A narrative that brings attention to the work-related grief that is experienced by nurse assistants and the need for more sufficient training and support. Necessary training and support that will help reduce the high burnout and turnover rates of nurse assistants and improve patient care.

1. A Cry for Change
Leilani Y. Roseberry

2. End-of-Life Care and Beyond

3. Currently…
๏ Many nurse assistants are not thoroughly
trained in end-of-life care beyond post-mortem
care.
๏ Nurse assistants work in a field, whether it’s
private homes, nursing homes or elsewhere,
which lacks end-of-life training, grief
counseling, and support.
๏ This can lead to Unresolved Grief

4. The Nurse Assistant…
๏ Must be given the opportunity to process
emotions surrounding end-of-life care and
beyond.
๏ Currently there is limited professional support
๏ Support from co-workers is minimal
๏ The in-home nurse assistant works alone and
experiences an even greater limitation on
support because he or she works alone.

5. Unresolved Grief…
๏ Causes
๏ Symptoms
๏ Negative Outcomes
๏ Impact on Patient Care
๏ Cry for Change

7. Causes of Unresolved Grief…
๏ Absent grief
๏ Delayed grief
๏ Inhibited grief
๏ Conflicted grief
๏ Chronic grief
๏ Unanticipated grief
๏ Abbreviated grief

8. Symptoms of unresolved grief
๏ Irritability
๏ Apathy
๏ Preoccupation with thoughts of the deceased
๏ Lack of acceptance of death

9. Negative outcomes for the nurse
assistant with unresolved grief
๏ Disenfranchised grief
๏ Compassion fatigue
๏ Moral distress
๏ Burnout

10. Disenfranchised Grief
๏ "Disenfranchised grief is when your heart is
grieving but you can't talk about or share your
pain with others because it is considered
unacceptable to others. It's when you're sad
and miserable and the world doesn't think you
should be, either because you're not entitled or
because it isn't worth it." E. Kupferman
๏ This leads to building of a protective shield
and depersonalization (negative, cynical
attitudes and feelings about one's clients)

11. Compassion Fatigue
๏ "It occurs as caregivers consistently give out
more energy and compassion than they
receive, and manifests itself as physical,
emotional, and spiritual exhaustion." BM
Frandsen
๏ "It can effect the ability to care for others."
TA Brosche

12. Moral Distress
๏ "The stress, anxiety, apathy, and burnout that
can often occur from repeated loss and when
personal values conflict with the
environment." TA Brosche
๏ "Cumulative exposure to patient death can
serve as a reminder of the nurses' own life
losses and can lead to painful awareness of
their own mortality." Chrisitina G. Shinbara,
Grief Support for Nurses: An Assessment of
Needs, 2008

13. Burnout
๏ Job performance declines
๏ Health-related problems occur
๏ Depression sets in
๏ Possible career change leading to turnover

14. The Impact on Patient Care
๏ Unresolved grief has negative outcomes for
the patient.

15. Impact of unresolved grief on
patient care
๏ Nurse assistants objectify patients-They "view
residents as room numbers rather than
people." KA Anderson
๏ They refer to patients by condition
๏ They provide care in an impersonal, hasty
mechanical manner.
๏ This manner of care causes patient and patient
family distress

16. Impact of unresolved grief on
patient care
๏ The turnover in nurse assistants causes
discontinuity of care which greatly upsets
patients who rely significantly on their
caregiver, especially patients receiving in-
home care.
๏ This is also “Reported as a primary concern of
nursing home residents and their families.”

