EXECUTIVE SUMMARY

Case managers and other healthcare workers carry heavy burdens of grief when it is unacknowledged and they have not learned coping skills.

• Bereavement overload can result in employee burnout.

• Studies show that healthcare workers generally need more bereavement support and resources from their organizations.

• Healthcare workers are vulnerable to disenfranchised grief in which they delay addressing their emotional distress as they return to work.


When a patient dies, case managers and other healthcare workers (HCWs) can experience grief that might be underestimated or misunderstood by their organization and managers. Their emotional distress can be compounded by insufficient bereavement support in their workplace. The result can be bereavement overload.1,2,3

Nurses, administrative staff, and doctors are among the healthcare professionals who might experience bereavement overload, which is when losses mount and there is too little time for normal grief.3

“It is very important for patients and family members to deal with their grief, but if the staff is not dealing with grief, then they end up with burnout,” says Jennifer Gray, PhD, MPP, associate professor of public health in the School of Health Studies at Northern Illinois University.

Gray’s research into HCWs’ grief found that they generally need more bereavement support and resources from their organizations.1

When HCWs are not supported in their grief, they could experience disenfranchised grief in which they delay addressing their emotional distress as they go straight back to work, she notes.

“The staff might go on the next day to a new patient, and there’s no time to process their loss,” Gray says.

People who have lost a family member typically receive grief support from their family, friends, and community organizations. There is little to no support for case managers and other healthcare professionals who experience a patient’s death, she says.

“It can be so hard because we were providing excellent case management while the person was living, but then what is our relationship [to the patient’s family] after the patient passed away?” says Eboni Green, RN, PhD, co-founder of Caregiver Support Services in Omaha, NE.

Case managers sometimes can experience a loss related to losing close contact with the patient’s family.4 For instance, in situations where a case manager is working with a disabled or chronically ill patient over a number of months, the case manager gets to know the family very well. When the patient dies and the case manager no longer visits the home, he or she may experience grief or concern from the loss of contact with the patient’s family as well as the loss of the patient. The case manager might experience regret that the family is no longer receiving help.

“I’ve thought about those families and what it looks like to go through all they’re going through, and then the relationship just ends,” Green says. “If you don’t have any way to provide support or follow-up, then the relationship between you and that client ends.”

The case manager’s support services were helping everyone in the household, and now that support is gone, she adds.

In some situations, case managers might look for signs that other healthcare staff helping the patient are grieving. Home health aides in particular can become very close to their clients and experience an emotional loss when a client dies, Green notes.

“Their clients become like family,” she says. “Case managers are the ones coming in and doing supervisory visits and making sure care is provided according to the plan of care.”

But case managers might also watch for signs that staff caregivers are grieving: “When they lose a client, that can be a reason why they don’t want to stay in healthcare — because of the grief they feel,” Green says. “We have to support the frontline people who are going into the home every day.”

The nature of the workplace makes little room for any employee’s grief. Even when people lose a parent or close family member, they typically are given a few days off of work for bereavement, Green says.

“That amount of time does not begin to cover the feelings you have about loss of a family member,” she says. “And rarely do I hear of organizations that give case managers or home care staff time off when a client passes away.”

Healthcare professionals are expected to keep moving, going immediately into a new home to care for a new patient. The more a case manager invests in a patient’s care — both emotionally and in work — the more difficult is the loss when the patient dies.

For example, Green recalls working with a patient who needed assistance programs. “I remember working closely with the patient’s daughter for quite some time,” she says.

“I contacted all of the pharmaceutical companies and applied for medication assistance for each medication,” she explains. “We really worked hard together, and when we got everything completely set, her mother passed away, and it was just so hard because we had worked so hard on it.”

These types of losses and grief compound over time, adding complexity to the grieving process.

“If we don’t have time to express our sadness and realize we’re doing something that improves quality of life for someone we’re serving, then we do end up having more burnout,” Green says. “And there is a disconnect because we’re human and need to be able to express our feelings.”

One reason why healthcare organizations sometimes find it difficult to address grief is because it varies so much between people. One person could grieve heavily over a patient’s death, while another person might be able to move on quickly.

“Grief is so individual in how people manage it,” Gray says. “It depends on how close the relationship is between the staff member and the patient/client.”

The solution is for healthcare organizations to recognize the risk of staff grief and provide support and programs for case managers and others who need it. In some settings, such as pediatric cancer units, there should be ongoing intervention programs and mourning rituals.5

One study of HCW grief in a pediatric oncology ICU found that 4% of professionals in areas of high pediatric complexity experienced burnout related to grief and 71% were at risk of suffering from burnout.5

The study concluded that professionals in this setting were at risk of burnout partly because of greater emotional exhaustion. The staff needed concrete support strategies and mourning rituals.5

“In general, organizations do not take enough time to give staff the resources people need or the policies that help staff heal from their grief,” Gray says.

Resource examples include holding a tradition or service to acknowledge the loss of a patient. In some places, this could be a painted rock with the patient’s name, placed in the facility’s garden or landscaping. Others might hold a ritual of lighting a candle and an informal service in which staff members can share their feelings and experiences with patients. Still other organizations might offer a support group and make individual counseling available, Gray says. (See story in this issue on how to help staff cope with grief.)

Case managers are very good at attending to their patients’ needs, but they also should pay attention to their own needs: “I think one of the first things you can do is recognize how you feel,” Green says.

REFERENCES

1. Gray JA, Kim J. Direct care workers’ experiences of grief and needs for support. J Appl Res Intellect Disabil. 2017;30(6):995-1006.

2. Sato HW. Building healthier workplaces by giving space for work-related grief. AACN Adv Crit Care. 2018;29(3):244-245.

3. Allie Z, LeRoux E, Mahlatsi K, et al. Bereavement overload and its effects on, and related coping mechanisms of health care providers and ward administrators at National District Hospital in Bloemfontein, Free State. Afr J Prim Health Care Fam Med. 2018;10(1):e1-e7.

4. Ghesquiere A, Bagaajav A. “We take care of people: what happens to us afterwards?”: home health aides and bereavement care in hospice. Omega (Westport); 2018 Jan 1:30222818754668. doi: 10.1177/0030222818754668. [Epub ahead of print]

5. Vega VP, Gonzalez RR, Bustos MJ, et al. Relationship between grief support and burnout syndrome in professionals and technicians of pediatric health. Rev Chil Pediatr. 2018;88(5):614-621.