Concept Paper

Concept Paper Adapting to Grief, Death & Loss George Sofield Langston University

NR 3323 - Conceptual Foundation of Health Professions Donna Thurman, BSN, RN October 25, 2011

Concept Paper Concept Paper Adapting to Grief, Death & Loss Introduction U.S. Census Bureau estimates by the year 2050 the number of persons 65 years old and older is expected to double from the 2010 number of 40.2 million persons (Craven & Hirnle, 2009, p. 665). That statistic will no doubt have an impact on the healthcare system. Statistics aside, nurses will tend to the needs of many patients throughout their career and without a doubt at some point the nurse will experience the death of a patient. With the aging of our baby boom generation the likelihood increases; however, one must keep in mind patients of all ages die and in all clinical settings. An unfortunate death experience can have deleterious effects on personal and professional levels. According to Brosche, this can negatively effect efficiency of care,

customer service, turnover, cost to the hospital, nursing morale, and nursing retention (Brosche, 2007, p. 21). The purpose of this paper is to explore the syndrome of grief, the grief response of nurses following the death of a patient, and identify ways to assist them in developing appropriate coping skills.

Literature Review Much literature is available related to training nurses how to comfort the bereaved through the loss of a loved one, but not much is available educating nurses how to handle their own grief after experiencing the loss of a patient. For the most part, nurses learn by way of tradition as they corral their feelings to cope with death (Gerow et al., 2010, p. 124). After analyzing data from surveys Gerow et al., identified four themes providing insight as to how nurses cope with the loss of a patient. First, the nurse views the relationship with patient as a reciprocal experience (Gerow et al., 2010, p. 124). In other words, the relationship is

Concept Paper symbiotic with each gaining something from the other. Second, death experiences early in a nurses career provide a footing for how they will handle future deaths (Gerow et al., 2010, p. 125). This stands true for both positive and negative experiences. For instance, if the nurse felt isolated, helpless and/or unsupported in an early significant death experience, the nurse would carry the trauma from that experience into future experiences. Conversely, if the nurse viewed the experience as positive this was also ingrained and carried forward. Third, their spiritual faith

strengthened (Gerow et al., 2010, p. 126). Lastly, in order for nurses to maintain professionalism they had to compartmentalize their feelings (Gerow et al., 2010, p. 126). Lange, Thom & Kline, concluded age and years of nursing experience are significant predictors of nurses attitudes toward death (Lange, Thom & Kline, 2009, p. 955). In other words, younger and/or newer less experienced nurses generally felt more inadequate in dealing with the death of a patient more so than older more experienced nurses. Subsequently, they recommend the implementation of educational programs during orientation for less experienced nurses to establish a supportive foundation and avoid maladaptive behaviors associated with unresolved grief (Lange, et al., 2009, p. 958). Other findings also maintain the need for educational opportunities and a supportive clinical environment with proper mentors for new nurses and student nurses (Gerow et al., 2010). Aside from education and training, Keene, Hutton, Hal and Rushton advocate offering bereavement debriefing sessions following a patient death as an intervention for healthcare workers (Keene, Hutton, Hal & Rushton, 2010, p. 185). The most common reason cited by staff members for requesting a bereavement debriefing session was professional distress. The researchers stated this was most often defined as the relationship of staff with the deceased patient and family, adding credence to Gerows reciprocal experience theme (Gerow, et al, 2010)

Concept Paper (Keene et al., 2010). Similar to bereavement debriefing sessions, Brosche (2007) proposes the assembling of a grief team to establish a setting where staff feel supported and nurtured as they

cope with their grief after the loss of a patient. The grief team approach is one-on-one as opposed to the group setting proposed in the bereavement debriefing session model. However, both models are similar in that they are attempting to create an atmosphere where the bereaved staff members feel supported. According to Brosche, early intervention will curtail maladaptive coping skills, compassion fatigue and moral distress (Brosche, 2007, p. 22).

