Research in Gerontological Nursing

Original Research: Multiple Regression Analysis 

Death in the Nursing Home: An Examination of Grief and Well-Being in Nursing Assistants

Keith A. Anderson, PhD; Heidi H. Ewen, PhD

Abstract

The grief that nurses experience when patients and residents die can be complex and has been linked to both problematic (e.g., depression) and beneficial (e.g., gains in coping) outcomes. In this study, 380 nursing assistants working in the nursing home setting were surveyed to gain an understanding of the relationship between grief and well-being. Findings indicated that participants experienced both distress and growth in their grief. Those who experienced greater distress from grief reported significantly higher levels of burnout and lower levels of psychological and physical well-being. Conversely, participants who experienced greater growth from their grief reported significantly lower levels of burnout, higher levels of psychological and physical well-being, and higher levels of job satisfaction. These findings suggest that grief may be an important determinant of well-being in nursing assistants, which, in turn, may impact quality of care in the nursing home.

Abstract

The grief that nurses experience when patients and residents die can be complex and has been linked to both problematic (e.g., depression) and beneficial (e.g., gains in coping) outcomes. In this study, 380 nursing assistants working in the nursing home setting were surveyed to gain an understanding of the relationship between grief and well-being. Findings indicated that participants experienced both distress and growth in their grief. Those who experienced greater distress from grief reported significantly higher levels of burnout and lower levels of psychological and physical well-being. Conversely, participants who experienced greater growth from their grief reported significantly lower levels of burnout, higher levels of psychological and physical well-being, and higher levels of job satisfaction. These findings suggest that grief may be an important determinant of well-being in nursing assistants, which, in turn, may impact quality of care in the nursing home.

The death of patients is an unavoidable reality for many health care workers, particularly for nursing staff who care for older adults in the nursing home setting. Past research (Anderson & Gaugler, 2006–2007) has shown that resident deaths tend to produce complex grief reactions in nursing home staff, including both complicated grief and growth from grief. These grief reactions can be associated with problematic outcomes, such as personal and professional burnout, as well as more positive outcomes, such as enhanced coping ability (Anderson, 2008).

While there is some understanding of grief in the nursing home setting, past research studies have typically been limited in scope, and few have provided rigorous empirical evidence. This precludes the development of a comprehensive understanding of grief and well-being in this setting. In the current study, the researchers surveyed a diverse sample (N = 380) of nursing assistants (NAs) working in the nursing home setting to further explore the effects of grief on the well-being of nursing staff. The findings from this study are important, as they will aid in the development of targeted interventions designed to support NAs, an essential group of caregivers.

Background

Grief has been described as “the psychological, behavioral, social, and physical reactions to the loss of something or someone that is closely tied to a person’s identity” (Rando, 1993, pp. 22–23). While the vast majority of research on grief has focused on familial losses, non-familial losses, such as those experienced by nurses, can also induce grief reactions. A growing body of research has found that nurses can experience grief reactions when working with patients and residents who die or who are in the process of dying (Anderson & Gaugler, 2006–2007; Papadatou, Bellali, Papazoglou, & Petraki, 2002; Saunders & Valente, 1994). This grief is often characterized as complex in nature, including elements of distress, as well as elements of growth. Outcomes from grief are reflective of this complexity. Researchers have found that grief can result in problematic and deleterious outcomes for nurses, including lasting feelings of overwhelming sadness and guilt (Rashotte, Fothergill-Bourbonnais, & Chamberlain, 1997), feelings of helplessness and moral distress (Davies et al., 1996; Papadatou et al., 2002), low morale and loss of efficacy at work (O’Hara, Harper, Chartrand, & Johnston, 1996), and compassion fatigue (Vachon & Benor, 2003). Researchers have also found that nurses can experience great satisfaction in working with dying people and that the deaths of patients and residents can result in opportunities for emotional and professional growth (Anderson & Gaugler, 2006–2007; Papadatou et al., 2002; Rashotte et al., 1997).

Among the various groups of nurses, growing evidence suggests that NAs working in the nursing home environment may be the most susceptible to grief. NAs in the nursing home often work with the same residents over the course of many years and tend to forge close, empathic relationships (Braun, Cheang, & Shigeta, 2005; Schell & Kayser-Jones, 2007). NAs often describe these relationships as “family like” and state that these relationships are a central element to why they became and continue to work as NAs (Carpenter & Thompson, 2008; Monahan & McCarthy, 1992; M.S. Moss, Moss, Rubenstein, & Black, 2003; Secrest, Iorio, & Martz, 2005).

