Grief is a natural response to loss, and while grief is often associated with death, it can accompany other sorts of loss, too. When grief is experienced in the workplace, it can impact an employee’s performance, especially if awareness and proper support measures are lacking.

1. Grief and Loss
in the Workplace

2. VITAS Healthcare programs are provided CE credits for their Nurses/Social
Workers and Nursing Home Administrators through: VITAS Healthcare Corporation
of Florida, Inc/CE Broker Number: 50-2135. Approved By: Florida Board of
Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical
Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home
Administrators and Respiratory Therapists through: VITAS Healthcare Corporation
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Division of Profession Regulation for: Licensed Nursing Home Administrators and
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VITAS Healthcare programs in California/Connecticut/Delaware/Illinois/Northern
Virginia/Ohio/Pennsylvania/Washington DC/Wisconsin are provided CE credit for
their Social Workers through VITAS Healthcare Corporation, provider #1222, is
approved as a provider for social work continuing education by the Association of
Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing
Education (ACE) program. VITAS Healthcare maintains responsibility for
the program. ASWB Approval Period: (06/06/15 - 06/06/18). Social Workers
participating in these courses will receive 1-2 clinical or social work ethics continuing
education clock hour(s). {Counselors/MFT/IMFT are not eligible in Ohio}
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Number 10517, expiring 01/31/2019.
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CE Provider
Information

3. The goal of this presentation is to enable
participants to understand the unique grief
and loss experience of the healthcare
professional and other helping professionals,
and to provide participants remedies to
manage their grief and loss.
Goal

4. • Describe physical, emotional and behavioral
manifestations of normal as well as
complicated grief.
• Identify current theoretical frameworks for
understanding grief and mourning.
• Discuss ways that a professional's personal
loss experience affects their work life.
• Describe how healthcare professionals are
additionally affected by loss in the workplace,
including the death of a co-worker as well
as death of a patient(s).
• Discuss helpful techniques for managing
grief in the workplace, including how to
assist grieving co-workers and what the
organization can do to support grieving staff.
Objectives

5. • Loss is a natural, human, universal
experience.
• Types of losses in life:
– Death
– Divorce
– Relocation
– Pet loss
– Death of a co-worker
– Decreased functioning
– “Loss of the Assumptive World”
Healthcare
Professionals
Are People
Too!
Rando, T.A. (1984) Grief, Dying, and Death: Clinical Interventions for Caregivers.
Research Press.

6. Healthcare Professionals…
• Experience loss in our personal life
• Experience loss in our work life
• Provide “Emotional Labor”
- Use of emotional and spiritual self as
labor commodity
• Experience secondary trauma
– We work with vulnerable patients.
– We vicariously absorb their suffering.
Emotional
Labor and
Secondary
Trauma
Hochschild, A. R. (2012).The Managed Heart Commercialization of Human Feeling.
University of California Press.

7. • Grief is a natural and normal reaction
to a loss.
• Humans are hardwired to attach.
• Therefore, death causes suffering.
• Grief manifestations include:
– Emotional
– Physical
– Cognitive
– Behavioral
– Social
– Spiritual
What Is
Grief?
Bowlby, J. (2008). Attachment. Basic Books; 2 edition.

8. • Tightening in the chest and throat
• Changes in sleep, appetite, activity habits
• Increased infections are common
– Can lead to increased absenteeism
• Can last a few days, few months, or even
a year or more
Physical
Effects of
Grief

9. • Confusion
• Memory gaps
• Difficulty concentrating
• Auditory and/or visual hallucinations
• Searching behavior
• Odd dreams
Cognitive
Disturbances

10. “Where you used to be, there is a hole in the world,
which I find myself constantly walking around
in the daytime and falling into at night.”
–Poet Edna St. Vincent Millay

11. • Mourner takes on tasks and roles the
deceased performed
• Mourner might have difficulty being
with others
– Small talk seems trivial
– Ambivalent about seeing others happy
and feeling joy
Social
Identity
Alterations

12. • Relationships change
• “New normal” develops in the family system
• In the case of a death of a co-worker:
– Potential for added caseload
– Potential need to support the
co-worker’s patients
Social
Identity
Alterations
(Cont’d)

