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School Nurses in the Age of Coronavirus:

Prevention and Well-Being for Self, Students, and Staff — Now More Than Ever!

The Lost Year— Grieving Losses and Normalcy

Please be mindful that some content may be triggering!

• Describe how the pandemic has brought about loss in the lives of students, staff and school nurses

• Identify grief, and grieving among students, colleagues and self.

• Recognize vicarious grief.

GOALS“Exactly how the pandemic will end depends in part on medical advances still to come. It will also depend on how individual Americans behave in the interim. If we scrupulously protect ourselves and our loved ones, more of us will live. If we underestimate the virus, it will find us.”

Veeterzy

Mc Neil, D. (2020,April 19). The Coronavirus in America: The Year Ahead. New York Times.

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CONTROVERSIES AND CAUTIONARY TALES• Grief can not be organized in categories

or stages. – Phases or staging suggests there is a prescribed,

optimum way to work through the process.

– Stages and phases suggest a linear model where one can move forwards or backwards.

• Grieving is more circular, much like a feedback loop. – There are some factors that can facilitate the

process and others that can impede it.

• Grief is not one single emotion– Loss affects the way we feel, think, interact with

other people, even the way our bodies feel

Goh Rhy Yan

“CLOSURE”“The act of closing or condition of being closed.”

• Frequently used in conjunction with

death, loss and grieving.

• In some situations “closure’ is represented by visiting the site of death or rituals.

• Consider that the word “Integration”may be more suitable, – “to make into a whole by bringing parts together” “to

unify.”

• Rituals and visitation are a beginning.

– The reality of the person’s death is recognized, but the real work of integration is just beginning.

W. S. Merwin, “Separation” from The Second Four Books of Poems. Port Townsend, Washington: Copper Canyon Press, 1993.

DEFINING GRIEF, BEREAVEMENT AND MOURNING

• Bereavement “To lose someone we care about or love through death. It is a state of deprivation, not a reaction or response. The event of death happens in another’s life, and, as a consequence of our caring about him or her, bereavement happens to us. This deprivation redefines and limits our life circumstances and possibilities.” Attig, P. 343

• Grief is the multi-faceted reaction to the death of a person in one’s life. It encompasses the emotional, cognitive, physical, functional, and behavioral reactions to the death. Therefore, grief is one’s reaction to loss and bereavement. Gaffney et al., 2016

– Grief refers to the emotional experience of the psychological, behavioral, social, and physical reactions the bereaved person might experience as a result of this death.

Boerner, K., Stroebe, M., Schut, H., & Wortman, C. B., 2015

Karim Manjra

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MOURNING• The socio-cultural and religious

activities established by a family, society, culture or religion to commemorate occurrences of death.

• After someone close to us dies, there is a process of mourning.

• Mourning is work and can be expressed through the written word, music or art.

• Public mourning can take many physical forms, spontaneous shrines, services, formal or informal monuments.

• Mourning can be expressed through signage and social media.

– #Je Suis CharlieRosenblatt, P. C., 2013

Museums Victoria

GRIEF. . . IS BOTH UNIQUE AND UNIVERSAL.

“Can’t confuse one element of a complex phenomenon for the entire thing.”

• Not simply physical labor (food, shelter, & closeness others)

• Nor is it only emotional expression and adjustment.

• Nor is it entirely psycho-dynamic accommodation, including revival of self-esteem and self-confidence and modification of identity.

• Nor is it simply meaning reconstruction,(cognitive adjustment and spiritual accommodation).

• Nor is it merely behavioral modification (adjusting desires, motivations, habits, and life patterns to new reality).

• Nor is it entirely family or community adjustment to loss, reassignment of roles, and shared meaning-making.

Attig, 2004

VICARIOUS GRIEF

• One feels vicarious grief for a mourner.

• The very sharing of another’s sorrow serves as a reminder of our own losses and thus re-activates our own unfinished grieving.

• Mainstream and social media, particularly the televised media, serve as a catalyst of vicarious grieving.