However, certain factors can affect these relationships and the eventual grief that NAs experience when residents die. The need to maintain professional distance can result in a degree of ambivalence in relationships, and the industry focus on bed-and-body work can objectify and dehumanize residents (Gubrium, 1975; Harr & Kasayka, 2000; S.Z. Moss & Moss, 2002). These institutional factors can complicate the grief experienced by NAs following resident death (Katz, Komaromy, & Sidell, 1999; Katz, Sidell, & Komaromy, 2000; Sidell, Katz, & Komaromy, 1997). NAs have also reported that their grief can be disenfranchised by the lack of focus on staff well-being and lack of support from supervisors and facility administration (S.Z. Moss & Moss, 2002; Sumaya-Smith, 1995).

To date, only one study has examined grief specifically in relation to personal and professional well-being in NAs (Anderson, 2008). This pilot study found that complicated grief contributed to elements of burnout, most notably depersonalization—an emotional hardening that can result in the objectification of nursing home residents. It was also found that NAs who experienced higher levels of personal growth in their grief reported higher levels of personal accomplishment, a factor thought to protect individuals from burnout. While the findings from this study shed some light on the relationship between grief and well-being in NAs, questions remain in terms of the impact of grief on other domains of well-being, such as physical, psychological, and occupational well-being (i.e., job satisfaction).

Using a basic premise of grief theory, the researchers attempted to address these questions in the current study. While individual reactions to loss vary, theorists often bifurcate grief reactions into two categories: complicated, atypical grief and uncomplicated, typical grief (Lindemann, 1944). Complicated grief is thought to result from the inability to move through the initial stages of grief and can result in problematic outcomes, such as preoccupation with the deceased, intrusive thoughts, and impaired social and psychological functioning. Uncomplicated grief can result in pain and distress for grievers; however, it is differentiated from complicated grief in that grievers move through the acute stages of grief, and negative emotions are replaced with positive feelings, such as increased resilience and emotional growth (Bonanno & Kaltman, 2001). Drawing from grief theory and past research on grief in NAs, the current study aimed to explore the impact of distress from grief and growth from grief on several domains of well-being. On the basis of this specific aim, the following two hypotheses were developed and tested:

  • NAs who report higher levels of distress from grief will report lower levels of overall well-being.
  • NAs who report higher levels of growth from grief will report higher levels of overall well-being.

Method

Sample

The sampling procedure in the current study was a multi-step process. In the first step, nursing homes were randomly selected from a database of facilities located within a 20-mile radius of a large Midwestern city. Upon receiving approval from the university institutional review board and written consent from facility administrators, the researchers visited each participating facility to recruit participants and to distribute and collect the quantitative surveys. Multiple visits were made to each facility across the different shifts to increase participation. Participants were paid an honorarium of $20 as an incentive.

The final sample consisted of 380 NAs working in 11 nursing homes. Participants were typically middle-aged (mean age = 39.6, SD = 11.4 years), African American (65.5%) women (90.8%) who had approximately 12 years of experience (mean = 12.4, SD = 9.0) in the nursing profession and 5 years of experience in their current facility (mean = 4.8, SD = 5.8). Participants were predominantly full-time employees (89.5%) who had received varying levels of grief training (no training = 28.4%, some training = 46.6%, a lot of training = 25%).

Measures

The following scales and subscales were included in the current study based on the researchers’ understanding of grief and the effects of grief:

Distress from Grief. The 21-item Texas Revised Inventory of Grief (TRIG) was used to measure feelings of distress related to grief. Responses were recorded using a 5-point scale (1 = completely false to 5 = completely true). Scores were reverse coded in this study; therefore, higher scores indicate higher levels of emotional distress in response to grief. The two-factor structure of the TRIG has been found to be valid, and reliability has been found to be acceptable (Cronbach’s alpha coefficient = 0.77 to 0.86; Faschingbauer, Zisook, & DeVaul, 1987).

