Creating a workplace bereavement plan.

Takeaways:

• When a nurse dies the team grieves.
• Developing a bereavement team and protocol will support the organization through the grieving process after a colleague dies.
• Providing adequate support during grief is seen as an act of caring in leadership.

HELPING PATIENTS and their families deal with death and grief is a fundamental part of nursing. However, nurses don’t receive training for dealing with the death of one of our own. But, of course, colleagues die, too, and these deaths can have profound effects on those left behind.

The nature of nursing (working in different departments) and the decentralization of healthcare staff (including physicians and ancillary team members) means that hundreds of colleagues beyond a deceased nurse’s current unit may be affected by the death. If grief management focuses only on the nurse’s current department, grieving people throughout the organization won’t have the opportunity for support. The solution is a workplace bereavement management team that works in concert with unit-level leadership to share information and provide access to support systems. We’ve learned from direct testimony that staff and physicians view outreach as an act of caring leadership, and that even if resources aren’t used, offering them is appreciated.

Understanding what to expect after a colleague’s death and incorporating the bereavement team steps outlined below can help healthcare teams process their loss.

Grief: What to expect

Grief is a universal, natural, adaptive, and instinctual reaction to the loss of a person who’s important in our lives. The acute manifestations of grief can span from barely noticeable discomfort and dysfunction to gut-wrenching pain and distress.

An acute grief response occurs in the early aftermath of the death. It can include shock, anguish, loss, anger, guilt, regret, anxiety, fear, intrusive images, depersonalization, feeling overwhelmed, loneliness, unhappiness, relief, and depression. At first, feelings of anguish and despair may seem ever-present but soon occur in waves or bursts (bouts of grief that initially are unprovoked and later are brought on by specific reminders of the deceased). Those who’ve never experienced the intense, uncontrollable emotionality of acute grief may find it disconcerting, shameful, or frightening. Some people may try to avoid reminders in what is frequently a misguided attempt to shield themselves from pain. Others may become disinterested in activities of daily life, focusing only on mourning.

For most of the bereaved, the pain and preoccupation with the person who has died gradually become less frequent and intense, wounds begin to heal, and they once again engage in pleasurable and satisfying relationships and activities. For some, however, a loved one’s death may trigger depression (especially in someone with a past history of major depressive disorder), post-traumatic stress disorder (especially if the death is sudden, unanticipated, or traumatic, such as death by suicide), or prolonged grief disorder or complicated grief in which the natural adaptation to loss is blocked and grief remains intense, preoccupying, and disabling beyond the time expected by social and cultural norms.

The bereavement team

The bereavement team should include representatives from nursing, medical staff, chaplaincy, social services, human resources, the employee assistance program (EAP), palliative care (experts in group facilitation and grief), and the organization’s wellness committee. (See Bereavement team members.) A mental health professional (bereavement team therapist) leads counseling efforts and coordinates communication.

Upon learning of a death

When a colleague death occurs, the team divides the work at hand. Use a prepared phone list to ensure everyone on the team has been contacted and that their roles are clear. Members of the team who worked closely with the decease nurse may need to be relieved from their duties and provided with support resources.

The deceased nurse’s unit manager finds replacements if friends can’t work during their shift because of acute grief. The manager also anticipates sick calls for the following days and proactively changes the schedule so that friends are offered days off for the funeral and memorial.

In the days to follow, leadership increases rounding to allow colleagues to express their feelings.

Immediate on-site support

The manager, or whomever learns of the death first, activates the bereavement team by phone, email, or page. The team therapist reaches out to those in departments most likely to be affected and visits them to be available for anyone who needs support.

Contact the family

The bereavement team therapist assigns someone (the deceased nurse’s manager or close work friend) to return employee property and invite the family to the organization’s memorial (which should not be on the same day as the family’s funeral). Even if the family doesn’t attend the organization’s memorial, the staff will need it. The contact also asks about the family’s funeral and whether hospital staff are welcome.

The family contact works with the chaplain, who will organize the memorial. In our experience, families who attended the hospital memorial appreciated the opportunity to hear work colleagues grieve with them.

The family contact arranges for packing and delivering personal belongings and returning any organization property (laptop, phone). He or she asks the family how they would like personal items returned. If they choose to pick up the belongings, the contact greets them and provides a private place to meet so they have an opportunity to share their feelings. The family contact also answers employees’ questions to avoid multiple employees contacting the family directly.

