This study examined the experiences of direct care workers (CNAs and HHAs) with patient death, including their grief symptoms and needs for training and support. Key findings include: 1) Both CNAs and HHAs reported grief symptoms similar to family caregivers after a patient's death, though some symptoms were less common in staff. 2) Most staff felt unprepared, both emotionally and informationally, for patient death due to little training. 3) Greater emotional preparedness and closer relationships with patients predicted more intense grief. 4) More intense grief was also related to more negative employment outcomes like increased emotional exhaustion. 5) Staff desired more training, preparation, rituals to acknowledge

1. Direct Care Workers’ Experiences with
Patient Death: Training and Support Needs
Kathrin Boerner
Jewish Home Lifecare/Icahn School of Medicine at Mount Sinai
The research presented herein was supported by a grant from the National
Institute on Aging (1 R03 AG034076), as well as by several private donors.

2. Background
• Bereavement typically considered in context of family
• Research focused on bereavement in informal caregivers
• Little is known about formal caregivers’ response to death
of person they have cared for
• Increasing number of elders have to rely on formal care
• Front-line staff providing bulk of direct care are CNAs in
nursing homes and homecare workers in community
• Staff often develop family-like ties, but grief of staff is
under-acknowledged or “disenfranchised” (Moss et al., 2003)
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3. Study Objectives
• To examine grief symptoms in direct care workers after
the death of a patient in their care
• To investigate the relationship between grief and
employment-related outcomes
• To identify training and support needs related to patient
death and dying
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4. Study Sample
CNAs (N =140)
HHAs (N = 80)
M = 50.5 (SD 8.9)
M = 43.2 (SD 12.5)
Gender (female)
89%
96%
Race/ethnicity**
84% Black;
11% Hispanic
67% Black;
29% Hispanic
HS/GED
48%
36%
Some college
30%
31%
College graduate
8%
11%
85%
81%
Age***
Education
Religiosity
Faith very important
Group differences CNAs vs. HHAs: *p < .05, **p < .01, ***p < .001.
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5. Study Sample (cont.)
CNAs (N =140)
Manhattan
Site/agency
51
Bronx
Jewish
Home Lifecare
62
Westchester
Shift
HHAs (N = 80)
27
38
42
Other
62 day, 58 eve, 20 night
--
Years on job***
M = 15.2 (SD = 7.4)
M = 6.5 (SD = 6.6)
Months with
patient***
M = 38.9 (SD = 36.9)
M = 18 (SD = 29.0)
Months since
death**
M = 1.5 (SD = 1.1)
M = 1.1 (SD = 1.0)
Group differences CNAs vs. HHAs: *p < .05, **p < .01, ***p < .001.
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6. Grief Symptoms Less Common in Staff
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Cry when think of Still feel need to cry
person
CNAs
6
HHAs
Can't avoid
thinking
No one can ever
take place
Family Caregivers

7. Grief Symptoms Equally Endorsed
100%
80%
60%
40%
20%
0%
Very much miss
person
CNAs
7
Things/people
remind me
HHAs
Painful to recall
memories
Hide my tears
Family Caregivers

8. Acceptance of Death More Difficult for CNAs?
30%
25%
20%
15%
10%
5%
0%
Cannot accept death Unfair person died
CNAs
8
HHAs
Unable to accept
Family Caregivers

9. Summary - Grief Experience
• Experiences of CNAs and HHAs reflected many core grief
symptoms and expressions typically reported by family caregivers.
• Only 4 of 13 grief symptoms showed clear contrasting pattern of
being reported by minority of staff vs. majority of family caregivers.
• Groups were very similar on core items such as very much missing
the person and that it’s painful to recall memories.
• Surprising percentage of staff endorsed item considered key
indicator of very close relationships (No one can ever take place).
• Striking percentage seemed to struggle with acceptance of death.
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10. “Not at All” Prepared for Death of Patient
50%
40%
30%
20%
10%
0%
Unprepared emotional
Unprepared informational
CNAs
10
HHAs
Unprepared - both

11. Lack of Training or Preparation for Patient Death
80%
70%
60%
50%
40%
30%
20%
10%
0%
No training from
employer
No training elsewhere
CNAs
11
HHAs
No training at all