13. • Shock and disbelief are common at first:
– Can be adaptive
– Can return throughout grief process
• Emotional pain/anxiety common as reality
of loss sinks in
– Happens in different ways/different
timing for everyone
There is not one right way to grieve, nor
one “right” amount of time to grieve.
Emotional
Grief
Reaction

14. • Yearning for the loved one
• Feeling lost, lonely
• Feeling insecure and disorganized
• Crying at unexpected times
• Being irritable over seemingly nothing
• Feeling embarrassed
–“I should be feeling better by now.”
Emotional
Grief
Reaction
(Cont’d)

15. • Anger toward:
– Deceased for dying
– Themselves
– Healthcare personnel
– God, higher power, universe
• Spiritual convictions may be shaken
– “How could God take my loved one
away from me?!”
Anger Is
Common

16. • Guilt about:
– Not doing more to prevent death
or suffering
– Absence at time of death
– Having survived the deceased
– Feeling relieved
– Things that did or did not happen
in the relationship
“We worked together for more than
15 years and I never once thanked her
for all the assistance she gave me over
the years.”
- hospice co-worker
Guilt Is
Common

17. • Intense, all-consuming grief that lasts a
long time
• Two primary views:
1. Presence of specific high-risk factors
coupled with the loss
2. Specific symptoms that are present in
normal grieving, but have abnormal
intensity and duration
What Is
Complicated
Grief?

18. • History of suicidal ideation/attempts
• Psychiatric illness or history
• Extreme emotional reaction that endures
at length
• Physical signs of distress, such as lack
of self care
• Alcohol or drug abuse
Risk
Factors for
Complicated
Grief

19. • Unresolved losses
• Extreme feelings of guilt or shame
• Extreme spiritual distress
• Extreme avoidance of the loss
• Isolation from self or others
• Radical change in lifestyle
Risk
Factors for
Complicated
Grief

20. • Nature of the relationship with the person
who died
• Circumstances surrounding the death
• Mourner’s support system
• Mourner characteristics:
– Age and gender
– Culture
– Religious beliefs
– Values and lifestyle
– Personality
– Life circumstances
Factors
That Make
the Grief
Experience
Unique

21. • Have changed the last 20 years
• Past: predictable “stages” or “tasks” to
adapt to loss
1. Shock and/or avoidance of the loss
2. Confront emotional pain as reality of
loss sinks sink in
3. Adaption to a new life
• Theorists well known for this “stage”
approach: Elizabeth Kubler-Ross, William
Worden, Therese Rando
Grief
Theories

22. • External adjustments: relocation, change
in financial status, acquisition of new
roles/tasks, new social relationships
• Internal adjustments: altered sense of self,
emotional regulation
• Spiritual adjustments: altered sense of the
world, search for meaning
William
Worden

23. • Stroebe and Shut: Dual Process Model
– Grief alternates between
rumination/emotional expression and social
adaptation of the loss.
• Robert Neimeyer: Narrative Approach
– There’s no discernable endpoint or
“recovery from grief.”
– Dwelling on what is lost has no
psychological benefits.
• White, Hedtke, Winslade:
– Relationship does not end with death
– Mourner reincorporates the deceased
– Remembering can be comforting
• Affirms hope, relationship, connection
Newer
Theories
About Grief

24. “As we cherish memories, we return to freshen and deepen
our understanding of those who died, attend to them again,
bring them closer, embrace them in their absence, reconnect
with some of the best in life, feel grateful, feel the warmth
of our love for them, sense that they are grateful for
our remembering, and feel the warmth of their love for us.”
—Tom Attig, The Heart of Grief

25. • In the 4th edition edition of Grief
Counseling and Grief Psychotherapy,
Worden redefined his forth “task” of
mourning:
– From: “Relocating the deceased
emotionally and moving on with life”
– To: “Finding an enduring connection with
the deceased in the midst of embarking
on a new life”
William
Worden,
Updated
Worden, J.W. (2008). Grief Counseling and Grief Therapy, Fourth Edition: A Handbook for
the Mental Health Practitioner. Springer Publishing Company

26. • Typical workplace expectation: “Grief is like the flu”
– 3 days bereavement leave
– Come back prepared to work at capacity
• Effect of grief on employee work performance
– Family illness/death is the 2nd most common
problem affecting workplace performance.
– 90% of workers in physical jobs have higher
incidence of injuries due to reduced concentration
– 70% of grievers reported increased/new use of
alcohol/mood-altering substances up to 6 months
following major loss
– 90% of grieving people reported their ability to
concentrate was reduced following loss
Grief and the
Workplace
James J.W. Friedman, R. Cline, E.(2003). Grief Index: the "Hidden" Annual Costs of
Grief in America's Workplace. Grief Recovery Institute Educational Foundation, Inc.,
Sherman Oaks, CA.