Growth from Grief. The 12-item Personal Growth subscale of the Hogan Grief Reaction Checklist (HGRC) was used to measure positive aspects of grief, such as growth through grief and effective coping. Responses were recorded using a 5-point scale (1 = does not describe me at all to 5 = describes me very well). Higher scores indicate higher levels of positive coping and greater emotional growth from grief. Validity of the HGRC has been established by the authors, and reliability for this subscale has been reported as acceptable (Cronbach’s alpha coefficient = 0.82; Hogan, Greenfield, & Schmidt, 2001).

Burnout. The 25-item Maslach Burnout Inventory (MBI) was used to measure the presence and strength of feelings of burnout, including emotional exhaustion, depersonalization, and a reduction in feelings of personal accomplishment. Responses were recorded using a 5-point scale (0 = never to 4 = always). The validity of the MBI has been established across populations, and the reliability for the subscales ranges from acceptable (Cronbach’s alpha coefficient = 0.71) to high (Cronbach’s alpha coefficient = 0.90; Maslach, Jackson, & Leiter, 1996).

Well-Being. The 8-item Physical Well-Being and the 8-item Psychological Well-Being subscales from the Perceived Well-Being Scale-Revised were used to measure well-being in participants. Items were recorded using a 7-point Likert scale (1 = strongly agree to 7 = strongly disagree). Validity has been established across populations, and reliability has been found to be acceptable (Cronbach’s alpha coefficient = 0.79 to 0.80; Reker, 1995; Reker & Wong, 1984).

Job Satisfaction. The 21-item Nursing Home Nurse Aide Job Satisfaction Questionnaire (NHNA-JSQ) was used to measure overall job satisfaction in NAs. Participants were asked to rate their satisfaction (1 = lowest rating to 10 = highest rating) on a wide variety of job characteristics. Although this scale is relatively new, validity and reliability for the NHNA-JSQ have been found to be acceptable in preliminary testing in the nursing home setting (Cronbach’s alpha coefficient = 0.78; Castle, 2005; Castle, Engberg, Anderson, & Men, 2007).

Other Information. Demographic information on participants included age, gender, race, marital status, education, employment status (full time versus part time), and level of formal grief training. Information was also collected on the nursing homes, including facility size (number of residents), religious affiliation (affiliated versus non-affiliated), and profit status (not for profit versus for profit).

Data Analysis

Data were entered and analyzed using SPSS version 17.0. Frequencies and descriptive analyses were performed to help describe the sample variables. Stepwise multiple linear regression models were run to test the relationships between grief and well-being. Stepwise regression was selected rather than hierarchal regression due to the paucity of existing literature on the relationships between predictors and outcomes in this population.

Prior to analyzing the data, a missing values analysis was conducted. Missing values constituted less than 5% on each item in the survey. Values were subsequently imputed using maximum likelihood estimation. Several variables were also found to have levels of skewness above 1.0 or below −1.0. Square root transformations were used to reduce skewness on the following variables: Growth from Grief (−1.02 prior to transformation, −0.53 following transformation), Job Satisfaction (−1.3, −0.56), and Burnout-Depersonalization (1.20, −0.14). Those variables that were reflected in the transformation process were re-reflected following transformation to facilitate interpretation.

Multicollinearity was assessed by computing bivariate correlations among predictor variables, covariates, and outcome variables. Two covariates—age and length of time in profession—were found to be correlated at 0.71; however, both variables were retained as this correlation only marginally exceeded the suggested 0.70 cut-off level. Variable inflation factors were computed, and multicollinearity did not appear to be an issue in any of the regression models (Tabachnick & Fidell, 2007).

Results

Frequencies and descriptive statistics for each measure were generated (Table 1). Participants reported moderate levels of Distress from Grief (mean = 2.3, SD = 0.7) and fairly high levels of Growth from Grief (mean = 4.0, SD = 0.7). In terms of well-being, participants reported low to moderate levels of Burnout (Emotional Exhaustion, mean = 2.0, SD = 0.6; Depersonalization, mean = 0.8, SD = 0.8; Personal Accomplishment, mean = 1.5, SD = 0.5), moderate to moderately high levels of Psychological (mean = 5.8, SD = 0.9) and Physical (mean = 4.9, SD = 1.0) Well-Being, and high levels of Job Satisfaction (mean = 7.9, SD = 1.3). Cronbach’s alpha reliability coefficients were computed and found to be acceptable. The Distress from Grief measure (Cronbach’s alpha coefficient = 0.91) and the Growth from Grief measure (Cronbach’s alpha coefficient = 0.91) exceeded the minimum criteria, and the measures of Psychological and Physical Well-Being (Cronbach’s alpha coefficient = 0.87) and Job Satisfaction (Cronbach’s alpha coefficient = 0.90) were very good.

