When your patients die, feelings of loss are inevitable. Depending on how much time you’ve spent with patients and families and the type of connection you may have had, some losses are more distressing than others, but each can leave a mark on your soul. What happens to the oncology nurse after weeks, months, or even years of these kinds of losses?

The terms “cumulative grief” and “compassion fatigue” have been used to describe the compounding emotional, physical, and spiritual responses to recurrent exposures to profound loss. Symptoms may manifest in many ways, including headaches, depression, irritability, and anger, even progressing to isolation, withdrawal, and detachment.

The Experience of Cumulative Grief

“Cumulative grief is a very profound phenomenon experienced by many nurses, myself included, but I do not think it is well recognized,” says ONS member Donna Yost, RN, OCN®, a staff nurse at Southeast Alabama Medical Center in Dothan, AL. “I am a breast cancer survivor, and I also lost my mother to cancer. This has made me much more sensitive to the loss I feel when a patient is dying.”  

ONS member Cynthia Mauldin, RN, OCN®, a home care nurse with the Home Care Network of the Jefferson Health System in Philadelphia, PA, expands on the effects she’s experienced from cumulative grief. “I find I become short tempered and lose my patience more easily. I get more tired and feel more overwhelmed at work and with my caseload.”

Types of Organizational Support

Workplaces vary in the type and formality of grief support available to healthcare staff.

“We currently do not have any formal support system or ritual in place to assist us in coping with grief and loss,” Yost explains. “Each nurse is primarily left to individualize a method to deal with these feelings that are, at times, quite overwhelming.”

Mauldin says the same is true for her work environment. “As home care nurses, we are on our own so much and rarely see any of our other team members. I try to take the new nurses out with me during orientation to acquaint them with oncology specifics, but no special training about grief is provided.”

Yost also notes the disparity between support for patients and their families and support for staff. “My floor has a quiet prayer room and hospital chaplains on call. Both are perceived as options for patients or their families, but not nursing staff. While the event involves only one patient, 90% of the nurses and support staff are affected, and each one may be dealing with the loss at a different level.”

The phenomenon affects not only individual nurses, but nursing staff as a whole, in areas of quality of care and retention, for example. “I feel that cumulative grief plays a strong role in relation to retention of experienced nurses,” Yost explains. “Coworkers who have transferred or changed jobs say that they need a ‘break’ from what we do. These daily experiences, without a method to channel feelings, can have—and has had—devastating effects on our staff. But I think that the cause is frequently classified as something other than cumulative grief.”

Other Sources of Stress

In addition to limited workplace structures, other hindrances can prevent oncology nurses from processing such grief. “Outside of work I find that most people, while supportive, really do not want to spend valuable free time they have with you discussing at great length the tremendously sad circumstances surrounding a patient’s health care or death,” Yost says.

Mauldin adds, “Others do not understand what is required in my job. They are not available, mentally or physically, because of their own stresses and time commitments.”

Even other nurses may not be able to relate if a nurse is experiencing cumulative grief from other sources in addition to patient death. “Another issue is the losses that occur outside the workplace, such as my elderly neighbor who was hospitalized, and whom I visited, during my work day,” Yost says. “When work and home intermingle, it becomes a real challenge to keep them separate. Effective relief may not be found on the home front either.”

Coping Strategies

Even with few formal structures in place to assist nurses in managing cumulative grief, individual and team strategies are forged. “We check on each other periodically, especially when we know a patient is nearing death,” Yost says.

As a home care nurse without the same camaraderie, Mauldin has developed her own mechanisms. “I try to take off at least a week every three to four months just to have time for myself, to regroup and reenergize myself. My supports are also my husband, family, church family, my religious faith, and prayer.

“I try very hard not to let my grief interfere with my patient care,” Mauldin continues. “I mourn in private, although I still cry with patients and their families and find nothing wrong with it.”

Yost is working to improve her institution’s support structures. “My unit council and I are meeting to plan a system of support, such as a debriefing, counseling session, or one-to-one check when our floor suffers a loss. We are hopeful that once we establish our unit plan, it can be used hospital wide.”

Education and information are also effective tools. Yost says she tries to read and attend webinars that cover topics such as end-of-life care, cumulative grief, palliative care, and pain management.

“This keeps me centered,” she explains. “I find that knowledge is power, and it has helped me channel frustration from the grief I experience into a positive outcome, rather than feel as is if I am drowning in it.”

Similarly, Mauldin’s agency provides its nurses with End-of-Life Nursing Education Consortium training, and as a member of the palliative care team, she received additional training. “My patients and families have also taught me so much and continue to teach me every day,” she adds.

Oncology nurses also derive strength from the patients and families they serve. “Patients and families definitely give me more strength than I give them. Their positive feedback about the care I give, the part I play in their lives, and the difference I make is really all I need. Even if there is no official recognition, I know I make a difference and that is why I continue to do what I do every day. My patients are living every day with their cancer; my goal is to help make it as easy and comfortable as possible,” Mauldin says.

Yost has a similar perspective: “Despite the fact that at times it is very sad and challenging, I can honestly say that I enjoy my job and I know I am working in the field that I should.”