27. • We may spend more time with a co-worker
than any other person.
• We develop a unique bond because of
shared experience.
• We may downplay our grief reaction:
“Disenfranchised Grief”
Death of a
Co-Worker
Doka, K.J. (1989). Disenfranchised Grief: Recognizing Hidden Sorrow. Lexington Books.

28. • How do we handle grief and loss?
• How do we cope with witnessing another
human’s suffering?
• How do we manage our fear?
• How do we acknowledge the existential
mystery of death?
• How do we give voice to the loss?
• How do we care for the next patient that
needs our expertise and service without
wallowing in despair?
The
Healthcare
Professional’s
“Balancing
Act”

29. • We self-identify as caring persons—
we want to help others.
• We believe we have that skill set and will
receive self-satisfaction.
• We use our “emotional self”
• We instinctively mirror that part of self
that understands vulnerability and being
“cared for.”
Healthcare
Professional
and the
“Use of Self”

30. • We cannot be helpful if we deny we are
affected by another’s suffering.
However:
• A “helper” is most helpful by aligning with
someone in their pain, “as if” it were their
own pain. Key phrase being “as if”
- Carl Rogers, Founder, Humanistic
Psychology Movement
• We relate to suffering as a fellow
human being.
• The key is to understand: This pain is not
MY pain.
True
Compassion
vs.
Compassion
Fatigue
Larson, D.G. (1993). The Helper's Journey: Working With People Facing Grief,
Loss, and Life-Threatening Illness. Research Press.

31. • Buddhism: State of mental/emotional
stability arising from deep
awareness/acceptance of the present
moment (Wikipedia)
• A way to make sense of needless suffering
• How I view suffering, have compassion for
suffering, but maintain my balance
• “Let our experiences with those who are
suffering pass through us, separating
ourselves from the experience we just had
in order to move into the next experience”
– Doing this takes practice!
Equanimity
Briere, J. W. (May 31, - Jun 1, 2012). Trauma and Compassion. Workshop.

32. • “Developing careful attention to minute
shifts in body, mind, emotions and environs
while holding a kind, non-judgmental
attitude toward self and others.”
• Acknowledging my beliefs about:
– The “purpose” of my helping
– How I relate to another’s suffering
• “Dual Awareness:” attending to, monitoring
the needs of the patient, the work
environment and one’s own subjective
experience
Cultivating
Self
Awareness
Kearney M.K., Weininger R.B., Vachon M.L., Harrison R.L., Mount B.M. (2009). Self-care
of physicians caring for patients at the end of life: "Being connected... a key to my
survival". JAMA. 301(11):1155-64.

33. • Self-awareness allows us to:
– Expand our range of choices and
creative responses
– Assess any self-defeating patterns and
choose to replace them
– Recognize we might be feeling “empty”
because of constantly giving
– Assess if we have become too attached
to the “outcome” of our care
Advantages
of Self
Awareness

34. • When I notice that I feel apprehensive about a
patient visit:
– I ask: “What am I dreading or what do I want
to avoid?”
– I think: “I’m not sure what to do. This patient
is non-compliant”
– I feel: “I am not helpful. I am not competent.”
– I ask: “Is it true that I am
incompetent/unhelpful?”
– I notice: “Is my ego wanting to control
the outcome?”
Self
Awareness
in Action

35. With this awareness:
– I might detach from this expectation;
let go of it being about me.
– I might explore non-judgmentally the
patient’s reasons for non- compliance
(thoughts, feelings, behaviors)
Self
Awareness
in Action
(Cont’d)

36. • "We help people with our strength, we fix
people with our expertise, we serve people
with our connection to them as fellow
suffering human beings.”
• “Fixing and helping can become work of
the ego. Service is the work of the heart,
that is, the work of the soul. Service is not
something that we learn, it is something
that we are.”
• “True compassion is service through our
connection with others and does not
involve the ego.”
The Work
of the Heart
and Soul
Remen, R. N., (2006). Kitchen Table Wisdom: Stories that Heal. Riverhead Books.