Summary of Study Variables (N = 380)

Table 1: Summary of Study Variables (N = 380)

Analyses of variance (ANOVA) were run to determine whether between-facility differences existed in terms of the outcome variables. Significant differences were found on two outcome variables: Job Satisfaction (F = 2.35, p < 0.05) and Burnout-Emotional Exhaustion (F = 2.12, p < 0.05). Except for size, religious affiliation, and profit status, facility-level data were not collected as part of this study. Interpretation of these between-facility differences are discussed in the Limitations section.

A total of six stepwise linear multiple regression models were generated to test the relationships between grief and well-being (Table 2). Distress from Grief and Growth from Grief served as the predictor variables in each model. Burnout-Emotional Exhaustion, Burnout-Depersonalization, Burnout-Personal Accomplishment, Psychological Well-Being, Physical Well-Being, and Job Satisfaction served as the outcome variables. Demographic factors (e.g., age, gender, facility profit status) that were found to be significantly correlated (p < 0.05) with outcome variables were included in the models as covariates.

Summary of Regression Analyses (N = 380)

Table 2: Summary of Regression Analyses (N = 380)

The first three regression models focused on the relationships of grief to the three dimensions of burnout. In the first regression model (df = 2, R2 = 0.01, F = 2.12, not significant), Distress from Grief was found to be a significant predictor of Burnout-Emotional Exhaustion (β = 0.10, p < 0.05). The model accounted for only 1% of the variance of Burnout-Emotional Exhaustion. Growth from Grief was not found to be a significant predictor in this model.

In the second regression model (df = 5, R2 = 0.10; F = 9.26, p < 0.001), Distress from Grief (β = 0.22, p < 0.001), Growth from Grief (β = −0.13, p < 0.05), female gender (β = −0.13, p < 0.01), and African American race (β = 0.12, p < 0.05) were found to be significant predictors of Burnout-Depersonalization. The model accounted for 10% of the overall variance in Burnout-Depersonalization. The covariate age was not found to be significant predictor in this model.

In the third regression model (df = 4, R2 = 0.06, F = 6.52, p < 0.001), Distress from Grief (β = 0.15, p < 0.01) and female gender (β = −0.14, p < 0.01) were found to be significant predictors of Burnout-Personal Accomplishment. The model accounted for 6% of the overall variance of Burnout-Personal Accomplishment. Growth from Grief and the covariate African American race were not found to be significant predictors in this model.

The fourth and fifth regression models focused on the relationships of grief to psychological and physical well-being. In the fourth regression model (df = 4, R2 = 0.14, F = 15.85, p < 0.001), Distress from Grief (β = −0.29, p < 0.001) and Growth from Grief (β = 0.21, p < 0.001) were found to be significant predictors of Psychological Well-Being. The model accounted for 14% of the overall variance of Psychological Well-Being. The two covariates included in this model, female gender and marital status (never married), were not found to be significant predictors.

In the fifth regression model (df = 5, R2 = 0.06, F = 5.60, p < 0.001), Distress from Grief (β = −0.11, p < 0.05) and Growth from Grief (β = 0.19, p < 0.001) were found to be significant predictors of Physical Well-Being. The model accounted for 6% of the overall variance in Physical Well-Being. The three covariates included in this model, age, marital status (never married), and time in profession, were not found to be significant predictors.

The sixth regression model focused on the relationship between grief and overall job satisfaction. Growth from Grief (β = 0.28, p < 0.001) was found to be the sole significant predictor of Job Satisfaction in this model (df = 4, R2 = 0.09, F = 10.32, p < 0.001). The model accounted for 9% of the overall variance in Job Satisfaction. Distress from Grief and the covariates African American race and for-profit facility status were not found to be significant predictors in this model.