Sullender, 2010

Few things in life are as painful as the sudden, traumatic death of a loved one.

The entire world has been shattered in a single second.

Reactions to this type of loss are as unique and varied as there are cultures and belief systems.

The confluence of loss and trauma is a continuing presence.

TRAUMATIC LOSS

Jillbert Ibrihami * For more information on traumatic loss & grief, see the end of this presentation

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HOW WE GRIEVE• Grieving, traumatic or otherwise, requires a

holistic view of the world.

• There is not one starting point nor is there a final endpoint.

• The grieving process is shaped by a number of factors: – Previous loss experiences, – Attachment to significant others, – The nature of the loss experience, – Social supports.

THE LOSS OF NORMALCY AND COVID 19

We long for what we had. . .

• It is tempting to wonder when things will return to normal but the fact is that it will not be the ‘old normal’. We can achieve a new kind of normalcy, even if this new world differs in fundamental ways.

• Rapid changes to our roles and routines • Facing an unpredictable future.

• Changes to our sense of security and normalcy• Impact of community change• Influence of silence or media messages

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GRIEVING LOSSES. . . THAT ARE NOT DEATHS• Unable to go back to the way things were, the world has changed, the world you once knew and experienced, is no longer there. (loss of our assumptive world)

• These losses occur in our lives, our families and our practices• Loss of our assumptive world- what we believe our nursing practice

to be.

• “Relearning the world or coming to terms with the loss of our assumptive world is primarily about learning new ways of acting and being in the world. It is a matter of coming to know how to go on in the world where so much of what we have taken for granted in the emotional, psychological, social, soulful, and spiritual dimensions of our lives is no longer supportable or practicable” Attig, 2002, p. 64

Bill Oxford

Many of us are experiencing an ongoing, pervasive sense of loss: • The tragic deaths and threatened loss of

loved ones or colleagues; • The loss of physical contact with family

members and social networks; • The loss of jobs, financial security, and

livelihoods; • The loss of pre-crisis ways of life and

threatened loss of hopes and dreams for the future; and

• The loss of a sense of normalcy in shattered assumptions about our lives and connections with the world around us.

The COVID-19 pandemic is different:

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BREAKOUT ROOM

Life is derailed, on hold, uncertain.There is a collective experience of shattered assumptions in our worldview.Our taken-for-granted beliefs and expectations about our lives and our connections to our world.

Invisibility of the virus, its lethal potential, and the possible spread by non-symptomatic persons heighten fears of infection.

“COVID Cognitive Cloud” describes the disorganizing impact of the pandemic. Ambiguities cloud our thinking and decision-making. Who can we trust, who can keep us safe?There is even anger at the loss of freedoms with lockdown and restrictions.

Loss of NormalcyShattered Assumptions

• Healing and resilience are forged gradually over time. Grief is a healing process. We do not get over grief— we go through it.

• Resilience is forged through suffering and setbacks; it involves struggling and integrating painful loss experiences into our life passage.

• More than surviving loss and coping with disruptions, resilience involves:• Positive adaptation.• Regaining the ability to thrive. • The potential for transformation and positive

growth forged through the searing experience.

• Contextualizes the distress;• Attends to the challenges, suffering, and

struggles ; • Strengthens relational processes that support

coping, adaptation, and growth. • With a multisystemic lens, this approach draws

on extended family, social connections, community, sociocultural, and spiritual resources, and strengthens larger systemic/structural supports.

A Resilience-oriented Approach with Loss

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• Multigenerational and sociocultural influences, comes to the fore in times of crisis and loss, shaping our experiences and their pathways in adaptation. Collective resilience is fostered by shared beliefs.• To make meaning of the crisis and

challenges; • To (re)gain a positive, hopeful outlook that

supports active agency, and • To transcend is to rise above suffering and

hardship through larger values, spiritual beliefs and practices, and experiencing transformations in new priorities, a sense of purpose, and deeper bonds.

