Grief and loss are fundamental to the human condition. As Doka has stated, "Grief is a constant companion to illness."1 We all experience loss in many forms: the loss of relationships and people we love, of faith and trust, of health. We grieve for the way things were or might have been. Yet we often lack effective ways of working through these feelings. And while coping with loss is a universal challenge, this can be intensified for health care professionals. The social context of the health care workplace generally discourages expressions of grief in favor of emotional compartmentalization, strict relational boundaries, and a stoic professional identity.2-6 Grief that isn't openly acknowledged, socially validated, or publicly observed has been termed disenfranchised grief.1 The toll of such grief can be especially high for people working in health care, for whom loss may be recurrent and cumulative.7-9
As professional caregivers, providers assume the responsibility of caring for seriously ill and dying patients. This exposes providers to ongoing distress in two significant ways: witnessing their patients' pain, suffering, and trauma; and experiencing their own feelings of grief and loss that arise in working with this population.10-12 Studies indicate that there are significant prevalences of secondary traumatic stress, bereavement, compassion fatigue, and burnout among health care providers at all levels.13-19 These issues can be compounded by any stress or trauma providers may experience in their personal lives, whether current or unresolved from the past.3, 20-22 Indeed, high levels of exposure to patients' suffering has been linked to the manifestation of posttraumatic stress disorder (PTSD) in providers, underscoring the need for strategies to help health care workers build resilience to secondary stress.23
Unaddressed grief has serious consequences for both employees and the organization. At the individual level, in addition to the aforementioned issues, unaddressed grief can lead to sleep disturbances; reduced cognitive ability; impaired judgment; feelings of isolation, anger, and guilt; and loss of self-worth and of a sense of meaning in one's life.24-31 At the organizational level, unaddressed provider grief can lead to the depersonalization of patients, reduced quality of patient care, increased absenteeism and turnover, lowered morale, decreased productivity, and greater risk of long-term health problems among staff.14, 30, 32-34
By addressing these concerns in a substantive way, organizations can help individuals practice effective self-care strategies,35 and provide needed staff support.36 A variety of approaches have been investigated and implemented in the hospital setting, predominantly in the areas of emergency medicine, palliative care, oncology, pediatrics, and family medicine. Strategies have included bereavement37 and critical incident stress debriefings38; facilitated discussion groups39, 40; staff trainings through a bereavement care service41; grief processing through writing, storytelling, and music42, 43; and skills training to build resilience and compassion,44, 45 as well as effective self-care practices.46-48 Interventions aimed at creating more supportive work environments and altering patient care assignments have also been used.49
The Healing Loss Workshop. In 2013, recognition of the impact of grief and loss on hospital staff led to a joint project by several entities within Montefiore Health System, a multifacility organization based in the Bronx, New York, and affiliated with the Albert Einstein College of Medicine. The project-named Healing Loss: A Residential Workshop for Montefiore Associates-was designed as an experiential and educational program to help professional caregivers identify and work through issues related to grief and loss. Conducted twice yearly by the Division of Human Resources, the Healing Loss Workshop offers participants a safe and supportive environment in which to authentically process grief and loss related to both professional and personal experiences that have affected their lives. For more details, see The Origins of the Healing Loss Workshop.
Study purpose. Through analysis of participation records and program feedback data from workshops held between October 2013 and October 2017, this study investigated the feasibility and effectiveness of offering an intensive bereavement support program to hospital employees in a large academic health system.
METHODS
Program overview. The Healing Loss Workshop is a three-day residential workshop offered each spring and fall at a retreat center located a few miles north of New York City. The program is based on models of peer group support. These include groups based on the work of Elisabeth Kubler-Ross, a Swiss-American psychiatrist who worked with dying patients, their families, and other caregivers50-52; subsequent workshops in a similar tradition53; and models from the fields of interpersonal trauma,54, 55 attachment theory,56, 57 and substance abuse recovery.58
Through a combined didactic and experiential approach, Healing Loss participants are offered the opportunity to share their stories, memories, and feelings in the supportive presence of a group. The workshops are facilitated by trained leaders and are based on ground rules that include confidentiality, nonjudgment, presence, and witnessing. This helps to create a safe space in which participants can identify, begin to work through, and release their unresolved feelings about a range of loss-related issues. The program is free to participants; all costs, including overnight accommodations and meals, are covered by Montefiore's Division of Human Resources. Continuing education credits are available for nurses, social workers, and physicians.