37. • Detachment:
– Arm’s-length relationship
– Will not feel the other’s pain nor get
hurt when caring
• Caring without attachment:
– Care deeply but without attachment
to the outcome of our caring
– Attachment to the outcome is what
causes suffering
Deep Caring
Without
Attachment
Gonzalez, M. (2016) Mindful Leadership: The 9 Ways to Self-Awareness, Transforming
Yourself, and Inspiring Others. Audible Studios on Brilliance Audio.

38. • We must:
– Validate our role in alleviating suffering
and in doing our best
– Cultivate self-compassion
– Renounce perfectionism!
– Set realistic self-goals
– Know our limits, without judging
that limit
– Not underestimate the benefit of simply
“being there”
When we recognize our helpfulness,
we gain compassion satisfaction.
Validate Our
Helpfulness

39. “Compassion is not an entity ‘we’ show
toward the ‘other.’ It is not something I
have and give to you. It manifests itself in
the relationship between human beings.”
• This “relationship” can give us energy,
satisfaction, personal emotional and
spiritual growth.
“Forgetting the self, for those moments,
listening intently and responding as best
we can, we let the world unfold for us,
rather than think it is we who must unfold
the world.”
Compassion
Satisfaction
Marr, L. (2009). Can Compassion Fatigue? Journal of Palliative Medicine,12(8), pp. 739–740.

40. We helping professionals are very
fortunate. We get the opportunity to feel
personal satisfaction when we’re able
to help someone who is suffering to feel
better.
It is an enormous gift that we receive.
All employees feel gratification in doing
their job well. I think there is icing on
the cake for helping professionals when
doing
a job well means being able to alleviate
suffering in a fellow human being.
Personal
Gratification

41. • “You cannot give to others what you do not
possess yourself.”
• Self-care prevents compassion fatigue and
improves patient care!
• Practical Self-Care Activities:
– Think about what are you grateful for;
look for meaningful moments.
– Find ways to acknowledge loss and grief.
– Examine your helping and caregiving
motivations without judgment.
– Take stock of the demands for your time and
energy. Can anything be altered?
– Clarify personal boundaries. What works and
what doesn’t? Negotiate if needed.
– Ask yourself what you can control and
what you cannot.
Self-Care

42. – Have alone time each day; use it to
re-organize and ground yourself.
– Commit to regularly scheduled time off.
– Develop awareness of what
restores/replenishes you.
– Allow mini-escapes during the day:
nature, music, talking to a friend.
– Plan pleasurable activities; laugh a lot!
Self-Care

43. – Turn off the news, avoid dark movies
– Develop your own spiritual side—however
you define it
– Stay committed to career goals; stay true
to your personal life mission
– Become proactive as opposed to
reactive; don’t avoid issues.
– See challenges as opportunities for
growth/change, not as problems/stressors.
Above all, be kind to yourself…
Self-Care
(Cont’d)

44. At the end of the work day:
• List things that were unfinished, prepare to do them
tomorrow.
• Acknowledge when the work day is complete.
– Remind yourself you’ve handed over your
patient’s care
• Reflect what went well that day.
• Acknowledge you did your best—no exceptions
• Take off your name badge; begin rituals that are
different from work.
• Make your trip home a separation between work
and private life.
– If you do take work home, create a separate
space in your house.
Personal
Debriefing
Model
Huggard, P.K. & Huggard, E.J. (2008). When the Caring Gets Tough: Compassion
Fatigue and Veterinary Care. VetScript,

45. • Discuss impact of your work with people
that validate your experience and provide
non-judgmental support.
– “Grief shared is grief diminished.” Rabbi
Grollman
• Co-workers can relate to what you are
experiencing at work.
– CAUTION: Use time together to express
feelings/thoughts about patients rather than
work-related conditions.
– We can change a culture of negative
complaining into one of positive support!
• Supportive supervision is important
• Consider developing your own peer
supervision group.
Use of
Support
Network