Communication

The bereavement team nurse works with the chief nursing officer to send a staff email about the death, an invitation to the memorial service, and information about emotional process debriefings. (If the memorial service and debriefing information isn’t immediately available, it can be shared later.) The team’s physician representative works with the chief of staff to send a similar email to physicians; other disciplines should be notified as appropriate. A separate email is sent by the bereavement team therapist to nurse leaders inviting them to encourage grief processing and adjust schedules accordingly. (Visit American Nurse Today to view email templates you can use in your organization for communication with leadership and staff.)

The bereavement team human resources representative communicates with benefits and payroll departments to begin the process of employee separation for the deceased nurse and to ensure patient care and other work is uninterrupted. (See The work of patient care continues.)

Emotional process debriefing

In collaboration with the deceased nurse’s unit manager, the team therapist schedules an emotional pro cess debriefing (separate from the memorial service) to include nurses, physicians, and other disciplines. During the debriefing, participants are encouraged to share their feelings. The therapist moderates the discussion, validates participants’ emotions, and builds the shared vision that no one in the group is alone, and that their pain is shared. A short evaluation is conducted at the end. The number of debriefings and participants is tracked, but no sign-in sheets or names are collected. We know from evaluations that participants value the opportunity to vent feelings during these caring events.

If demand exceeds the designated bereavement therapists’ capacity, volunteers from the bereavement team (palliative care, psychiatry, social services, chaplaincy, wellness committee) may need to be activated.

JIT grief training

Offer just-in-time (JIT) grief training to managers, which takes about an hour. Provide hints and advice for about 15 minutes, ask the managers what they’ve been experiencing and seeing, and answer questions about how to handle situations. Then review when grief counseling should be escalated to formal therapy; for example, when staff share thoughts of self-harm, grief prevents work, or thoughts about the death or deceased can’t be quieted. Provide the managers with the bereavement team phone number, employee assistance phone numbers, and the National Suicide Prevention Help – line number (1-800-273-TALK). If the employee died by suicide, share the “After a suicide: A toolkit for physician residency/fellowship programs“. The toolkit was designed for medical trainees but it’s directly applicable to nursing.

Planning for grief

Planning ahead for a colleague’s death can help everyone in the organization grieve and heal. Deny-ing the opportunity to grieve may erode morale and decrease productivity. These steps can be tailored for use in any organization to optimize the grief management process after a nurse’s death.

Judy E. Davidson is a nurse scientist at the University of California San Diego (UCSD) Health Sciences and a scientist in the department of psychiatry at UCSD School of Medicine. Rachael Accardi is a program coordinator/counselor in the UCSD HEAR program, where Courtney Sanchez is a program counselor. Sidney Zisook is a distinguished professor in the Department of Psychiatry at UCSD.

Deanna Syrek provided advice on human resources’ role after an employee’s death.

Selected references

Davidson J, Mendis J, Stuck AR, DeMichele G, Zisook S. Nurse suicide: Breaking the silence. National Academy of Medicine. January 2018. nam.edu/nurse-suicide-breakingthesilence

Davidson JE, Proudfoot J, Lee K, Zisook, S. Nurse suicide in the United States: Analysis of the Center for Disease Control 2014 National Violent Death Reporting System data – set. Arch Psychiatr Nurs. 2019. bit.ly/2mg6Ar2

Davidson JE, Zisook S, Kirby B, DeMichele G, Norcross W. Suicide prevention: A healer education and referral program for nurses. J Nurs Adm. 2018;48(2):85-92.

Dyrbye L, Moutier C, Wolanskyj-Spinner A, Zisook S. After a Suicide: A Toolkit for Medical Schools. American Foundation for Suicide Prevention. 2018. chapterland.org/wpcontent/uploads/sites/13/2018/09/13719_AFSP_Medical_School_Toolkit_m1_v3.pdf

Norcross WA, Moutier C, Tiamson-Kassab M, et al. Update on the UC San Diego Healer Education Assessment and Referral (HEAR) Program. J Med Regul. 2018;104(2):17-26. afsp.org/wp-content/uploads/2018/11/HEAR.Update.JMR-Aug-2018.pdf

Shear MK, Reynolds CF, Simon NM, Zisook S. Grief and bereavement in adults: Clinical features. UpToDate. 2018.

Stroebe M, Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007;370 (9603):1960-73.

Zisook S, Iglewicz A, Avanzino J, et al. Bereavement: Course, consequences, and care. Curr Psychiatry Rep. 2014;16(10):482.