Setting and participants. Each workshop is open to up to 24 employees of any profession or department. Workshops are held offsite, which helps to cultivate an emotional space apart from the workplace. Participants are required to stay at the retreat center in order to foster group cohesion and to ensure personal safety during what can be an emotionally intense experience.
Employees learn about the workshops through advertisements on Montefiore's intranet and internet, direct e-mails, and departmental in-service trainings. The advertising flyer explains that participants can expect an intensive experience, one that offers opportunities to "release some of the emotional 'baggage' and 'unfinished business' that can get in the way of our being truly present for ourselves and others," as well as to gain "new tools for self-care and healing, to help build resilience when facing stress in the future." Employees can contact staff in Montefiore's Healing Arts Program or Arthur D. Emil Caregiver Support Center to learn more. Interested parties submit a written application, which is reviewed by Healing Loss staff. The lead facilitator (PAS) speaks with each applicant as an added screening mechanism.
Program facilitators. The lead facilitator is a physician with board certification in palliative care and extensive experience working with patients and caregivers at the end of life. He was trained by Kubler-Ross and has over 25 years' experience cofacilitating workshops like Healing Loss throughout the United States. The workshops are staffed by experienced clinicians from different disciplines-physicians, nurses, social workers, and family therapists-who have completed extensive training in the workshop's methods.
The intervention. Each workshop begins with introductions and an explanation of the ground rules. The first half day is devoted to teachings on topics that include acceptance of personal grief; attachment styles related to grieving; identification of healthy versus disordered emotional responses; and the roles of the physical, intellectual, emotional, and spiritual domains in grief processing. The next day and a half are devoted to individual sharing; emotional work; and teachings on addiction as avoidance, attunement and connection, and self-care practices. Participants sit in a circle. Each participant has an opportunity to share their story of loss with the group, with a facilitator's guidance. The facilitator stays deeply attuned to the speaker and helps the speaker navigate whatever emotions arise, such as sadness, feelings of abandonment, or anger. Those in the circle act as silent witnesses, "holding space" for the speaker with acceptance and support. The entire group remains together for the duration of the workshop, with one exception: if, after sharing, a participant wants to continue privately, they can opt to work one-on-one with a facilitator in another room while the group continues.
Interspersed at various points during the workshop are activities aimed at facilitating a sense of catharsis and respite. These are based on work by leaders in the fields of mindfulness, such as Tara Brach, Pema Chodron, and Jon Kabat-Zinn,59-61 and of gratitude practice, such as David Steindl-Rast.62 The workshop also incorporates arts-based approaches to exploring emotion, such as 5Rhythms movement meditation (http://www.5rhythms.com) and Jungian-based spontaneous drawings.63
The last day is dedicated to integrating the experiential work and teachings and preparing participants for return to daily life. Discussions focus on the importance of practicing self-care, having healthy relationships with oneself and others, and identifying one's own caregiving style. Participants are encouraged to take time over the next few days for rest, relaxation, and self-care. After each workshop, optional follow-up meetings are held at Montefiore to allow participants to reconnect and further process the experience. Participants can also enroll in a one-day continuation workshop, held twice yearly, in which past participants can deepen their healing in the group context.
Data collection. At the close of each workshop, participants receive a written questionnaire to be answered anonymously. This feedback questionnaire consists of 14 Likert-scale and open-ended questions assessing several domains. These include overall satisfaction; perception of personal benefit related to grieving loss, relieving stress, and coping as a caregiver; whether the workshop provided new tools for healing and self-care; changes in how they felt before and after the workshop; the effectiveness of workshop staff; whether they would recommend the workshop to colleagues; suggestions for improvement; and whether they'd be interested in similar workshops at Montefiore. Participants applying for continuing education credits complete an additional questionnaire anonymously. Topics covered by that questionnaire include assessments of one's ability to recognize grieving patterns, identify grief processes and means of self-care, and integrate these elements into one's life and caregiving style; evaluation of the staff's knowledge and presentation of the subject material; and overall satisfaction with the learning experience. Participants place their completed questionnaires into envelopes that are sealed and returned to the Healing Loss program manager for entry into a secure database.
Analytic methods. With the approval of the Albert Einstein College of Medicine's institutional review board, we conducted a retrospective analysis of participation records and program feedback data for workshops held during the study period. We developed a coding framework that reflected key themes and content areas.64, 65 Two investigators (RF, ET) applied this initial framework to all questionnaire data, then resolved discrepancies through discussion and consultation with a third investigator (TB). All investigators agreed on the revised framework, and it was applied to all questionnaire data.
