Nurses Are Talking About...

Meaningful Ways to Cope With Patient Death

Troy Brown, RN


March 23, 2017

Do Nurses Use Meaningful Rituals?

A recent Medscape article examined rituals used by hospice staff and others who care for patients at the end of life. "Rituals are symbolic activities that can provide comfort, meaning, and support and relieve anxiety associated with uncertainties, such as those faced at the end of life," author Betty R. Ferrell, PhD, RN, wrote in the article. Such rituals can be a significant part of the healing process for patients and staff alike.

Dr Ferrell explained that although certain rituals, such as memorial services, have been around for years, these rituals may occur sporadically and be of limited value to staff members. A recent online survey took a deeper look at personally meaningful rituals used by hospice nurses and other staff who work with patients at the end of life. Of 399 respondents from 38 states, 71% said that they used such rituals as attending funerals, calling bereaved family members, journaling, lighting candles, and praying.

The survey found that those who used meaningful rituals scored higher on a compassion-satisfaction scale and lower on a burnout scale, although no differences were seen on measures of secondary traumatic stress.

Compassion fatigue, or secondary traumatic stress, is commonly discussed at hospice and palliative care conferences as well as in related literature, Dr Ferrell wrote. However, "less frequent attention has been given to interventions that can potentially mitigate compassion fatigue in the professionals and volunteers who care for seriously ill and dying patients and support their families," she continued.

Self-care and Replenishment

Over and over, nurses and other respondents to the Medscape article said that working with patients at the end of life and their families is profoundly rewarding but also incredibly "taxing." One nurse and hospital chaplain said that rituals help sustain staff by helping to keep them "emotionally and spiritually healthy and balanced."

Dr Ferrell told Medscape that nurses often find it difficult to perform rituals because they do not have enough time. Although this is true, it need not be an obstacle, she said.

"For example, nurses have said that as they are washing their hands, they can use this as a time to say a silent prayer or meditation or to be reminded that their hands are sacred and a means of caring. Others have said that when they arrive at work or at the end of the day when they get in their cars, they pause for a few deep breaths and to be mindful of the sacred work they are about to do or have done," Dr Ferrell explained.

"Nurses sometimes take 5 minutes to stop by the hospital chapel just to be centered. One nurse said that every time she is about to walk into a patient's room she pauses at the door, takes a deep breath, and takes 30 seconds to be focused and ready to be present for that patient," she continued.

One hospice nurse said that different rituals have been meaningful for her at different "seasons" of her professional career. Some commented that they like to journal about life lessons they've learned from different patients.

"I have found it helpful to 'say my goodbyes' by stopping in at little country cemeteries on my routes and taking a short break, either to sit with my thoughts or with my lunch," another wrote.

Several nurses noted the importance of exploring hobbies and other interests, including music, camping, backpacking, crafting, and sports, as well as spending time with friends and others outside of the work setting. One nurse said that she involves coworkers in team-building activities outside of work. Another wrote, "Being with the living is important when working with the dying."

Religious faith was a common theme in readers' comments, and several nurses said that their religious beliefs give them comfort.

Rituals are not only for those who follow a specific faith or religion, however. "We always say that some of our patients are religious, but all of our patients are spiritual. The same is true for nurses. Some have a religious affiliation, and for others spirituality is expressed through nature, the arts, relationships, or other sources. Attending a concert, being outside, laughing, a great meal—all can be spiritual experiences," Dr Ferrell explained.

Several nurses commented on the importance of maintaining professional boundaries. Nurses who care for dying patients and their families, "must be proactive to prevent burnout and maintain a level of compassion that is real and not mechanical," wrote one nurse. They must care for their patient's emotional needs as well as manage medical issues that may be complex.

"This is very individual. Definitely all nurses need to practice self-care and to have boundaries to separate their lives as professionals from their lives as humans in the community and as a part of families," Dr Ferrell told Medscape.

One nurse wrote, "I have some families who continue to call or text me for support, and I continue in a professional demeanor, often suggesting grief counseling and reminding them how much they were loved."

Some Rituals Are Patient-Oriented

Rituals that are aimed at patients and families can also be healing for staff. In the past, it was common for nursing homes to hide a patient's death, covering the body with a white sheet and removing it through a back door. Nursing homes are now taking steps to normalize the process and honor the person who has died.

When the funeral home representative comes to their facility, "one of our comfort quilts is placed over the cot. Everyone who leaves is covered with one of the two comfort quilts that were made specifically for this purpose. A prayer is said, either by the chaplain (myself), a nurse, an aid, another resident, or a family member," Elizabeth Heard, pastoral and spiritual coordinator, the Alverno Health Care Facility, Clinton, Iowa, told Medscape.

Music plays, and "the family follows their loved one out the front door as staff and other residents and guests line both sides of the hallway. We believe it is important to show reverence to our residents and to the loved ones gathered. Everyone is taken out the way they came in, unless they request to be taken out through a back door," Ms Heard explained.


Readers had mixed feelings about whether to attend a patient's funeral. Some wrote that it was too difficult emotionally to see the families grieving, but even then they usually found other ways to let families know that they were thinking of them. Other nurses commented that they felt that attending funerals blurred professional boundaries.

Some nurses, however, said that they find it therapeutic to attend funerals and that it is an important way to express care to patients' families.

"The follow-through was critical to us as we didn't feel our service was complete without it. Our families were more than clients, and we wanted them to know how deeply we cared. We relied on visits of this nature for 'closure'...but it also strengthened our team and kept us close," wrote one nurse.

"There are times when it is important to attend a memorial, for example for a patient whom you have had a long-term relationship with, but I think in all things there is a need for reflection and balance," Dr Ferrell told Medscape.

"For me personally, I pray for the people who have died and the families. Sometimes, for those I am closer to, I will attend the funeral or other service when possible. I have been honored by several families to officiate the service for their loved one, and this is a good experience for me. I always learn new things about someone whom I already loved and admired. It is a real gift to my spirit to do this," Ms Heard told Medscape.

Nurses can develop personally meaningful rituals to reduce compassion fatigue and increase job satisfaction. Personally meaningful rituals need not be time-consuming, and nurses can incorporate them into their daily routines.


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