MDS Alert

Death is part of life in the long-term care industry, and acknowledging it can help everyone.

One of the realities of working in the long-term care industry is that the residents rarely get better. In residential facilities, especially, many people enter their new homes expecting to spend the rest of their lives there, meaning that facility staff often have more exposure to death and dying than the average American.

As death has become defined principally on clinical terms, especially in the healthcare-centric environments where many Americans now die, Americans have lost the connection to other facets of death and dying, including how to process grief and bereavement.

Consistently Witnessing Death can be Traumatic

Though nursing facility staff may witness death or dying more regularly because of the exposure to residents dying, the acknowledgement of grief and the practice of bereavement aren’t necessarily part of the long-term care industry culture.

Because providing high-quality care necessarily requires and fosters a particular intimacy between a resident and facility staff, losing a resident — and not having the time or space to grieve the loss, especially because it occurs on the clock in the workplace — can feel overwhelming.

The staff members who provide the most hands-on care, like certified nursing assistants (CNAs) are particularly vulnerable to the shock and grief of suddenly losing someone in their care. Staff working with particular populations, such as residents with dementia, may see death and experience grief even more frequently.

Note: The continual exposure to grief while on the clock, especially if a workplace culture fails to support bereaved workers or acknowledge their grief, is a contributing factor to high turnover.

“Healthcare providers working with people living with dementia often experience a profound sense of grief when the person they support dies or moves to an alternative level of care. Unattended staff grief can impact healthcare leaders by reducing quality of care, increasing staff turnover and absenteeism, lowering morale, and creating a greater risk of long-term staff health problems. Organizational and self-care strategies can mitigate these challenges,” says Mary schulz, MSW, CSW, in her paper “Taking the lead: Supporting staff in coping with grief and loss in dementia care,” published in Healthcare Management Forum 2017, Volume 30.

If your facility doesn’t already have some kind of structured program or policies in place to help staff (and surviving residents) more fully acknowledge and express any grief they feel at the passing of a resident, the new year is a great time to make adjustments.

Remember: Though the loss and bereavement of residents may be most fully on your facility’s radar, other types of loss outside of work — like divorce, for example — can majorly affect how staff copes with day-to-day situations. A comprehensive bereavement and loss policy and support plan can help staff feel supported — and help your facility maintain its workforce in the longer term as well. Keep an eye out next month for more on how to incorporate compassionate bereavement and grief policies for staff who experience losses outside of the facility.

“Changing the culture of silence around death and dying in long-term care settings is essential in promoting healthy ways for staff to acknowledge, express, and resolve their grief, which enhances their ability to continue providing compassionate and quality care,” Shulz says.

Help Staff ‘Prepare’ for Death

Although relatively few studies have been conducted on the reality of grief in the long-term care industry and amongst its workers, the studies that have been done suggest that preparedness is key to processing grief.

Part of this preparedness can come from acknowledging the significance of observations about the resident, such as not just determining that a resident is in pain for the clinical record, but also understanding the bigger picture of what that pain means, in terms of death and dying.

In a study about how front-line staff approach the reality of death for residents in their care, Isabelle van Riesenbeck, MS; Kathrin Boerner, PhD; Adrita Barooah, MS; and Orah R. Burack, MAdescribe how staff who observe and acknowledge a dying resident’s pain are less surprised and more prepared for the resident’s death.

“CNAs who experienced their resident as in pain or aware of dying were likely to report both greater emotional and informational preparedness. Specifically, observing the resident as being in pain seemed to be most strongly related to greater preparedness levels,” say van Riesenbeck, Boerner, Barooah, and Burack in their paper “Preparedness for Resident Death in Long-Term Care: The Experience of Front-Line Staff,” which was published in the Journal of Pain and Symptom Management in July 2015.

Experience and Support Crucial, Too

Helping staff members acknowledge that a resident is dying — and providing everyone with a facility culture that allows them the space to discuss a resident’s state honestly and debrief — can do a lot for everyone’s emotional well-being, as well as the facility’s staffing retention rates.

“Greater emotional preparedness was reported by CNAs who were older, had a longer tenure in the job, perceived the resident as in pain, and perceived that the resident was aware he/she was dying. Greater emotional preparedness also was found for CNAs who turned to their coworkers for support in the last weeks of the resident’s life, who had a resident die on hospice, and who viewed the hospice involvement as positive,” say van Riesenbeck, Boerner, Barooah, and Burack.

Look to your facility’s leaders — or take charge, if appropriate — in integrating small changes to effect bigger shifts.

“Leaders can support a healthy grieving process among peers by allowing and encouraging staff to gather after the death of a client either informally or through a formal grief support program. Informal grief support can be easily integrated into existing and routine processes in long-term care homes, such as a regular team huddle on each shift,” Shulz says.

“It is a built-in forum that gives staff a meaningful opportunity to recount stories about and feelings of loss for a client who has died in an atmosphere where grief is acknowledged and supported,” she explains.

Helping staff more fully honor resident deaths, as well as acknowledging the loss of a resident formally, can help both staff and surviving residents more fully express their grief and help everyone better process the taboo and taxing reality of death in the long-term care industry. See accompanying sidebar for some ideas on how to honor a resident’s death.