RESULTS
Quantitative results.Program utilization. Nine Healing Loss Workshops were held between October 2013 and October 2017, serving 198 Montefiore employees from a range of professions and departments. (Although every workshop had full registration with a waiting list, the final sample size was 198 rather than 216 because 18 people either withdrew at a point too late to fill their spots from the waiting list or didn't come on the first workshop day.) The average age of participants was 49 years (range, 21 to 67 years). Participants had worked for an average of 17 years in their profession (range, one to 63 years) and for an average of nine years at Montefiore (range, three months to 44 years). Nurses and NPs constituted the majority of participants (34%), followed by social workers (27%), case managers (14%), administrative staff (9%), physicians (6%), and professionals from other clinical specialty areas (10%) (see Table 1). The majority of participants (62%) worked for clinical departments, including oncology, palliative care, pediatrics, psychiatry, and surgery. Eight percent worked in nursing (department unspecified), 20% in case management or social service departments, and 11% in nonclinical administrative departments (see Table 2).
Satisfaction with experience. Participants expressed high satisfaction with their experience. Ninety-eight percent were "extremely" or "very" satisfied and would recommend the workshop to a coworker or friend. Over 95% reported the workshop helped them "very much" or "extremely" in grieving loss, relieving stress, caregiving, and having new tools for self-care (see Table 3). Ninety-five percent felt the workshop had "exceeded" or "totally met" their expectations, and 97% indicated interest in similar workshops if offered through Montefiore.
Qualitative results. The Healing Loss Workshop had profound effects on participants, with people describing their experiences as "life changing," "indescribable," and "like none I have ever experienced."
Participants arrived with a range of emotions and psychological states, describing themselves with such words as "lost," "empty," "alone," "sad," "broken," "angry," "anxious," "hopeless," "stressed," "depleted," "depressed," "guilty," "confused," "frazzled," and "scared." Comments included:
"I was so full with heaviness in my heart and mind."
"I felt unsure of me, my role as a caregiver, my purpose and my strength."
"I felt as if I had reached my limit and had no more left in me to carry on."
As the workshop proceeded, participants reported discovering that it was a "safe haven," which one person described as a "nonjudgmental space, where everyone was allowed to share as much or as little [as desired], at [one's] own pace." Participants worked through unresolved feelings that had either surfaced recently or been buried, often for many years. As one participant said, the workshop "gave me that moment of clarity to be able to identify my main issue, and helped me relive as much as I could and was willing to." Others reported that the workshop provided "[an] outlet for what felt like stigmatized feelings" and "allowed us an opportunity to be vulnerable and express our full truth."
A sense of community appeared to permeate the workshop experience. Many participants noted the "incredible energy in the room" and "the togetherness" created in such a short time. Among those who said they normally guarded their emotions and tended to worry about what other people thought, one remarked with surprise, "I was able to open up and be genuine." Another participant was similarly struck: "I let my guard down so quickly with strangers and [could] heal myself and them." Many people expressed a sense of relief, noting that they had been "able to let go," "sort out my emotions with more clarity," and "release feelings that would otherwise stay bottled up." Many also shared how isolated they had felt in their grief, and their relief at discovering that they were "not alone." As one participant said,
"To experience a sudden loss and you are hurting but the rest of the world just marches on like nothing happened, you feel alone. This workshop showed that so many people are hurting and feeling similar, and it was wonderful to help one another."
The workshop facilitators sought to cultivate a safe, nurturing environment for participants, in order to foster their willingness to engage in such an intensely personal process. The responses indicate that this effort was successful. As one participant noted, "The extremely caring, compassionate leaders and the [sensitive] way they [facilitated][horizontal ellipsis] helped participants with such delicate, raw subjects." Another participant said that the facilitators knew "how to make people in pain feel at ease." Others reported that the facilitators did so by "integrating themselves into the group, making themselves equal to us" and by "[expressing] gentleness and concern[horizontal ellipsis] for our comfort during the workshop and our emotional well-being as a person."
Through the teaching portions of the workshop, participants gained new knowledge and tools that empowered them "to address and move through loss." As one participant said, "By listening, sharing, singing, breathing, identifying, and reflecting, I can heal and help and teach others [to] heal." Other comments included:
"The workshop's material greatly influenced me and served as teaching tools towards healing, understanding, forgiving, and accepting myself. I [went] back to review the course materials recently when I had a difficult situation."
