to their lack of knowledge regarding the families’ bereavement practices. This further added to the nurses’ frustration in being able to help the families through a very trying period in their lives.
Psychological therapy for nurses dealing with disenfranchised grief is an effective intervention. Grief may lead to depression. Depression is associated with feelings of extreme sadness which not only last for long periods of time, but it is also recurrent and may further develop into suicidal tendencies (NHS, 2010). It is usually manifested with negative behaviours stemming from negative emotions. Sometimes, the person experiencing it is not even aware that he is undergoing depression. One approach that has gained prominence in helping clients with depression is Cognitive Behaviour Therapy developed by Aaron Beck (1975). Clients who suffer from psychological problems focus on their flaws rather than their potentials that would bring them success. Beck agrees that “cognitive distortions” of one’s acknowledged fallibility cause much prevailing psychological problems The basic premise of Cognitive Behaviour Therapy is the clients’ belief that they are at fault in everything that has brought them to their pathetic situations. For nurses, it may be self-blame for inappropriate care they may have provided the patient contributing to the worsening of the disease leading to his or her death. The nurse may feel overwhelming guilt, remorse and devastation at his/her failure to help the patient survive. The goal of therapy is to help the nurse realize that reorganizing the way she views situations will call for a corresponding reorganization in her behaviour. The focus of Cognitive Behavior Therapy is more on thinking and acting more than just expressing feelings (Corey, 2005). Beck (1975) writes that, in the broadest sense, “cognitive therapy consists of all of the approaches that alleviate psychological distress through the medium of correcting faulty conceptions and self-signals” (p. 214)
Ellis’ Rational Emotive Behavior Therapy (REBT) is considered to be the forerunner of Cognitive Behavior therapies. Its contention is that emotions come from one’s beliefs, evaluations, interpretations and reactions to what has happened in his or her life. Ellis believes that we have an inborn potential for growth and actualization but we often sabotage our movement toward it because of self-defeating patterns we have learned in the process. Through therapeutic processes, the client learns skills to isolate and dispute their irrational views which were mostly self-constructed and maintained by self-indoctrination (Corey, 2005). REBT helps clients replace such irrational views with rational and constructive ones, thus resulting in more productive change in behaviour and reactions to situations.
Another discipline that has been founded and developed by Martin Seligman and Mihaly Csikszentmihalyi to combat negative emotions that adversely affect one’s life is Positive Psychology. Gable & Haidt (2005) explain that positive psychology studies the factors and conditions that contribute to people’s optimal functioning. Lawson (2004) contends that it focuses on cultivating one’s strengths and maintaining an optimistic approach to life rather than on dwelling on human frailty and disease. It offers a brighter view of reality and encourages and empowers people to take more proactive steps in maximizing their strengths when life throws them problems. Nurses suffering from grief may very well benefit from a full dose of encouragement for all the hard work they do and for the exceptional skills they possess that enable them to be the efficient nurses that they are.
Seligman and Csikszentmihalyi (2000), identify four different personal traits that contribute to positive psychology ase subjective well-being, optimism, happiness and self-determination. Subjective well-being is what people think and feel about their lives. It entails much introspection to determine the state of happiness and contentment they are in. The important thing is how the person himself views his own well-being. The grieving nurse needs to empower him/ herself with the belief that he or she is a good nurse and is capable of helping their patients in their recovery. Optimism has more to do with positive thinking. In the textbook of Pervin, Cervone and John (2005), optimism is defined as a coping strategy that features relatively realistic expectations about one’s capabilities. The word “coping” in this definition implies that a person can “resort” to being optimistic in a trying situation such as death of a patient. Optimism calls upon cognitive, emotional and motivational components of a person to survive challenges. Optimistic people show positive moods, are more persevering, possess better health and are more successful. This may be because they give more emphasis to the positive possibilities more than the negative consequences (Pervin, Cervone and John, 2005).
Further, Seligman & Csikszentmihalyi (2000) contend that complex psychological issues embedded in social and cultural contexts cannot just be isolated and analysed apart from its full context. It follows that a pessimistic culture is more tolerant of, and perhaps, even expect, negative events such as depression and mental illness as a consequence of grief and bereavement as opposed to an optimistic culture which upholds positive values such as family solidarity, peace and order, good mental health and a great capacity to move on without the dearly departed loved one.
It is common knowledge that every person seeks happiness in life. Research on this topic validates traditionalists’ views that the more ethereal values such as religious faith and close personal relationships are better sources of happiness than more worldly values such as economic growth and income (Myers, 2000). The pursuit of true happiness is one major motivation of the Positive Psychology movement.
The Self-determination theory enumerates the need for competence, the need for belongingness and the need for autonomy as three related human needs that when satisfied, one may claim well-being and optimized social development (Ryan and Deci, 2000). Resilient nurses fall under this condition and show propensity to be motivated intrinsically and the ability to reach their full potentials while seeking out greater challenges to conquer (Seligman & Csikszentmihalyi, 2000). They do not easily buckle under pressure and are able to move on after allowing themselves to grieve for their losses and failures. This is the kind of nurses that are direly needed by the health care industry.
Conclusion
Although doctors and nurses and other members of the medical profession are aware that death is part of the normal course of life, losing a patient to death remains to be a difficult fact to accept. It is a human tendency to grieve over a loss, especially for someone one has cared for over a period of time. Nurses are especially vulnerable to such grief and it is important to understand what they go through and not ignore the negative emotions that may burden them. If left disenfranchised, their grief may overcome them and affect their personal and professional functions. Hospitals and health care institutions should be able to support their nurses who grieve for patients they cared for but have died anyway. Simple acts such as holding memorial services for the deceased, use of positive psychology to empower the grieving nurses or engaging in psychological therapies are just some of the support strategies that can greatly help such nurses to recover from their grief and continue being efficient professionals who give their best in helping patients recover and providing them with the care and comfort their patients deserve.
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