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Some aides at a Dayton, OH, home care agency began missing work and meetings and behaving as though they were depressed.
The problem, the agency’s education manager discovered, was that about 10 of them had long-term patients who had died in recent months, and the aides were silently grieving.
The education manager realized that was the problem after holding an inservice that received a "huge attendance," says Annie Jones, RN, MS, home care aide educator for Fidelity Health Care of Dayton, OH. The full-service, nonprofit agency serves 13 counties in southwest Ohio.
Experts on death and dying say home care agencies need to remind aides and nurses that grief is natural. It’s a part of caring for the sick and dying. Education managers can help by holding an inservice on grief that gives employees practical tools for coping with patients’ deaths.
Jones asked David Rex, MA, CEAP, a counselor at Miami Valley Employee Care, an employee assistance program, in Dayton, OH, to conduct the 11¼2 hour grief inservice.
"It was very beneficial," Jones says. "He gave us a list of things we could do to manage grief."
Rex says health care professionals often reach a point where they can detach from death. "But over time it accumulates and can be quite painful," he says. "They need to be aware of the processes they go through in their own grieving, or they could be wounded healers."
After the inservice on grief, the Fidelity Health Care aides became more open about their feelings of grief.
"They’re willing to talk about grief now," Jones relates. "Before they would think they should be over it when someone died."
Also, the aides began to recognize how their behavioral changes, such as missing a staff meeting because of oversleeping, were because of their grief.
"They didn’t know what was wrong with them before," she adds. "Now when they lose a patient, they feel bad, but they can talk about it and recognize that they’re grieving — that’s the biggest benefit."
Education managers who want to develop their own grief inservice could begin by using the following suggestions made by experts in the field:
1. Begin by discussing the process of dying and the experiences of those who are near death.
"We talk about the needs of people who are dying and how people have a need to participate in their own death and maintain dignity as they die," says Pat Ehsanipoor, RN, MSN, staff development manager of CareOne Home Health in Savannah, GA.
These needs include hope, an opportunity to ventilate, and belief that he or she is a valuable person, Ehsanipoor says. (See outline on teaching death and dying, pp. 21-22.)
"One home health aide told us about a patient’s family where the dying grandmother was feeling hopeless and depressed," she relates. Then the 8-year-old granddaughter asked her grandmother to tell her a story that she would tape record. Every Sunday afternoon, for the last few weeks of the grandmother’s life, the child and grandmother spent time together, talking.
"The girl really looked forward to her time with her grandmother, and the grandmother’s words were a gift to the family," Ehsanipoor says.
Ehsanipoor also discusses the clinical signs of approaching death and has employees complete an exercise in which they pretend to be a person who is dying. (See exercise on death, p. 23.)
2. Cover the five stages of grief, but explain that people can switch back and forth between the stages before they recover.
Rex says these stages, which were developed by Elisabeth Kubler-Ross in the book On Death and Dying, might help home health aides and nurses understand what their patients are going through, as well as give them insights into their own feelings.
The stages are as follows:
• Shock or denial.
"This can take different forms," Rex says. "They can act as if it never happened or just not talk about it."
Home care professionals might close themselves emotionally from a loss or act as though it’s not significant. But this facade only masks their grief, experts say.
"I think sometimes they believe they have to be the consummate professionals, but sometimes the most healthy thing they can do is be a part of it; acknowledge it; embrace it, and talk about it," Rex explains.
This stage is when those who are grieving try to make a bargain with themselves or with God.
"Sometimes, people in the helping profession will think, I’ll work harder, and that will save more people,’" Rex says. "Or they’ll say, Maybe if I’d done this differently, he wouldn’t have died.’"
Rex adds, "I think we use bargaining as a way of lessening the emotional impact it has on us, especially if the loss is significant to us."
"It’s unjust; it’s not fair; people can get mad and ticked off about death," Rex says, adding that men are more likely to exhibit signs of anger, while women will often show more signs of depression.
Missing meetings, coming to work late, and forgetting things that normally the person would never forget are all signs of depression, experts say.
Grief workshops and support groups, experts suggest, will help home care professionals reach this final stage of grief in which they can serenely talk about the loss.
3. Give employees some ideas of how they can help others, including coworkers, who are grieving for loved ones.
A support group might be one way to allow employees to help one another deal with loss. But support also can be offered casually, says Phyllis Davies, an author in San Luis Obispo, CA. Davies has written two books about death and dying that have been used by hospice, home care, and other health industry professionals.
Davies is one of those rare individuals whose own grief was shared publicly when her 13-year-old son died during a mid-air plane collision in 1984.
She offers health care providers advice from the perspective of the family that is grieving. She says these tips also could help coworkers who are grieving from the loss of a family member:
• "Take a few moments to listen and encourage them to start a notebook of their own, where they can record the memories of that person," Davies suggests. "Have them start an I remember’ section and an I feel’ section, and just record the memories as they come."
• If home care professionals are able to go to the funeral of a former patient or of a colleague’s family member, then they should do so, Davies says. This means more than they can imagine to the family of the deceased.
"More than 700 people attended the memorial service for my son, and I can name every person and tell you where each person sat," she adds.
• Also, it helps a grieving person if a friend shares memories. "Instead of sending just a sympathy card, send an I remember when he laughed at such and such,’ note. Or write, I will never forget his blue eyes and beautiful hair,’" Davies says.
• "Mark your calendar when the death occurred and also the deceased’s birthday, and then send a card a year later," she urges. "It’s a lovely thing to do."
• Davies’ advice of what not to do is quite simply, "Avoid giving advice [to the person who is grieving]; the family will appreciate knowing your feelings but not what you think and how you can fix things."
4. Give employees support for discussing and working through grief.
"In our society, we are told that we have three days to grieve, and then we have to go back to work," says Sherry E. Showalter, MSW, bereavement care coordinator for VNA Community Hospice of Arlington, VA. The nonprofit agency serves northern and western Virginia.
"We spend more time at work than we do at home sometimes, so allow people to talk about it at work," Showalter insists.
"If we as health care professionals can give people permission to grieve and let them know that it’s OK, then we will have better people to attend the sick and dying."
VNA Community Hospice holds regular memorial services for staff to provide employees with an outlet for grieving. Showalter says they also prepare people for the holidays by holding a ritual she has chosen from her Cherokee background: "Calling of the Names."
During the ritual, employees tell small stories about those who have died.
"Talking about it and telling stories are wonderful ways of remembering," Showalter says. "Maybe twice a year we pull people together so they can remember the people who died whom they were privileged to serve."
If an aide or nurse needs extra help in coping with a patient’s death, Showalter suggests a special ritual that is in keeping with the person’s own spiritual beliefs.
This ritual could evoke images of angels or use candles as they’re used by some religions. If the person is open to native American traditions, Showalter will use one of those rituals. (See grief rituals story, below.)
One nurse Showalter knows created her own ritual for releasing grief. Whenever the woman traveled to the Big Sur on the West Coast, she would sit in front of the ocean and reflect on the patients and people she knew who had died.
"She thought about them and described it as casting out a butterfly,’" Showalter recalls. "She had them wrapped inside her like a cocoon. So when she visited the Big Sur, she would let go of the cocoons she had guarded and taken care of, and they would become everlasting butterflies, leaving her free to rebuild."