For those working in palliative care, encountering death is a familiar part of their daily work. Many community care staff encounter death and dying during their professional visits to patients' homes. Death and dying episodes tend to provoke a negative impact on professionals (Nicol and Nyatanga, 2017) as they are constantly exposed to patients at the end of life, thereby being reminded of their own existential fragility. While the focus of care and support remains on the dying patient and then their family following the death, we must also consider what kind of impact these experiences have on community nurses (CNs). Nicol and Nyatanga (2017) explained how healthcare professionals (HCPs) forge caring relationships with their patients, and through this, become emotionally attached. The advent of death breaks this attachment and results in expressions/feelings of grief. Most literature on loss, including but not limited to Stroebe and Schut (1999), claim that affectionate bonds are formed as people develop relationships with each other. The claim is that the closer or stronger the relationship is, the deeper the emotional bond is between people. It therefore translates that when death occurs, the bereaved feel pain that reflects the depth of the emotional attachment. The critical point is that CNs may develop multiple relationships with these patients and consequently, may also experience multiple losses and grief episodes.
Support for those deemed important to the dying
The literature is full of strategies to support families and close friends during and after death. For example, one modern approach is the Dual Process Model for coping with bereavement developed by Stroebe and Schut (1999), which is progressive in its support for the bereaved. First, the model recognises two important theories that most bereaved people experience:
- The need to deny the death (denial) and
- The difficulty of ‘letting go’, especially where strong emotional bonds are formed with the deceased person.
Here, we should view denial in a positive way (although, unfortunate that we often refer to it negatively) as people are literally taking time out to reorganise, compose and refocus themselves and find new energy to grieve. Therefore, time out (we call it denial) can, in fact, be quite positive in helping the bereaved adjust and face up to life without the deceased. The challenge is how much time out is positive before it becomes pathological.
Letting go is the idea of somehow relinquishing everything about the deceased so that they can move on with their life. The reality of achieving this is not as straight forward as the literature suggests. The Dual Process Model recognises these issues and rightly addresses them by creating a dynamic process that encourages the bereaved to oscillate between different emotions. The oscillation is between loss-oriented emotional states and restoration-oriented tasks of everyday life activities. This approach is seen as a perfect balance for grieving and moving on with life at the same time. The oscillation time is also important in that the bereaved can ‘clear their mind’ as they move from one phase to another.
Stroebe and Schut (1999) made an interesting observation with gender differences by claiming that most females are loss-oriented, whilst males are restoration-oriented when coping with death. The point to emerge may simply be that females may take longer to process their losses. The implication from this should draw our attention to finding better ways of supporting bereaved female family members.
However, a bigger challenge is that while the Dual Process Model might help relatives cope, no such model exists for HCPs who (as argued above) may experience similar losses and grief. Nursing is predominantly female, which is also reflected in community nursing. This suggests that they may take longer to process and manage their own feelings of loss and expressions of grief. Therefore, more care and support is needed for community palliative care nurses.
The challenge for community managers is to embrace this reality and offer support for staff to negotiate their loss and grief. Most organisations offer formal support (supervised debrief, spiritual care and safe spaces) while staff seek peer support, which offers an opportunity to talk about the death informally. This way, staff have immediate support, while reframing their thoughts and reenergising to continue to provide care.