OUR BELIEF SYSTEMS

• Foster well-being-trust, safety, order, predictability• Meaning making and recovery involve a struggle to understand what

has been lost, how to build new lives, and how to prevent future tragedy.

• Sense-making efforts over time. • Put it in perspective to make it more bearable. • Forge a sense of coherence.• Envision a new sense of normality, identity, and relatedness to adapt

to altered conditions. • Take efforts to gain and share helpful information and become

involved in community efforts. • Weaving the painful experience and the resilience forged into the

fabric of individual and collective identity and life passage.

Making Meaning During the Pandemic

• Affirming individual and family strengths in the midst of difficulties can counter a sense of helplessness, failure, and despair.

• Family members’ mutual encouragement bolsters active efforts to take initiative and to persevere.

• Resilience is fostered by focusing efforts to master the possible, accepting that which is beyond control, and coming to terms with what cannot be changed.

Building a Positive Outlook: Hope

Innovation Creativity is vital in our lives, as we need to invent new ways to overcome pandemic-related challenges.

TransformationLearning, change, and positive growth.More than surviving loss or managing stressful conditions, family processes in resilience can yield personal and relational transformation and positive growth.

Transcendence

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Time OutTo reflect on our personal and collective lives.

Reconnecting with the past Understandings and connections to our past, to the joys and sorrows experienced.

Re-envisioning the future We can dream and direct our energies toward our preferred vision.

Linking the past, present, and future A transformation from ongoing physical presence to continuing bonds.

Present time/precious time Time does not heal all wounds, but offers new perspectives, experiences, and connections that can help people forge new meaning and purpose in their lives.

Time Lost and Found And as for grief, as for missing people who are gone, dedicating time and emotion to thinking about what that missing is, and how that missing relates to the way that you are in love, or parenting, or working. I refuse to let it lie.Isn't it time you stopped thinking about X?and moved on? No, no, no, no, no.The thinking is the moving and it is a howling living story which is on words, not as a train moves forward, but as a plant grows.

Max Porter, April 3, 2016

DEALING WITH LOSS IN THE SCHOOL COMMUNITY

• Honesty and Trust• Self-Compassion• Safety• Sensitivity• Connection• Community Building• Loss as a part of the life cycle• Legacy

• Pausing for a moment of reflection after learning about a death reconnects us to the mission of school health & well-being.

• It reconnects students, staff & family members, with the essence of humanity.

• Often when we hear of someone’s death, we are silent, or even walk away from the situation to spare ourselves the pain. We lose a ritual of honoring.

• Inspired by the actions of a hospital chaplain who once requested the care team stop and pray after an unsuccessful resuscitation. (Jon Bartels)

THE PAUSE

Melissa Askew

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• The Pause poses minimal risk and has considerable benefits.

Benefits include:• Increased perceived team cohesion. • A moment for reflection, and a

method by which we honor the deceased.

• Allows us to feel more present to meet the needs of students, staff, families and peers.

THE PAUSE

Cunningham, 2019

Felip Pelaquim

"Could we stop and honor this person who was alive before today, who was loved by others, who loved others, who had a life—and also take the moment to honor all the efforts we put into knowing (working for, teaching) this person? I ask that we hold the space, to honor this person in your own way and in silence."

This allows us to own the practice and honor someone’s last rite of passage.

Silence for one minute.

Thank you.Bartels, 2009

GRIEVING WITH COLLEAGUES• Embrace the power of presence

– A respectful empathic engagement with peers

• Provide a safe and healing setting to:– Assess one’s needs,

• Especially related to the death & traumatic grief.– Create a safe “relational container” for a “re-telling” of

the story of one’s death. • Listen to the narratives of the death to more fully take in the

unspoken meaning of one’s grief.• Not the ‘details’ but the story.

– Help integrate the loss event into the larger narrative of life and work, in our practice.

– Therapeutic change is initiated in moments of experiential intensity (not discussion).

• Self-care and being in touch with one’s emotions and the full spectrum of responses.

Robert Neimeyer, 2012, Techniques of Grief Therapy

TRAUMATIC LOSS• Occurs suddenly or without warning, providing no

opportunity to say goodbye.