Discussion

This study focused on grief and well-being in 380 NAs working in the nursing home environment. While past research has established that NAs often experience grief when nursing home residents die, little is known about the effects of grief on NAs’ overall well-being. In the first hypothesis for this study, we anticipated that NAs who experienced higher levels of distress from grief would report lower levels of overall well-being. In the second hypothesis, we anticipated that NAs who experienced higher levels of growth from grief would report higher levels of overall well-being. The results of this study largely support these hypotheses and suggest that grief may be an important contributor to emotional, physical, and occupational well-being in this group of health care workers.

In terms of burnout, distress from grief was directly related to emotional exhaustion in NAs and to the depersonalization of nursing home residents. Growth from grief was inversely related to the depersonalization of residents. It certainly comes as no surprise that NAs who are having problems processing grief would have higher levels of emotional exhaustion and a more difficult time interacting with and humanizing residents. This finding partially reflects previous work in which NAs who experienced greater difficulties with their grief reported higher levels of burnout (Anderson, 2008). Burnout has been identified as one of the more troubling and challenging aspects of working in the nursing home setting, resulting in higher levels of lost time (e.g., sick time, tardiness); substance abuse among staff; conflict among staff, residents, and family members; staff turnover; and perhaps even resident abuse and neglect (Joshi & Flaherty, 2005; Laschinger, Finegan, Shamian, & Wilk, 2001). Confirming the link between grief and burnout is important, as it may aid in the development of targeted interventions to address these interconnected problems. Interestingly, the findings also indicated that NAs who experienced higher levels of distress from their grief reported higher levels of personal accomplishment. It may be the case that these NAs are able to experience feelings of accomplishment on the job despite the associated grief, indicating a high level of resilience in this population.

As hypothesized, grief was also found to be a consistent predictor of psychological and physical well-being in the current study. Specifically, NAs who experienced greater distress in their grief reported lower levels of psychological and physical well-being. Conversely, NAs who experienced greater growth in their grief reported higher levels of well-being on these two indices. Again, these findings were not unanticipated, as grief has long been found to affect the psychological and physical well-being of individuals, particularly those who are experiencing difficulties in processing their grief (Rando, 1993). As with burnout, the costs associated with lower psychological and physical well-being may extend beyond simply the health of NAs and affect the quality and continuity of care received by residents and the financial health of the facility (e.g., sick time, employee health care costs).

In terms of occupational well-being, NAs who experienced greater growth from their grief reported higher levels of job satisfaction. Job satisfaction for NAs in the nursing home has traditionally been composed of several domains, such as satisfaction with pay, organizational structure, and career opportunities (Castle et al., 2007). The findings from this study are important, as they establish the first link between grief and job satisfaction. Identifying the factors that contribute to job satisfaction is critical because many of these factors are also related to turnover. In the health care industry, turnover in nursing staff is a serious problem with a number of ramifications, including financial costs to the institution (e.g., recruiting, retraining), disruption of services and organization, and decreased consumer satisfaction (see Tai, Bame, & Robinson, 1998, for a review). Turnover of NAs in long-term care has proven to be especially problematic, with turnover rates estimated at between 49% and 143% across regions and facilities (NCCNHR, 2001). Acknowledging and supporting the grief of NAs may be an effective method for increasing job satisfaction and, ultimately, reducing turnover in this critical group of caregivers.

Two covariates were also found to have significant relationships in this analysis. Female NAs were found to have significantly lower levels of depersonalization and personal accomplishment in their work. Since the vast majority of nursing home residents are women (71%; Centers for Disease Control and Prevention [CDC], 2004), it may be the case that female NAs are able to identify more with residents of the same gender, thereby reducing objectification and depersonalization. In terms of personal accomplishment, female NAs may have less opportunity for advancement and less recognition of their work, resulting in a depleted sense of accomplishment on the job. Disentangling the intersection of grief, gender, and burnout may require a more gender-diverse sample and complex analyses that are beyond the scope and intent of the current article.

The second covariate, race, was also linked with burnout in NAs. NAs who identified themselves as African American reported significantly higher levels of depersonalization. Past studies have also found that nurses from minority backgrounds tend to experience higher levels of burnout and subsequently leave their jobs at higher rates than nonminority nurses (see Tai et al., 1998, for a review). As the majority of nursing home residents are Caucasian (86%; CDC, 2004), African American NAs may be less inclined to identify with residents of a different race and more prone to depersonalize such residents.