46. • Developing and maintaining
positive/nourishing relationships with
family and friends outside of work is key.
• This allows perspective away from the
stress of working with vulnerable
populations.
Support
Network
Outside of
Work

47. • Simply listen attentively.
• Ask open-ended questions:
– “How does this patient’s case affect you?”
– “What are you feeling about your patient’s
experience?”
• Resist the temptation to distract, interrupt or
change the subject. Allow silence.
• Don’t quiz for details.
• Try not to give advice.
• Accept in a nonjudgmental way whatever
feelings (including anger) are expressed
without defending, arguing or minimizing
• Listen for content but also for the feelings
expressed
Supporting
Co-Workers:
Listening
Skills

48. • How are you doing?
• I’ve been thinking about you.
• I was sorry to learn that [deceased’s
name] died.
• You are grieving just the right way for you.
• It’s okay for you to grieve/cry/be angry.
• You must have loved him/her very much.
• He/she was very lucky to have you.
• What I remember most about [deceased’s
name] is…
• What would he/she want you to remember
about him or her?
What to Say
When
Someone Is
Grieving

49. • I know how you feel.
• You shouldn’t feel that way.
• It was God’s will.
• Don’t think about it.
• Be strong. You must get on with your life.
• You’ll find someone else.
• He/she led a full life…it was time.
• It would have been worse if…
What to
Avoid Saying
When
Someone Is
Grieving

50. …About staff “disenfranchised” grief
• May believe they should adopt a professional
demeanor and adapt well to a loss
• May not consider themselves “legitimate”
griever
– May believe the “appropriate” grievers are
family/friends
• Helpful if the healthcare organization:
– validates significance of staff loss
– reassures them support is available
– provides assistance, acknowledgment,
commemoration
What Can
Organizations
Do?
MacDermott & Keenan, 2014; Papadatou, 2000; Simpson, 2013

51. • Staff Memorials
– Allow staff to share memories as patients are
named.
– Create a ritual wreath where staff pin the
names of patients.
– Create a “quiet room” where staff can
meditate and renew.
– Display bulletin boards with patient
obituaries and family thank yous
– Provide journal books for staff to share
feelings/memories.
• Rededication Ceremonies
– Allow staff opportunity to remember/share
their motivation for and commitment to
hospice “work”
Organizational
Support
Practices

52. • Blessing of the Hands Ritual
– Chaplain pours water over the hands
of RN and HA while sharing a blessing
re: comfort/care hands provide in
daily work.
• Care for the Caregiver Program:
– Yoga or exercise classes
– Massage therapy
– Breathing, relaxation, meditation
in-services
– In-service on Compassion Fatigue
Organizational
Support
Practices

53. We went into this work because
we thought we wanted to help people…
and more than likely we are pretty good
at that. What we maybe did not
anticipate was that working with
vulnerable and dying patients imparts to
us some important answers to life’s big
questions, has
provided us personal growth we never
imagined possible, and has given us
an opportunity to see that we can truly
make a difference.
In Closing…

54. Caring does have it costs, though…
We must be diligent about developing
self-awareness, developing equanimity
and what Tara Brach calls “radical self
acceptance” and be diligent about
practicing true self-care.
Charles Figley, the person who first
coined the term “compassion fatigue,”
reminds us that to be really effective,
compassionate helpers, we must
always abide by the motto of
Hippocrates: First, do no harm.
He goes on to include however,
First, do no SELF-harm.
In Closing

55. “When we permit our professional skills to mingle
with our human awareness and experiences,
our sense of self is enhanced and we experience
that wonderful, unexpected, mysterious moment in
which what we do and who we are flows as one….”

