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When patients die and nurses grieve: understanding the grieving process of nurses after the death of a patient.

After 390 days of being hospitalized, Mr. L. died in the Intensive Care Unit of a large medical center. It had been a long and difficult journey for Mr. L and his nurses. Mr. L was morbidly obese, suffering from diabetes, respiratory problems and multiple organ failures.

When the nurses on the medical surgical floor learned about his death, they felt relief. But many of the RNs also expressed sadness and regret. They had tried so hard to get him well, and yet all efforts to move him out of the hospital to a long-term care facility had failed. Mr. L fit the image of the difficult patient, the one who is non-compliant and at times aggressive and moody. The nurses struggled with liking him. Yet they cared for him with compassion and dignity.

Now that he had died, the nurses felt that they needed to do something to find closure for themselves and to honor the humanity of the patient. They decided to gather for a brief memorial service in the hospital chapel. A group of 12 nurses and their manager came together for a 30-minute service led by the hospital chaplain. She invited them to share their memories of the patient, the struggles, the moments of satisfaction and even joy. The nurses were able to effectively express a whole range of emotions that this patient invoked in them. The structure of the service and the comfort of the chapel assisted the RNs in entering a process of healthy grieving.

The way the nurses dealt with their grief in this situation is not typical. It is well-known that registered nurses provide compassionate end-of-life care and bereavement support to adult and pediatric patients and their families. In many cases, nurses form special relationships with terminally ill patients and their families that go beyond the traditional professional role of taking care of the patient's physical needs. Nurses grieve the loss of their patient on a personal level, especially (a) when the relationship was based on mutuality and reciprocity, (b) when this was an initial death early in one's career; (c) when coping strategies include spirituality and caring rituals; and (d) when the understanding of professionalism requires compartmentalization (Gerow, 2010).

When a patient dies, many nurses may not have the opportunity to take care of their own needs for closure and for processing feelings. The impact of death on families has been well-researched in numerous publications, while the grieving process of nurses and other health care providers has remained largely unexamined.

Findings of a few research projects assert that the grieving process for nurses is significantly different than the families' journey through grief. Nurses can play conflicting roles. They are supposed to remain strong and supportive for the families, while being affected by the loss of a person that they cared intimately for (Gerow 2010). As a result of this conflict, nurses often practice coping behaviors such as avoidance and compartmentalization of the experience. This can lead to burnout, physical, emotional and spiritual problems such as decreasing morale and motivation to continue caring for ill people (Gerow, Ruggles, Brunelli). Most nurses interviewed in various studies reported unresolved grief issues that manifest in recurring memories of the dying condition, fatigue, moodiness and difficulty concentrating.

The spiritual dimension of grief was the focus in a study by Shinbara and Olson, who advocate for spiritual coping strategies as helpful and healthy for nurses. Otherwise, they assert the experience of multiple patient losses can lead to spiritual burdening, to a faith crisis, spiritual pain and the questioning of meaning (Ewing & Carter, 2004; Rushton, 2004).

Nurses who utilized their nursing colleagues to recall positive memories of the patient felt more supported. They were able to re-orient themselves toward caring for new patients and to integrate the grieving experience into their clinical practice, increasing their ability to be compassionate (Brunelli, 2005).

Reviewing the literature and reflecting upon my experiences as a chaplain working with nurses has made it quite clear that addressing the grief of nurses after the loss of a patient is crucial for continued professional functioning and satisfaction on the job.

Even though the grieving process of nurses might be different than that of family members, there are similarities. Generally, grieving means to feel sorrow and pain (Merriam-Webster's Online Dictionary, 2004). The grieving process of releasing and working through emotional experiences of shock, denial, anger, depression, bargaining, blaming and sadness is a journey of reconciling and finding peace within oneself. A nurse will reach a place of acceptance and adjust to a changed reality when given the space to freely express all different emotions. It is work--grief work, as Sigmund Freud stated a long time ago. Grieving involves remembering, working through emotions and integrating the experience into your life (Pisarski, 1982).