Limitations

A number of limitations should be considered when interpreting these findings. First, this study was cross-sectional; therefore, causal relationships cannot be established. The racial makeup of the sample is also considerably different from that of the general population of NAs. Almost 66% of the sample identified themselves as African American, whereas a recent national survey of NAs found that approximately 39% of participants identified themselves as Black (Squillance et al., 2009). This limits our ability to generalize the findings from the current study.

Scores on the job satisfaction measure were also high, which may indicate a response bias. Despite reassuring participants that the information they provided would be de-identified and would not be revealed to facility administrators, some individuals may have overstated their job satisfaction in fear of facility retaliation.

Analysis of these data also called for a high number of regression models. This may have increased the potential for Type I error. Finally, the regression models accounted for a relatively small amount of variance in the outcome variables. This indicates that other factors may have a greater impact on well-being than those included in this analysis. Indeed, the ANOVA analysis reported in the Results section revealed significant between-facility differences on two outcome measures Job Satisfaction and Burnout-Emotional Exhaustion. While certain participant (e.g., level of grief training) and facility factors (e.g., religious affiliation) were included in the analysis, other factors (e.g., grief support programs) may exist that contribute to these outcomes. Future studies should consider including additional facility-level variables in the analysis of grief in this setting.

Conclusion

The findings from this study provide further evidence that nurses, specifically NAs in the nursing home setting, experience grief reactions in response to the deaths of individuals for whom they care. These grief reactions tend to be complex and can affect well-being across a number of domains, including burnout, psychological and physical health, and job satisfaction. These outcomes, in turn, may affect the quality and continuity of care in nursing home settings—issues that have been identified as critical concerns and priorities by leading advocacy groups and health care entities. Future research should focus on identifying specific elements within the nursing home environment that contribute to both distressful and beneficial grief reactions. In doing so, we may be able to limit the deleterious effects of grief and expand opportunities for NAs to experience emotional growth in response to the deaths of nursing home residents.