17. Nurse assistant turnover
๏ In 2007 the turnover was 65.6%
๏ In 2008 the US experienced a "turnover rate
for Certified Nurse Assistants [that] was
higher than other nursing staff, at 54%"
(American Healthcare Association-Department
of Research)
๏ "The current instability in the nursing
workforce implies adverse impacts on the
continuity and quality of patient care." Sung-
Heui Bae, RN, MPH, PhD

18. Nationwide shortage of CNAs
๏ "Shortages of CNAs are estimated to be
200,000 and anticipated to increase." KA
Anderson, MSW, PhD
๏ In 2003 there were 52,000 vacant CNA
positions nationwide-Robyn I. Stone, DrPH

19. True Healing
๏ Unresolved grief and the negative
consequences can only be overcome by true
healing

20. Where is the support for grief in
our professional lives?
๏ "Sad to say that many text books for NAs only
address Stage of dying and how to do post
mortem care-We don't have a lot of good
training materials for NAs-so we borrow from
other fields." Genevieve Gipson RN Med
RNC, Director, National Network of Career
Nursing Assistants

21. Cry for Change
๏ There is need for further empirical research
focused on unresolved grief and the nurse
assistant
๏ Require thorough CNA training programs
๏ Require employer provided routine access to
grief counseling and support
๏ Maintain a support system for newly certified
nurse assistants

22. Cry for change
๏ "We must protect, enhance, and continue to
develop and educate staff in end-of-life issues.
The support of a bereavement counselor,
educational workshops, and spiritual
enhancement is of the utmost importance for
staff." Sally Wheeler, RN, Personal Touch
Homecare-West Springfield, Massachusetts

23. Cry for change
๏ "Without proper support and death education,
staff are on a quick road to burnout and
turnover, and may be subject to issues related
to grieving and depression" George Mercier,
Administrator, Heritage Hall West Nursing
Home-Agawam, Massachusetts

24. Cry for change
๏ "All nursing home staff must have an
orientation that covers the stages of dying, the
problems faced by those dying, bereavement
issues for the family, and care for themselves."
Donalyn Gross, PhD, LCSW, CMP, Creator of
the Good Endings Program

25. Cry for change
๏ According to research findings by Lesley
Spencer SRN BSc(HonS) PGDE MSc in 1994,
there was a cry for change then and "All
nurses [in the study] felt that more training
about how to deal with thier own grief was
needed."

26. With support we can move
forward
๏ With training and support it is possible to find
peace
๏ "The healthy resolution of grief is associated
with gains in self-efficacy, positive memories,
and inner peace." KA Anderson, MSW, PhD

27. In Conclusion
๏ "I say there should be just as much prevention
and support for the psychological aspect of the
job as there are for the physical aspects."
Leilani Y. Roseberry

28. Bibliography
Anderson, KA. “Grief Experiences of CNAs-Relationships with Burnout and Turnover.” Journal of Gerontological Nursing, Vol.
34, (1) 42-49, 2008
Anderson, KA and Joseph E Gaugler, “The Grief Experiences of Certified Nursing Assistants: Personal Growth and
Complicated Grief.” OMEGA, Vol. 54 (4) 301-318, 2006-2007
Bae, Sung-Heui, Barbara Mark and Bruce Fried. “Impact of Nursing Unit Turnover on Patient Outcomes in Hospitals.” Journal
of Nursing Scholarship, 42 (1), 40-49, 2010
Brosche, TA. “A Grief Team Within a Healthcare System.” Dimensions of Critical Care Nursing, Vol. 26 (1), 21-28, 2007
Brosche, TA. “Death, Dying, and the ICU Nurse.” Dimensions of Critical Care Nursing, Vol. 22 (4), 173-179, 2003
Frandsen, BM. “Burnout or compassion fatigue?” Long Term Living, 50-52, May 2010
G. Gipson (Personal Communication, October 31, 2010)
Gross, D. “Missing: Death education for nursing facilities.” Nursing Homes Magazines, 76-78, September 2004
Kupferman E. Grief Counselor, Expressive Counseling, http://www.expressivecounseling.com/
Shinbara, CG. “Grief Support for Nurses: An Assessment of Needs.” Dissertation, June 16, 2008
Spencer, L. “How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given
to enable them to overcome their grief effectively?” Journal of Advanced Nursing, Vol. 19, 1114-1150, 1994
Stone, RI, Steven L. Dawson and Mary Harahan. “Why Workforce Development Should Be Part of the Long-Term Care Quality
Debate.” Institute for the Future of Aging Services, 1-12, 2003
Zalaquett, CP and Richard J. Wood, eds. “Evaluating Stress.” A Book of Resources, 191-217, 1997
28