"Loss is part of life and must be dealt with and so it is great to have learned tools to deal with it."
"The workshop gave me the opportunity to learn new therapeutic techniques through which I can better express loss and stress in a nonjudgmental and very supportive way."
At the close of the workshop, the words people used to describe their emotional state shifted: "peaceful," "relaxed," "relieved," "calm," "rejuvenated," "stronger," "clear," "open," "unburdened," "whole," "empowered," "hopeful," and "with a lighter heart." Forgiveness, of both oneself and others, was an important theme. As one participant stated, "[The workshop] opened me up to the process of opening my heart and beginning to forgive," while another felt she had gained "a new spirit in dealing with forgiveness at a higher level." A greater sense of self-acceptance was repeatedly expressed:
"I found peace and comfort in knowing that I am grieving my loss in an effective way for myself."
"I learned that the way I felt was normal and [that] there is no time limit with [mourning] a loss."
"I was able to reconnect with the good feelings about me."
Many participants seemed to reach a degree of catharsis they had neither expected nor believed possible.
Several participants noted they appreciated that the workshop was held at a retreat center, which created a physical and psychological separation from their actual workplace. As one said,
"Being offsite and away from work and family really has a profound impact on letting the material penetrate those dark areas that we mask and cover on a daily basis."
The leading suggestion for improving the program was to hold it more often during the year so more employees could participate.
Follow-up results. In February 2018, the Healing Arts Program administered an electronic follow-up questionnaire in order to learn about the Healing Loss Workshop's long-term effects on participants. Respondents' anonymity was preserved. Of the 198 past participants, 98 (49%) completed the survey. All the delivered workshops were represented. Of the 98 respondents, 30 (31%) were nurses or NPs, 29 (30%) were social workers, seven (7%) were physicians, six (6%) were administrative staff, and 26 (27%) were professionals from other clinical specialty areas.
Since attending the workshop, 94% of respondents felt they had a better understanding of grief, grieving patterns, and "unfinished business," as well as how people manifest these. This had direct application to their personal and professional lives. Most respondents reported feeling more equipped to cope with loss in their personal lives (84%) and with patients (86%), and better able to carry out their caregiver role both personally (84%) and professionally (89%). A majority reported continuing to use the self-care tools taught at the workshop (89%) and felt better able to manage stress (82%) (see Table 4).
As one participant explained,
"The workshop had an incredible impact on my life. I was dealing with some acute trauma from a very big loss. It helped me process the immediate grief that stemmed from that, [and] also address the general trauma and "baggage" I had. It's helped me be more present in my day-to-day [life], process the challenges of my work and state of the world[horizontal ellipsis] and just be better equipped at self-care and the stress of life."
One of the more poignant themes expressed was having a deeper sense of compassion and shared humanity:
"I have a different perspective of the people in the community around me. You never know what people are going through, even when they are functioning well in their lives."
"I have a new understanding that most [people] have a loss to heal in their life, and [I] approach [them] as such."
Ninety-eight percent indicated that the Healing Loss Workshop is an important form of employee support at Montefiore. Several participants felt the workshop demonstrated the organization's understanding of their needs and care for their well-being, especially because the experience was so intimate:
"Thank you to the leadership for recognizing that we are all human beings with "stuff." More importantly, for providing associates with a means to learn how to take care of that stuff in a safe space."
"I am grateful to Montefiore for helping its associates become better caregivers. If I am healed, I can heal others."
"I am very thankful to the facilitators for their dedication and to Montefiore for supporting this program. This workshop showed that so many people are hurting and feeling similar and it was wonderful to help one another. I believe this work is necessary for everyone and especially for health care providers and caregivers. I would never be able to express the value of this workshop and how it has changed my life."
Participants' feedback was consistent regarding the lasting effects of the workshop, no matter how much time had passed since they had attended.
DISCUSSION
The sustainability of Montefiore's Healing Loss Workshop over the four years of the study indicates that it's both feasible and effective to offer an intensive bereavement support program to hospital employees from diverse clinical and nonclinical professions in a large academic health system. The study further demonstrates that acknowledging and addressing employees' grief and loss through an organizational intervention can facilitate the process of healing and improve self-care, strengthen their resilience as caregivers both personally and professionally, enhance their sense of community within the organization, and increase their appreciation of the organization. Notably, the follow-up data for every workshop group revealed comparably positive responses, suggesting that the workshop consistently made a strong impression that lasted over time.
