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FIONA ROWAN asks how well the caring profession cares for its own when nurses lose loved ones and shares findings from her survey of 70 bereaved nurses that indicate New Zealand could do better.

We are all familiar with the mantra ‘should an oxygen mask appear in front of you, secure your own mask before helping others’, and also being told to ‘take note of our nearest exit’.

In other words, ensure your own safety first so you can then care for others, and also have an escape plan in case things don’t go well. These are recommendations that few airline travellers would argue with.

But to what extent are these strategies relevant when a nurse has experienced a personal bereavement through the death of a family member, friend or colleague? My recent research indicates that while some bereaved nurses adopt the airlines’ ‘care for yourself first so you can care for others’ approach, others do not, or are unable to do so.

Bereaved nurses feel ‘unsafe’

For my Master of Nursing research thesis I asked nurses in three district health boards about their experiences of returning to work following a personal bereavement, including whether or not they felt safe to work on resuming their nursing duties.

Alarmingly, 28 per cent of the 70 nurses who responded indicated that they felt unsafe while working, with over one third testifying that their critical analysis skills were adversely affected. Bereaved nurses returning to work described enduring physical and psychological symptoms of grief including ongoing fatigue (64 per cent), tearfulness (57 per cent), insomnia (48 per cent), inability to stop thinking of their loved one (60 per cent), difficulty concentrating (42 per cent), being easily distracted (42 per cent), poor memory (28 per cent), and difficulty making decisions (22 per cent).

Nurse managers and charge nurses were also asked to comment about the strategies they use to assess a bereaved nurse’s safety to work. Eighteen per cent of the 31 nurse leader respondents indicated they initiate an informal conversation with the nurse or request that the nurse self-assesses their own safety to work. The remaining nurse leaders (82 per cent) did not assess bereaved nurses’ safety to work in any way.

The validity of relying solely on a bereaved nurse’s self-assessment of their safety to work must be questioned. Nearly half of the 72 per cent of nurse respondents who described themselves as safe to work went on to express an array of grief symptoms upon resuming their nursing duties. Although the impact of these symptoms was not explored, the study data suggests that bereaved nurses may not be in the right place to critically analyse and make decisions about their own safety to work, as it is these very skills that are adversely affected by bereavement.

This limited consideration of nurses’ safety to work following a personal bereavement is of concern, particularly given that American nursing academics Marguerite Purnell and Lucy Mead suggest that bereaved nurses should be considered as a unique cohort of the bereaved, separate from the general population.

Anyone experiencing personal bereavement will require support to adjust to the changed reality of living without their loved one. However, Purnell and Mead contend that, unlike the general public, nurses need to do so while remaining empathetic to and understanding of their patient’s concerns – patients who themselves may be experiencing illness, pain, grief or impending death. Purnell and Mead have termed this intermingling of nurses’ personal grief with the professional response to their patient’s grief, as “layered suffering”.

Presenteeism risk

That bereaved New Zealand nurses report nursing while experiencing this disruption to their physical health and cognitive proficiency confirms that some bereaved nurses practice what is known as presenteeism; that is, working when unwell. A presenteeism study by American nurse researcher
Susan Letvak and her colleagues published in 2012 found that nurses who worked while unwell escalated patient risk, resulting in an increase in medication errors and patient falls, and a decrease in the quality of care. When this practice of presenteeism in bereaved nurses is combined with shift work-related fatigue and the increasing acuity of today’s healthcare environment, there is the potential for creating a ‘perfect storm’ for these grieving nurses and their patients.

The nurses’ motivations for practicing presenteeism were not explored in detail in this research. However, respondents indicated that limited access to both paid and unpaid leave, limited nurse manager understanding of the impact of bereavement on core nursing values, and the socialisation of nurses to the caring role (whereby their own needs are subsumed by the dominant team culture) were all contributing factors.

Bereavement leave recommendations

• A number of recommendations and suggestions have arisen from this research around bereavement leave, including:
• improving flexibility and extension of leave options to help reduce the practice of presenteeism in bereaved nurses
• recognising that legislated bereavement leave requirements are frequently insufficient to meet the needs of grieving nurses
• advocating regular nurse manager contact with the bereaved nurse, focusing on acknowledging the nurse’s loss and helping them to identify the impact of the bereavement and any specific needs
• assessing a bereaved nurse’s safety to return to nursing duties. This may involve identifying existing or developing novel grief assessment tools.

Return-to-work strategies

The research also recommends the adoption of some practical strategies for when bereaved nurses return to work. Adopting such strategies may mitigate the adverse layering effects of bereaved nurses caring for patients who themselves may be grieving and the risks associated with presenteeism in bereaved nurses. Some return-to-work strategies suggested include:

• a phased return to work
• allowing for flexible work hours and/or workload
• allocating an empathetic caseload (ie, avoiding the care of palliative clients or those with particular conditions)
• adopting a routine supported practice model for bereaved RNs returning to work; for example, the grieving nurse working alongside a mutually agreed experienced colleague. (Both caseloads could be managed as one so decision-making is shared, medications co-checked, and support provided in a personalised and timely manner.)

Further consideration needs to be given to identifying the impact that personal bereavement may have upon nurses’ core values and upon their ability to retrieve tacit and formal knowledge.

Ultimately, we need to consider the implications for our patients if bereaved nurses fail to attend to their own needs first, or are unable to identify when using an ‘exit strategy’ is the safest course of action for all. :

Author: Fiona Rowan, RN, MN, Nurse Educator, MidCentral Health. Her MN thesis for the Eastern Institute of Technology was inspired by her personal experience following the tragic death of her brother as a result of the 22 February 2011 Christchurch earthquake. Rowan’s thesis ‘When nurses grieve: how well are we caring for the carers?’ can be downloaded at www.digitalnz.org/records/36302521