Concept The aforementioned research articles reveal a need to confront grief head-on. A proactive approach with education and training and a reactive approach with interventions such as a grief team and/or bereavement debriefing session models are essential to the long term wellness of the nurse and growth of the profession (Keene, et al., 2010) (Lange, et al., 2009) (Brosche, 2007). It is recommended grief team members consist of professionals trained in grief, crisis management, stress management and bereavement and be available 24 hours/day (Brosche, 2007). Palmer (2008) maintains that in addition to grief, nurses may experience feelings of anxiety and cumulative loss when unable to cope successfully with multiple losses, which can lead to avoidance and emotional distancing. According to Townsend, loss and bereavement are universal events encountered by all beings who experience emotions (Townsend, 2007, p.361). Therefore it would be careless to ignore the possibility of a nurse occasionally experiencing grief after the death of a patient. Theorists characterize grief more as a syndrome than an isolated behavior with conventional routes to resolution (Townsend, 2008). Each person is a unique being and

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progresses towards grief resolution at an individual pace. According to Craven and Hirnle there are no clear-cut stages of grief, nor are there any exact timetables (Craven & Hirnle, 2009, p. 1314). Elisabeth Kbler-Ross was the first to attach a label to the journey through grief into five identifiable stages: denial, anger, bargaining, depression and acceptance (Townsend, 2008, p. 362). Her work was tantamount in classifying the stages of grief for the dying patient. William Worden, on the other hand, proposes a more modern-day theory of grief resolution in terms of the bereaved accomplishing a series of tasks (Townsend, 2008, p. 362). Perhaps a more relevant theory to apply to a nurse dealing with the loss of a patient is one proposed by John Bowlby. First, the nurse experiences a sense of disbelief and shock at the loss (Townsend, 2008, p. 363). Then a state of disequilibrium often characterized by feelings of guilt and ambivalence follows (Townsend, 2008, p. 363). The nurse may feel as though more could have been done to change the outcome or mistakes were made. The third stage is characterized by disorganization, despair, restlessness and social isolation (Townsend, 2008, p. 363). How many nurses leave the profession due to the loss of a patient or because they felt isolated and unsupported by their coworkers or employer during a time of uncertainty? This certainly supports the aforementioned notion of compartmentalizing feelings and further substantiates the need for an organized internal support system to assist the nurse through to grief resolution, e.g., grief support team and/or grief debriefing session. Bowlbys final stage is characterized by a reorganizing of thoughts and processes as one displays a readiness to move past the grief (Townsend, 2008, p. 363). Again, this can be accomplished more efficiently and compassionately by having adequate training and education programs available along with a considerable support system to react to incidents on an as needed basis. According to Keene, et al., the opportunity to express ones grief and reflect on the experience of caring for a particular patient and family allows health care

Concept Paper professionals to learn to manage their own grief experience to continue to serve the many families who need their expertise and care (Keene, et al., 2010, p. 190).

Conclusion Grief is a complex emotional response outlined by numerous theorists of which, sufficient similarities have been observed to warrant characterization of grief as a syndrome that has a predictable course with an expected resolution (Townsend, 2008, p. 362). Nurses grieving the loss of a patient should feel supported in their attempt to cope and reach resolution. Employers can accomplish this through new hire and on-going training and education programs as a means to raise awareness and provide nurses with the necessary coping skills. Moreover, the implementation of a grief team and/or a bereavement debriefing sessions can act as a hasty response to provide emotional support as needed. Creating an environment where nurses feel supported and nurtured will only translate to better patient outcomes and inspire nurses to transform, grow, and blossom in body, mind and spirit while beautifying the work environment (Brosche, 2007, p. 28).

Concept Paper References Brosche, T. A. (2007, February 1). A grief team within a healthcare system. Dimensions of Critical Care Nursing, 26(1), 21-28. Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing (6). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Gerow, L., Conejo, P., Alonzo, A., Davis, N., Rodgers, S., & Williams-Domain, E. (2010). Creating a curtain of protection: Nurses' experiences of grief following patient death. Journal of Nursing Scholarship, 42(2), 122-129. Keene, E. A., Hutton, N., Hal, B., & Rushton, C. (2010). Bereavement debriefing sessions: An

intervention to support health care professionals in managing their grief after the death of a patient. Pediatric Nursing, 36(4), 185-190. Retrieved September 13, 20011, from http://www.medscape.com/viewarticle/729872. Lange, M., Thom, B., & Kline, N. (2009, January 14). Assessing nurses' attitudes toward death and caring for dying patients in a comprehensive cancer center. Oncology Nursing Forum, 35(6), 955-959. Retrieved September 12, 2011, from http://www.medscape.com/viewarticle/585692. Palmer, A. (2008, April 1). Coping with death and dying. Nursing Today. Retrieved September 6, 2011, from http://www.asrn.org/journal-nursing-today/325-coping-with-death-anddying.html. Townsend, M. C. (2008). Nursing diagnoses in psychiatric nursing: Care plans and psychotropic medications, 7th edition. Philadelphia, PA: F.A. Davis Company.