• Approximately 60% of the population will experience the sudden traumatic death of a loved one at some time in their lives.

– People feel as though their entire world has been shattered in a solitary moment.

– Communities are shaken, resources and networks are disrupted.

• The world which once offered security, safety, and predictability, has now revealed a darker side; one that is painful, frightening and out of control.

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TRAUMATIC GRIEF• A complex interplay between trauma and loss by

traumatic means; a sudden, unanticipated and shocking death(s).

• Those who experience traumatic loss have to cope with the trauma and any resulting stress in addition to the death and the grieving process.

• Having to deal with posttraumatic stress as a result of a traumatic loss can interfere with the grieving process.

• Grieving a traumatic loss requires additional work:•Decreasing arousal•Recognizing the interaction of trauma and grief

responses•Reframing traumatic reminders. Neira & Litz, 2010

HEALING FROM TRAUMATIC GRIEF• Psychoeducation, a universal & crucial component of

traumatic grief treatment.• Normalize symptoms as well as help grieving individuals

anticipate potential triggers for trauma and grief-related symptoms.

• Tailored to each individual, depending their own unique symptoms and circumstances.

• Connecting and gaining support from others in a support group. – Social support is known to be a critical element in

decreasing stigma.– Founded on the key principle of respect, shared

responsibility, and mutual agreement.– Mutual aid.

Rheingold & Williams, 2018

And . . . Time for . . .

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BIBLIOGRAPHYAttig, T. (2004). Meanings of death seen through the lens of grieving. Death Studies, 28(4), 341–360.

Bartels, J. B. (2014). The Pause. Critical Care Nurse, 34(1), 74–75. doi:10.4037/ccn2014962

Boerner, K., Stroebe, M., Schut, H., & Wortman, C. B. (2015). Theories of grief and bereavement. Encyclopedia of geropsychology, 1-10.

Combe, L. G. (2020). School Nurses: Living the Framework During COVID-19. NASN School Nurse. 183-187.

Gaffney, D., Kaplow, J., Layne, C., A., & Primo, J. (2016). A Selective Literature Review on Childhood Grief and Bereavement: Current Research Findings and Future Directions. Unpublished manuscript.

Idoiaga, N., Berasategi, N., Eiguren, A., & Picaza, M. (2020). Exploring children’s social and emotional representations of the Covid-19 pandemic. Frontiers in Psychology, 11, 1952.

Kapoor, S., Morgan, C. K., Siddique, M. A., & Guntupalli, K. K. (2018). “Sacred pause” in the ICU: Evaluation of a ritual and intervention to lower distress and burnout. American Journal of Hospice and Palliative Medicine, 35, 1337-1341. doi:10.1177/1049909118768247

BIBLIOGRAPHYMiller, E. D. (2020). The COVID-19 Pandemic Crisis: The Loss and Trauma Event of Our Time.

Journal of Loss and Trauma, 1–13.

Moules, N. J., Simonson, K., Prins, M., Angus, P., & Bell, J. M. (2004). Making room for grief:

Walking backwards and living forward. Nursing Inquiry, 11(2), 99-107.

Moules, N. J., Simonson, K., Fleiszer, A. R., Prins, M., & Glasgow, R. B. (2007). The soul of sorrow

work: Grief and therapeutic interventions with families. Journal of Family Nursing, 13(1), 117-141.

Stroebe, M., & Schut, H. (2020). Bereavement in Times of COVID-19: A Review and Theoretical

Framework. OMEGA-Journal of Death and Dying.

Sullender, R. S. (2010). Vicarious grieving and the media. Pastoral Psychology, 59(2), 191-200.

Walsh, F. (2020). Loss and resilience in the time of COVID-19: Meaning making, hope, and

transcendence. Family process, 59(3), 898-911.

Weaver, M. S., & Wiener, L. (2020). Applying palliative care principles to communicate with

children about COVID-19. Journal of Pain and Symptom Management.

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