References

  • Anderson, K.A. (2008). Grief experiences of CNAs: Relationships with burnout and turnover. Journal of Gerontological Nursing, 34(1), 42–49. doi:10.3928/00989134-20080101-01 [CrossRef]
  • Anderson, K.A. & Gaugler, J.E. (2006–2007). The grief experiences of certified nursing assistants: Personal growth and complicated grief. Omega, 54, 301–318.
  • Bonanno, G.A. & Kaltman, S. (2001). The varieties of grief experience. Clinical Psychological Review, 21, 705–721. doi:10.1016/S0272-7358(00)00062-3 [CrossRef]
  • Braun, K.L., Cheang, M. & Shigeta, D. (2005). Increasing knowledge of skills and empathy among direct care workers in elder care: A preliminary study of an active-learning model. The Gerontologist, 45, 118–124.
  • Carpenter, J. & Thompson, S.A. (2008). CNAs’ experiences in the nursing home. Journal of Gerontological Nursing, 34(9), 25–32. doi:10.3928/00989134-20080901-02 [CrossRef]
  • Castle, N.G. (2005). Job satisfaction of nursing home administrators. Long-Term Care Interface, 4(3), 5–13.
  • Castle, N.G., Engberg, J., Anderson, R. & Men, A. (2007). Job satisfaction of nurse aides in nursing homes: Intent to leave and turnover. The Gerontologist, 47, 193–204. doi:10.1093/geront/47.2.193 [CrossRef]
  • Centers for Disease Control and Prevention. (2004). National Nursing Home Survey. Retrieved from http://www.cdc.gov/nchs/nnhs.htm
  • Davies, B., Clarke, D., Connaughty, S., Cook, K., MacKenzie, B. & McCormick, J. et al. (1996). Caring for dying children: Nurses’ experiences. Pediatric Nursing, 22, 500–507.
  • Faschingbauer, T., Zisook, S. & DeVaul, R. (1987). The Texas Revised Inventory of Grief. In Zisook, S. (Ed.), Biopsychosocial aspects of bereavement (pp. 111–124). Washington, DC: American Psychiatric Press.
  • Gubrium, J.F. (1975). Living and dying at Murray Manor. New York: St. Martin’s Press.
  • Harr, R. & Kasayka, R. (2000). The power of place and the preservation of personhood. Nursing Homes and Long-Term Care Management, 9(6), 30–35.
  • Hogan, N.S., Greenfield, D.B. & Schmidt, L.A. (2001). Development and validation of the Hogan Grief Reaction Checklist. Death Studies, 25, 1–32.
  • Joshi, S. & Flaherty, J.H. (2005). Elder abuse and neglect in long-term care. Clinics in Geriatric Medicine, 21, 333–354. doi:10.1016/j.cger.2004.10.009 [CrossRef]
  • Katz, J., Komaromy, C. & Sidell, M. (1999). Understanding palliative care in residential and nursing homes. International Journal of Palliative Nursing, 5, 58–64.
  • Katz, J., Sidell, M. & Komaromy, C. (2000). Death in homes: Bereavement needs of residents, relatives and staff. International Journal of Palliative Nursing, 6, 274–279.
  • Laschinger, H.K.S., Finegan, J., Shamian, J. & Wilk, P. (2001). Impact of structural and psychological empowerment on job strain in nursing work settings: Expanding Kanter’s model. Journal of Nursing Administration, 31, 260–272. doi:10.1097/00005110-200105000-00006 [CrossRef]
  • Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 151, 155–160.
  • Maslach, C., Jackson, S.E. & Leiter, M.P. (1996). Maslach Burnout Inventory manual (3rd ed.). Palo Alto, CA: Consulting Psychologists Press.
  • Monahan, R.S. & McCarthy, S. (1992). Nursing home employment: The nurse’s aide’s perspective. Journal of Gerontological Nursing, 18(2), 13–16.
  • Moss, M.S., Moss, S.Z., Rubenstein, R.L. & Black, H.K. (2003). Metaphor of “family” in staff communication about death and dying. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 58, S290–S296.
  • Moss, S.Z. & Moss, M.S. (2002). Nursing home staff reactions to resident deaths. In Doka, K.J. (Ed.), Disenfranchised grief: New directions, challenges, and strategies for practice (pp. 197–216). Champaign, IL: Research Press.
  • NCCNHR. (2001). The nurse staffing crisis in nursing homes: Consensus statement of the campaign for quality care. Washington, DC: Author.
  • O’Hara, P.A., Harper, D.W., Chartrand, L.D. & Johnston, S.F. (1996). Patient death in a long-term care hospital: A study on the effect on nursing staff. Journal of Gerontological Nursing, 22(8), 27–35.
  • Papadatou, D., Bellali, T., Papazoglou, I. & Petraki, D. (2002). Greek nurse and physician grief as a result of care for children dying of cancer. Pediatric Nursing, 28, 345–353.
  • Rando, T.A. (1993). Treatment of complicated mourning. Champaign, IL: Research Press.
  • Rashotte, J., Fothergill-Bourbonnais, F. & Chamberlain, M. (1997). Pediatric intensive care nurses and their grief experiences: A phenomenological study. Heart & Lung, 26, 372–386. doi:10.1016/S0147-9563(97)90024-8 [CrossRef]
  • Reker, G.T. (1995). Reliability and validity of the Perceived Well-Being Scale-Revised. Unpublished manuscript, Trent University, Ontario, Canada.
  • Reker, G.T. & Wong, P.T.P. (1984). Psychological and physical well-being in the elderly: The Perceived Well-Being Scale (PWB). Canadian Journal on Aging, 3, 23–32. doi:10.1017/S0714980800006437 [CrossRef]
  • Saunders, J.M. & Valente, S.M. (1994). Nurses’ grief. Cancer Nursing, 17, 318–325.
  • Schell, E.S. & Kayser-Jones, J. (2007). “Getting into the skin”: Empathy and role taking in certified nursing assistants’ care of dying residents. Applied Nursing Research, 20, 146–151. doi:10.1016/j.apnr.2006.05.005 [CrossRef]
  • Secrest, J., Iorio, D.H. & Martz, W. (2005). The meaning of work for nursing assistants who stay in long-term care. Journal of Clinical Nursing, 14(8B), 90–97. doi:10.1111/j.1365-2702.2005.01282.x [CrossRef]
  • Sidell, M., Katz, J.T. & Komaromy, C. (1997). Death and dying in residential and nursing homes for older people. London: Open University Press.
  • Squillance, M.R., Remsburg, R.E., Harris-Kojetin, L.D., Bercovitz, A., Rosenhoff, E. & Han, B. (2009). The National Nursing Assistant Study: Improving the evidence base for policy initiatives to strengthen the certified nursing assistant workforce. The Gerontologist, 49, 185–197. doi:10.1093/geront/gnp024 [CrossRef]
  • Sumaya-Smith, I. (1995). Caregiver/resident relationships: Surrogate family bonds and surrogate grieving in a skilled nursing facility. Journal of Advanced Nursing, 21, 447–451. doi:10.1111/j.1365-2648.1995.tb02726.x [CrossRef]
  • Tabachnick, B.G. & Fidell, L.S. (2007). Using multivariate statistics (5th ed.). Boston: Allyn and Bacon.
  • Tai, T.W.C., Bame, S.I. & Robinson, C.D. (1998). Review of nursing turnover research, 1977–1996. Social Science and Medicine, 47, 1905–1924. doi:10.1016/S0277-9536(98)00333-5 [CrossRef]
  • Vachon, M.L.S. & Benor, R. (2003). Staff stress, suffering, and compassion in palliative care. In Lloyd-Williams, M. (Ed.), Psychosocial issues in palliative care (pp. 165–182). Oxford, UK: Oxford University Press.