One of the main questions we had during planning was whether employees would be willing to participate in a program of such a personal and intense nature offered by their employer and with other employees as coparticipants. Although concerns about the workshop's ties to the workplace may have kept some people from applying, every workshop had full registration with a waiting list. Indeed, one of the primary drivers of application was word of mouth from past participants. Several participants indicated that being able to attend the workshop in a neutral location, away from the workplace, allowed them to feel safer. The workshop facilitators played a key role in cultivating an environment of safety and nurturance. Participants also valued the workshop's equalizing effect, bringing employees from different professions together in a way that broke down workplace barriers.
The organizational support received, particularly from the Division of Human Resources, was critical to the program's operations and sustainability. Having the cost of participation underwritten was critical in allowing many employees to attend, as the out-of-pocket costs would have been prohibitive for them. Other factors that facilitated attendance included having the opportunity to receive continuing education credits, being able to use paid "conference days" for the workshops, and having the option of free round-trip group transportation. Many department and division leaders also helped promote the workshop by hosting in-service presentations about it for their employees.
Because the Healing Loss Workshop was a workplace initiative, it did raise unique considerations, particularly around the issue of confidentiality. Several strategies were adopted to address this issue, including
* keeping application information in a secure database accessible only to program staff.
* informing applicants that a current or past colleague could be in their workshop before they accepted.
* openly discussing the issue at each workshop and giving participants the option of requesting that a colleague leave the room when they were sharing with the group.
* offering participants the option of working privately with a workshop facilitator rather than in the group.
* requiring all participants and staff to agree to maintain confidentiality about who took part and what was shared.
Given that healing from loss is inevitably a long-term process, the progress participants made during the short workshop time frame is all the more remarkable. We believe there are several reasons the Healing Loss Workshop had such a powerful impact. First, for many people it's rare to find a space where they can express strong emotions-especially emotions deemed "negative," such as anger, guilt, abandonment, or lingering sadness-to other people and be met with unconditional acceptance. The workshops cultivated a sense of safety that allowed participants to access buried feelings and memories that may have blocked their healing and to unburden themselves by expressing these aloud. Furthermore, the experience of being witnessed with acceptance and of providing witness for others in turn can be profound. It shifted participants' understanding of loss from one that was internal and solitary to one that was communal and validated. As one participant commented, the workshop illuminated "the universality of pain as the connecting human experience."
Limitations include the relatively small sample size of the study population and the fact that all participants came from within one health care system, which could affect generalizability of the findings. Data collection by program staff, despite the precautions taken to ensure participants' anonymity, may have introduced bias into the findings. Lastly, our program received significant financial support from within the organization; cost factors could pose a barrier to other organizations.
Future research. Studies involving larger sample sizes, the use of standardized evaluation instruments, the inclusion of identifiers to link individual questionnaires, and analyses of objective measures (such as employee retention data) in a correlational research design would provide more rigorous assessment of intervention effects. Qualitative interviews with participants could yield useful information about preferences, perceived mechanisms of action, and issues relevant to the program's sustainability and scalability.
CONCLUSIONS
Overall, the Healing Loss Workshop was shown to have a clear impact on health care professionals' ability to cope with grief. The process fostered their ability to reconnect with themselves and others, and to build resilience in the face of professional and personal loss. Our results suggest that an intervention that allows for the complexity of grief and loss is essential to helping people integrate, rather than compartmentalize, their experiences. Loss that is not openly acknowledged engenders a state of internal disenfranchisement1; and it is precisely the act of giving voice to one's grief that can begin the process of healing. This in turn can have a powerful mediating effect on compassion fatigue, secondary traumatic stress, and burnout, which are so prevalent among health care professionals. Kubler-Ross affirmed that "working through the fears, pains, angers, hurts, and unfinished business from [one's] own past" clears the way for one "to work better with dying patients and/or other people."66
Our results further indicate that it is the voicing of grief in community that promotes healing and renewal. It's been described thus: "Strangers come together, find themselves supporting one another in an unconditional and nonjudgmental way, and emerge, no longer strangers because they are no longer strangers to themselves."66 Participants in our workshops seemed to concur, and the sense of release and catharsis they experienced was profound. In their words:
"I feel found, whole, relieved, living my truth."
"I have no words to describe the lifting of a very dark cloud."
"I feel at peace for the first time in a very long time."
REFERENCES