56. Questions

57. 57
• Attig, T. (2006). The Heart of Grief. New York: Oxford University
Press.
• Bowlby, J. (2008). Attachment. New York: Basic Books; Second
edition.
• Brach, T. (2004). Radical Acceptance. New York: Random
House.
• Briere, J.W. (2012). Trauma and Compassion. Workshop.
• Briere, J.W. & Scott C. (2014). Principles of Trauma Therapy: A
Guide to Symptoms, Treatment and Evaluation. SAGE
Publications, Inc; Second edition
• Doka, K.J. (1989) Disenfranchised Grief: Recognizing Hidden
Sorrow, Lexington Books.
• Figley, C.R. (2007). The Art and Science of Caring for Others
without Forgetting Self-Care. Available at:
https://docplayer.net/24583955-The-art-and-science-of-caring-for-
others-without-forgetting-self-care-by-charles-r-figley.html
References

58. 58
• Funk, L.M., Peters, S., Roger, K.S. (2017). The Emotional
Labor of Personal Grief in Palliative Care: Balancing Caring
and Professional Identities. Qualitative Health Research. Sage
Publications.
• Gonzalez, M. (2016) Mindful Leadership: The 9 Ways to Self-
Awareness, Transforming
• Yourself, and Inspiring Others. Audible Studios on Brilliance
Audio.
• Grollman, E. A. & Malikow, M. (1999). Living When a Young
Friend Commits Suicide. Boston: Beacon Press.
• Hofress, R. Grief and Loss in the Workplace. The Forum
(Association for Death Education and Counseling). Volume
28, Issue 2.
• Hochschild, A. R. (2012).The Managed Heart
Commercialization of Human Feeling. University of California
Press.
• Huggard, P.K. & Huggard, E.J. (2008). When the Caring Gets
Tough: Compassion Fatigue and Veterinary Care. VetScript
References

59. 59
• James J.W., Friedman, R. Cline, E. (2003). Grief Index: the
"Hidden" Annual Costs of Grief in America's Workplace. Grief
Recovery Institute Educational Foundation, Inc., Sherman
Oaks, CA.
• Kearney M.K., Weininger R.B., Vachon M.L., Harrison R.L.,
Mount B.M. (2009). Self-care of physicians caring for patients
at the end of life: "Being connected... a key to my survival.”
JAMA, 301(11):1155-64.
• Kubler-Ross, E. (1969). On Death and Dying. New York: The
Macmillan Company.
• Larson, D.G. (1993). The Helper's Journey: Working With
People Facing Grief, Loss, and Life-Threatening Illness.
Research Press.
• Marr, L. (2009). Can Compassion Fatigue? Journal of
Palliative Medicine,12(8), pp. 739–740.
• Neimeyer, R.A., (2007). Meaning Reconstruction and the
Experience of Loss Washington: American Psychological
Association.
• National Association of Hospice & Palliative Care Webinar.
Complicated Grief. June 14, 2012.
References

60. 60
• Papadatou, D. (2000) A Proposed Model of Health
Professionals' Grieving Process. Journal of Death and Dying.
https://doi.org/10.2190/TV6M-8YNA-5DYW-3C1E
• Rando, T.A. (2000) Clinical Dimensions of Anticipatory
Mourning; Theory and Practice in Working with the Dying,
Their Loved Ones, and Their Caregivers. Champaign, IL:
Research Press
• Rando, T.A. (1984) Grief, Dying, and Death: Clinical
Interventions for Caregivers. Champaign, IL: Research Press.
• Remen, R.N. (2000). My Grandfather’s Blessings. New York:
Riverhead Books.
• Remen, R.N. (2006) Kitchen Table Wisdom: Stories that Heal.
New York: Riverhead Books.
• Rogers, C.(1951). "Client-Centered Therapy." Cambridge
Massachusetts: The Riverside Press.
• Stroene, M., Schut, H, Barkham, M., Hardym G., Llewelyn, S.,
Turpin, G. (2013). The Dual Process Model of Coping with
Bereavement: Rationale and Description. Clinical psychology
II: Treatment Models and interventions, 2; SAGE Publications
Inc.
References

61. 61
• Vachon,M.L. (2011). Four decades of Selected Research in
Hospice/Palliative Care: Have the Stressors Changed? In: I.
Renzenbrink (ed). Caregiver Stress and Staff Support in
Illness, Dying, and Bereavement. Oxford: Oxford University
Press, pp. 1-24.
• VITAS Innovative Hospice Care®: Grief, Loss, and
Bereavement. Power Point presentation.
• Winslade, J and Hedtke, L. (2017). Remembering Lives:
Conversations with the Dying and the Bereaved. London:
Routledge.
• Worden, J. W. (2009). Grief Counseling and Grief Therapy. 4th
Edition. New York: Springer Publishing Co.
References

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