In her article "The Grieving Process for Nurses," Tina Brunelli, RN, suggested that nurses first need to speak up about their hurt and grief. Further, hospital nursing leaders are asked to respond by providing space, time and trained personnel such as Employee Assistance counselors or professional chaplains for grief support groups that invite the multidisciplinary team. Grieving in community has a long tradition in all cultures, and it may help break down professional barriers. When physicians, nurses, social workers, chaplains and other providers share their grief together, they may discover similarities that can lead to more effective collaboration and more holistic and compassionate care for the patients.

Other writers, like Gerow, advocate for developing a comprehensive understanding of the grieving and coping process for nurses, including the significant influence of spiritual worldviews. Nursing faculty, administrators and leaders can provide better learning opportunities and supportive practice environments in which the professional nurse can grow and change within life's journey (Gerow, 2010).

In addition, memorial services have proven to be an effective tool for caregiver's coping process, as Brunelli pointed out. This corresponds with my experience as a chaplain who has coordinated special non-denominational services for caregivers and families to honor the lives of patients who died during the past year. These services have provided a structure to remember and celebrate in community as well as being part of a larger reality. The receptions after the services invite fellowship; sharing of stories over food and drink. This custom is as old as the Jewish-Christian text from Ecclesiastes 3: "There is a time for everything under the heavens, a time to Patients Die and Nurses Grieve continued on page 6 mourn and a time to laugh," and it assists with the adjustment to a new reality. It may result in less burnout and more happy, caring nurses who will stay in the field because they, too, feel cared for by their employers.

In their research on the role of spirituality in coping, Shinbara and Olson found that a large percentage of nurses are connected to spirituality through such avenues as worship, prayer, meditation or self-reflection. Spirituality is understood as making meaning out of one's experiences and feeling a connection to something larger than oneself. Similar to the findings around grief, education on spirituality is predominantly provided around the patients' spiritual needs.

Many nurses collaborate with chaplains in their institutions to meet the needs of patients and families. Some findings show that spiritual care providers are being utilized to provide education on spirituality and loss, and to offer support to the nursing staff. That has been true in my experience as a hospital chaplain. Once I had established trusting relationships with the RNs on one oncology unit, they would call me when they felt sad about the loss of a patient or when they needed an informal debriefing, a blessing or a special healing service.

Faith and spirituality in their many forms can be healthy ways of coping with grief. For nurses who may not want to attend group sessions or attend memorial services, the practice of focusing on the three "G" principle might be an alternative: be grateful for the gift of working with the patient, allow for grief over the loss, and find ways of letting go (Shinbara, Olson, 2010 and Carlsen, et al. 2005). This may include some well-known self-care strategies such as listening to music, taking a bath, scheduling a massage, exercising, going for walks, hugging, spending time alone in nature or with friends and family, and writing a letter or journal (Ruggles, 2011). Nurses need to give themselves permission to grieve and let go in their own ways. I join Brunelli in quoting Reese, who wrote (1996), "It's only human to hurt, to cry, to grieve, when a person who's influenced you in some way has died. Please cry with your patients and their families; it is okay for you to grieve, too," and to ask for support.

References:

Brunelli, Tina, RN, BSN: A Concept Analysis: The Grieving Process for Nurses, Nursing Forum, Volume 40, No. 4, 2005

Gerow, Lisa, RN, MSN et al: Creating a Curtain of Protection: Nurses' Experiences of Grief Following Patient Death, Journal of Nursing Scholarship, 2010, 42:2, 122-129

Pisarski, Waldemar, M.Div.: Wege durch die Trauer; Munich, Germany 1982

Ruggles, Tammy, BSW, MA: How Nurses Can Grieve the Loss of a Loved One or Special Patient, Working Nurse, California 2011, online journal

Shinbara, Christina G.; Olson, Lynn: When Nurses Grieve: Spirituality's Role in Coping, JCN, Volume 27, Number 1 2010

Submitted by: Ute Schmidt, M.Ed., Board Certified Chaplain (APC)

Certified Pastoral Educator (ACPE)

Director of Spiritual Care and Clinical Pastoral Education

Fletcher Allen Health Care

Burlington, VT
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Author:Schmidt, Ute
Publication:Vermont Nurse Connection
Date:Jun 21, 2011
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