12. Types of Training or Preparation
Learned about Patient Death/Dying
CNAs
HHAs
%
Intro training/orientation
5
10
Inservice
27
26
Written information from employer**
0
8
Support/focus groupsᵻ
3
0
Informal on-site instruction
4
10
Instruction not to get close*
4
13
Personal experience
7
13
Previous work experience
6
4
Certification/school
12
9
Group differences CNAs vs. HHAs: ᵻ p < .10, *p < .05, **p < .01.
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13. Need for More Training and Preparation!
We have a lot of residents just coming in for comfort care.
You’re looking at death every week. It’s like a hospice
atmosphere. If you’re gonna do hospice, we should be
trained for that. I don’t think it’s fair to bring a resident in
when you’re not trained to deal with that.
CNA
The in-service on death and dying, it was more about what to
expect in terms of symptoms. Not for us really - not support.
HHA
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14. Support in Context of Patient Death
CNAs
HHAs
N (%)
Support before death:
From supervisor
Helpful
From coworker ***
Helpful
22 (16)
10 (12)
19 (86)
9 (90)
75 (54)
8 (10)
73 (97)
7 (88)
13 (9)
15 (19)
12 (92)
14 (93)
84 (60)
12 (15)
78 (93)
9 (75)
Support after death:
From supervisor *
Helpful
From coworker ***
Helpful *
Group differences CNAs vs. HHAs: *p < .05, ***p < .001.
Support (yes); Helpful (somewhat/very).
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15. Desired Support in Context of Patient Death
50%
45%
40%
35%
30%
25%
CNAs
HHAs
20%
15%
10%
5%
0%
Memorial
Ensure better Opportunity to Better training
ritual at work
EOL care
talk
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16. Emotional Preparedness and Closeness of
Relationship with Patient Predict Grief
b
Staff factors
Emotional preparedness
R2 change
.08*
–.21*
Institutional factors
.01
ns
Patient/relational factors
Months with patient
Relationship with patient
Total R2
.06**
.21**
.19**
.15**
Variables accounted for but not significant: Age, Education, Time since death,
Other patient deaths, Informational preparedness, Care setting, Support
availability supervisor/coworkers, Patient suffering, Caregiving benefits.
*p < .05, **p < .01, ***p < .001.
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17. More Intense Grief Related to More
Negative Employment Outcomes
Depersonalization
Emotional Sick days after
exhaustion patient death
Grief
symptoms
.17*
.08
.17**
Grief
avoidance
.26**
.13ᵻ
.06
N = 220. ᵻ p < .10, *p < .05, **p < .01.
Would you say that taking sick time was related? Yes.
How would you say it was related? I was all day in bed thinking
about him. I was so down, I couldn’t go to work. I just called and
said I don’t feel well.
CNA
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18. Key Points
• “Caring about those one cares for” desirable in long-term care, but
flip-side is grief after patient death, which comes with potential costs
for employment outcomes.
• To date, direct care staff receive little training, preparation, and
support to help them deal with patient death/dying.
• However, these are important venues to improve the work
experience and employment outcomes of front-line staff.
• Solution is not to prevent grief but to find ways to increase staff
acceptance/preparedness for death, strengthen staff handling of
patient death, to mitigate grief or prevent need for avoidance.
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19. Apply Study Findings
• Use study findings to generate training material, which can be
integrated into existing training programs and curricula, as well
as can be used to design new programs.
• Work towards more integrated involvement of front-line staff in
care process, allowing them to be more prepared and better
positioned to provide high quality care.
• Draw on study findings for concrete suggestions in terms of
supports and acknowledgements desired by front-line staff.
Context-specific plans: Next steps for training,
support, and ritual-building need to consider particular
circumstances and dynamics of each care setting.
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20. Staff Appreciative of Opportunity to
Talk about Patient Death
This [study] is a good thing. Like now: it makes me feel like I’m kind of
getting real closure with [resident]. I got to say what I wanted to say.
Even if I’m not getting answers back, I’m letting out all I had here. If we
had this a long time ago, maybe new CNAs would act different with it.
CNA
For me, I’m grateful you did come. I wanted to tell someone [about
client]. You did inquire about her, and I was able to tell you. That’s the
part I’m gonna hold.
HHA
This interview makes me happy. It makes me happy that [JHL] wants to
know what is my emotional state, how the employee felt or how it
affected him/her. Truth is I did not do it for the money. This interview
has a value and I feel happy that [JHL] is concerned about me.
HHA
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