Summary of Study Variables (N = 380)

Variable Mean (SD) Range
Grief
  Distress from Grief 2.3 (0.7) 1.0 to 4.6
  Growth from Grief 4.0 (0.7) 1.0 to 5.0
Burnout
  Emotional Exhaustion 2.0 (0.6) 0.0 to 3.9
  Depersonalization 0.8 (0.8) 0.0 to 4.0
  Personal Accomplishment 1.5 (0.5) 0.0 to 3.5
Well-Being
  Psychological 5.8 (0.9) 2.3 to 9.8
  Physical 4.9 (1.0) 1.6 to 7.0
Job Satisfaction
  Overall job satisfaction 7.9 (1.3) 1.0 to 10.0

Summary of Regression Analyses (N = 380)

Model 1 Model 2 Model 3

Burnout-Emotional Exhaustion Burnout-Depersonalization Burnout-Personal Accomplishment

Variable B SE B β B SE B β B SE B β

Distress from Grief 0.08 0.04 0.10* 0.15 0.03 0.22*** 0.11 0.04 0.15**
Growth from Grief –0.08 0.12 –0.03 –0.24 0.01 –0.13* –0.18 0.11 –0.09
Age 0.00 0.00 –0.01
Female gender –0.22 0.08 –0.13** –0.26 0.09 –0.14**
African American race 0.13 0.05 0.12* 0.10 0.06 0.09
df = 2 df = 5 df = 4
R2 = 0.01 R2 = 0.10 R2 = 0.06
F = 2.12 F = 9.26*** F = 6.52***

Model 4 Model 5 Model 6

Psychological Well-Being Physical Well-Being Job Satisfaction

Variable B SE B β B SE B β B SE B β

Distress from Grief –0.36 0.06 –0.29*** –0.15 0.07 –0.11* 0.02 0.03 0.03
Growth from Grief 0.72 0.17 0.21*** 0.72 0.20 0.19*** 0.40 0.07 0.28***
Female gender 0.27 0.15 0.09
Age –0.01 0.01 –0.12
African American race –0.03 0.04 –0.04
Marital status (never married) 0.17 0.09 0.09 0.11 0.12 0.05
Time in profession 0.00 0.00 0.01
For-profit facility status 0.06 0.04 0.09
df = 4 df = 5 df = 4
R2 = 0.14 R2 = 0.06 R2 = 0.09
F = 15.85*** F = 5.60*** F = 10.32***
Authors

Dr. Anderson is Assistant Professor, The Ohio State University, College of Social Work, Columbus, and Dr. Ewen is Assistant Professor, Miami University, Department of Sociology and Gerontology, Oxford, Ohio.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Address correspondence to Keith A. Anderson, PhD, Assistant Professor, The Ohio State University, College of Social Work, 1947 N. College Road, Columbus, OH 43210-1162; e-mail: anderson.1630@osu.edu.

Received: July 17, 2009
Accepted: March 22, 2010
Posted Online: July 30, 2010

10.3928/19404921-20100702-01

Sign up to receive

Journal E-contents